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Hepsen S, Gul U, Bostan H, Akhanli P, Sencar ME, Kizilgul M, Unsal IO, Cakal E. Cushing's syndrome screening with the 1-mg dexamethasone suppression test in metabolically healthy and unhealthy obesity phenotypes. Int J Obes (Lond) 2024:10.1038/s41366-024-01598-0. [PMID: 39122909 DOI: 10.1038/s41366-024-01598-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 07/14/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The ongoing debate regarding the need for screening Cushing's syndrome (CS) in patients with obesity continues. The objectives of this study were to establish the prevalence of CS in the population with obesity and assess how metabolic health status influences cortisol levels following the 1 mg dexamethasone suppression test (DST). METHODS This retrospective study included 1008 patients with obesity who underwent screening with the 1 mg DST for CS. These patients were categorized into two groups as metabolically healthy obesity (MHO) and unhealthy obesity (MUO). RESULTS Out of the 1008 patients, 779 (77.3%) belonged to the MUO group. Within the entire study cohort, 12 (1.2%) patients exhibited a cortisol level of ≥ 1.8 after the 1 mg DST. Cortisol levels following the 1 mg DST were also significantly higher in the MUO group than in the MHO group (p = 0.001). Among these 12 patients, 11 were presenting a MUO phenotype. Hypercortisolism was definitively diagnosed in two patients, resulting in an overall prevalence of 0.2%. The 1 mg DST demonstrated a specificity of 99% and 100% sensitivity for screening for CS. CONCLUSIONS While the 1 mg DST is a practical screening test for CS with high specificity in obesity, the number of CS cases detected remains relatively low. Therefore, it may be more reasonable and applicable to screen patients with MUO phenotype rather than all individuals with obesity.
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Affiliation(s)
- Sema Hepsen
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey.
| | - Umran Gul
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Hayri Bostan
- Canakkale Mehmet Akif Ersoy State Hospital, Department of Endocrinology and Metabolism, Canakkale, Turkey
| | - Pinar Akhanli
- Erzurum Regional Training and Research Hospital, Department of Endocrinology and Metabolism, Erzurum, Turkey
| | - Muhammed Erkam Sencar
- Medicana International Ankara Hospital, Department of Endocrinology and Metabolism Ankara, Ankara, Turkey
| | - Muhammed Kizilgul
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Ilknur Ozturk Unsal
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Erman Cakal
- Ankara Etlik City Hospital, Department of Endocrinology and Metabolism, Ankara, Turkey
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Ren X, Nan M, Zhang X. Evaluating the efficacy of surgical and conservative approaches in mild autonomous cortisol secretion: a meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1399311. [PMID: 39086899 PMCID: PMC11288901 DOI: 10.3389/fendo.2024.1399311] [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: 03/11/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The management of Mild Autonomous Cortisol Secretion (MACS) remains a topic of debate among clinicians, with differing opinions on the effectiveness of surgical intervention compared to conservative treatment methods. This meta-analysis provides a comprehensive assessment of available literature to determine the most effective approach for treating this condition. Methods On December 1, 2023, an exhaustive literature search of English databases Embase, PubMed, the Cochrane Library, Scopus, Web of Science, as well as the Chinese databases China HowNet, Wanfang Database, SinoMed Database, and Weipu Database using the keywords "Mild Autonomous Cortisol Secretion", "Subclinical Cushing's Syndrome", "Subclinical Hypercortisolism", "Mild Cortisol Autonomous Secretion", "Adrenal Incidentaloma", "Surgical Treatment" and "Adrenalectomy". The data were statistically analyzed using STATA version 15.0. Results In this comprehensive analysis involving 629 patients with MACS, the therapeutic efficacy of adrenalectomy was evident. The meta-analysis results indicate that compared to conservative treatment, surgical intervention more effectively improves obesity indicators in patients: waist circumference (SMD=-0.62, 95% CI: -1.06 to -0.18), BMI (SMD=-0.41, 95% CI: -0.62 to -0.20), enhances glycemic control: fasting blood glucose (SMD=-0.47, 95% CI: -0.68 to -0.26), glycated hemoglobin (SMD=-0.66, 95% CI: -0.95 to -0.38), improves lipid metabolism: triglycerides (SMD=-0.45, 95% CI: -0.73 to -0.16), lowers blood pressure: systolic blood pressure (SMD=-1.04, 95% CI: -1.25 to -0.83), diastolic blood pressure (SMD=-0.89, 95% CI: -1.12 to -0.65), and ameliorates hormonal metabolic disorder: 24h urinary free cortisol (SMD=-1.10, 95% CI: -1.33 to -0.87), ACTH (SMD=2.30, 95% CI: 1.63 to 2.97). All these differences are statistically significant. Conclusion This meta-analysis shows that, compared to conservative treatment, surgical treatment is more effective in improving obesity indicators, glycemic control, lipid metabolism, reducing blood pressure, and ameliorating hormonal metabolic disorders in patients with MACS. These statistically significant results highlight the importance of considering surgical intervention in the management of patients with MACS. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42023492527.
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Affiliation(s)
| | | | - Xiaomei Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, China
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Koh JM, Song K, Kwak MK, Suh S, Kim BJ, Sung TY, Hong JH, Jeong BC, Kim JH, Lee SH. Adrenalectomy Improves Body Weight, Glucose, and Blood Pressure Control in Patients With Mild Autonomous Cortisol Secretion: Results of an Randomized Controlled Trial by the Co-work of Adrenal Research (COAR) Study. Ann Surg 2024; 279:945-952. [PMID: 38126763 DOI: 10.1097/sla.0000000000006183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the metabolic effects of adrenalectomy in patients with mild autonomous cortisol secretion (MACS). BACKGROUND Despite retrospective studies showing the association of adrenalectomy for MACS with beneficial metabolic effects, there have been only 2 randomized prospective studies with some limitations to date. METHODS A prospective, multicenter study randomized 132 patients with adrenal incidentaloma without any features of Cushing syndrome but with serum cortisol >50 nmol/L after a 1 mg overnight dexamethasone suppression test into an adrenalectomy group (n = 66) or control group (n = 66). The primary outcomes were changes in body weight, glucose, and blood pressure (BP). RESULTS Among the 118 participants who completed the study with a median follow-up duration of 48 months (range: 3-66), the adrenalectomy group (n = 46) exhibited a significantly higher frequency of improved weight control, glucose control, and BP control (32.6%, 45.7%, and 45.7%, respectively) compared with the control group (n = 46; 6.5%, P = 0.002; 15.2%, P = 0.002; and 23.9%, P = 0.029, respectively) after matching for age and sex. Adrenalectomy [odds ratio (OR) = 10.38, 95% CI = 2.09-51.52, P = 0.004], body mass index (OR = 1.39, 95% CI = 1.08-1.79, P = 0.010), and cortisol after a 1 mg overnight dexamethasone suppression test levels (OR = 92.21, 95% CI = 5.30-1604.07, P = 0.002) were identified as independent factors associated with improved weight control. Adrenalectomy (OR = 5.30, 95% CI = 1.63-17.25, P = 0.006) and diabetes (OR = 8.05, 95% CI = 2.34-27.65, P = 0.001) were independently associated with improved glucose control. Adrenalectomy (OR = 2.27, 95% CI = 0.87-5.94, P = 0.095) and hypertension (OR = 10.77, 95% CI = 3.65-31.81, P < 0.001) demonstrated associations with improved BP control. CONCLUSIONS adrenalectomy improved weight, glucose, and BP control in patients with MACS.
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Affiliation(s)
- Jung-Min Koh
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Keeho Song
- Department of Medicine, Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Mi Kyung Kwak
- Department of Medicine, Division of Endocrinology and Metabolism, Hallym University Dongtan Sacred Heart Hospital, Dongtan, Korea
| | - Sunghwan Suh
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Beom-Jun Kim
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Department of Medicine, Division of Endocrinology and Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Department of Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Favero V, Eller-Vainicher C, Morelli V, Cairoli E, Salcuni AS, Scillitani A, Corbetta S, Casa SD, Muscogiuri G, Persani L, Chiodini I. Increased Risk of Vertebral Fractures in Patients With Mild Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2024; 109:e623-e632. [PMID: 37738555 PMCID: PMC10795935 DOI: 10.1210/clinem/dgad560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/07/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
CONTEXT The risk of vertebral fractures (VFx) in patients with adrenal incidentalomas (AI) and mild autonomous cortisol secretion (MACS) is debated. OBJECTIVE To evaluate the VFx prevalence and incidence in patients with AI and MACS. METHODS This cross-sectional and longitudinal study using retrospective data from 4 Italian endocrinology units included 444 patients (cross-sectional arm) and 126 patients (longitudinal arm, 24.9 ± 5.3 months follow-up) to evaluate prevalent and incident VFx, respectively, in patients with MACS (MACS-yes) and without MACS (MACS-no). The main outcome measures were serum cortisol after a 1-mg dexamethasone test (F-1mgDST), bone mineral density (BMD) by dual-energy x-ray absorptiometry at spine (LS) and femur (FN), and VFx presence by x-ray. RESULTS Cross-sectional arm: 214 and 230 patients were MACS-yes and MACS-no, respectively, based on F-1mgDST >1.8 µg/dL (50 nmol/L). Patients with MACS had higher VFx prevalence (62.6%) than those without MACS (22.9%, P < .001); MACS was associated with prevalent VFx (odds ratio, 5.203; 95% CI, 3.361-8.055; P < .001; relative risk [RR] 2.07), regardless of age, body mass index, gender distribution, LS-BMD, and presence of type 2 diabetes mellitus (T2D). Longitudinal arm: 66 and 60 patients were MACS-no and MACS-yes, respectively. Patients without MACS showed higher number of incident VFx (36.4%) than patients without MACS (10.0%, P < .001); MACS was associated with the presence of an incident VFx (RR 4.561; 95% CI, 1.600-13.003; P = .005) regardless of age, LS-BMD, gender distribution, presence of prevalent VFx, and T2D. Results were confirmed in women and men when separately evaluated. CONCLUSION Women and men with AI and MACS are at higher risk of VFx.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Valentina Morelli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Elisa Cairoli
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Antonio Stefano Salcuni
- Unit of Endocrinology and Metabolism, University-Hospital S. Maria Della Misericordia, 33100 Udine, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology, “Casa Sollievo della Sofferenza,” Hospital, IRCCS, San Giovanni Rotondo, 71013 Foggia, Italy
| | - Sabrina Corbetta
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20100 Milan, Italy
| | - Silvia Della Casa
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, 00100 Rome, Italy
| | - Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Unità di Endocrinologia, Andrologia e Diabetologia - University of Naples “Federico II”, 80131 Naples, Italy
- UNESCO Chair “Education for Health and Sustainable Development”, University of Naples “Federico II”, 80131 Naples, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Endocrinology Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy
- Unit of Endocrinology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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Hackett RA, Jackson SE, Corker E, Steptoe A. The role of stress and health behaviour in linking weight discrimination and health: a secondary data analysis in England. BMJ Open 2023; 13:e072043. [PMID: 37709322 PMCID: PMC10503332 DOI: 10.1136/bmjopen-2023-072043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE To examine the role of stress and health-risk behaviours in relationships between weight discrimination and health and well-being. DESIGN Secondary data analysis of an observational cohort study. SETTING The English Longitudinal Study of Ageing. PARTICIPANTS Data were from 4341 adults (≥50 years) with overweight/obesity. PRIMARY OUTCOME MEASURES We tested associations between perceived weight discrimination at baseline (2010/2011) and self-rated health, limiting long-standing illness, depressive symptoms, quality of life and life satisfaction over 4-year follow-up (2010/2011; 2014/2015). Potential mediation by stress exposure (hair cortisol) and health-risk behaviours (smoking, physical inactivity, alcohol consumption) was assessed. RESULTS Cross-sectionally, perceived weight discrimination was associated with higher odds of fair/poor self-rated health (OR=2.05 (95% CI 1.49 to 2.82)), limiting long-standing illness (OR=1.76 (95% CI 1.29 to 2.41)) and depressive symptoms (OR=2.01 (95% CI 1.41 to 2.85)) and lower quality of life (B=-5.82 (95% CI -7.01 to -4.62)) and life satisfaction (B=-2.36 (95% CI -3.25 to -1.47)). Prospectively, weight discrimination was associated with higher odds of fair/poor self-rated health (OR=1.63 (95% CI 1.10 to 2.40)) and depressive symptoms (OR=2.37 (95% CI 1.57 to 3.60)) adjusting for baseline status. Those who reported discrimination had higher hair cortisol concentrations (B=0.14 (95% CI 0.03 to 0.25)) and higher odds of physical inactivity (OR=1.90 (95% CI 1.18 to 3.05)). These variables did not significantly mediate associations between discrimination and health outcomes. CONCLUSIONS Weight discrimination is associated with poor health and well-being. While this discrimination is associated with stress exposure and physical inactivity, these variables explain little of the association between discrimination and poorer outcomes.
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Affiliation(s)
- Ruth A Hackett
- Health Psychology Section, Department of Psychology, King's College London, London, UK
| | - Sarah E Jackson
- Department of Behavioural Science and Health, University College London, London, UK
| | - Elizabeth Corker
- Clinical, Educational and Health Psychology, University College London, London, UK
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, UK
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Favero V, Aresta C, Parazzoli C, Cairoli E, Eller-Vainicher C, Palmieri S, Salcuni AS, Arosio M, Persani L, Scillitani A, Morelli V, Chiodini I. The degree of cortisol secretion is associated with diabetes mellitus and hypertension in patients with nonfunctioning adrenal tumors. Cardiovasc Diabetol 2023; 22:102. [PMID: 37131218 PMCID: PMC10155432 DOI: 10.1186/s12933-023-01836-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/16/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Similarly to cortisol-secreting adrenal tumors, also non-functioning adrenal tumors (NFAT) may be associated with an increased cardiovascular risk. We assessed in NFAT patients: (i) the association between hypertension (HT), diabetes mellitus (DM), obesity (OB), dyslipidemia (DL) and cardiovascular events (CVE) and cortisol secretion; (ii) the cut-off of the cortisol secretion parameters for identifying NFAT patients with a worse cardiometabolic profile. PATIENTS AND METHODS In 615 NFAT patients (with cortisol levels after 1 mg overnight dexamethasone suppression test, F-1mgDST < 1.8 µg/dL [50 nmol/L]) F-1mgDST and adrenocorticotroph hormone (ACTH) levels and data on HT, DM, OB, DL and CVEs prevalence were retrospectively collected. RESULTS HT, DM and HT plus DM were associated with F-1mgDST levels (area under the ROC curve: 0.588 ± 0.023, 0.610 ± 0.028, 0.611 ± 0.033, respectively, p < 0.001 for all comparisons) but not with ACTH. The cut-off for identifying patients with either HT or DM or HT plus DM was set at ≥ 1.2 µg/dL (33 nmol/L). As compared with patients with F-1mgDST < 1.2 µg/dL (n = 289), patients with F-1mgDST 1.2-1.79 µg/dL (33-49.4 nmol/L) (n = 326) had lower ACTH levels (17.7 ± 11.9 vs 15.3 ± 10.1 pg/mL, respectively, p = 0.008), older age (57.5 ± 12.3 vs 62.5 ± 10.9 years, respectively, p < 0.001), and higher prevalence of HT (38.1% vs 52.5% respectively p < 0.001), DM (13.1% vs 23.3%, respectively, p = 0.001), HT plus DM (8.3% vs 16.9%, respectively, p < 0.002) and CVE (3.2% vs 7.3%, respectively, p = 0.028). F-1mgDST 1.2-1.79 µg/dL was associated with either HT (odd ratio, OR, 1.55, 95% confidence interval, 95% CI 1.08-2.23, p = 0.018) or DM (OR 1.60, 95% CI 1.01-2.57, p = 0.045) after adjusting for age, gender, OB, DL, and DM (for HT) or HT (for DM), and with the presence of HT plus DM (OR 1.96, 95% CI 1.12-3.41, p = 0.018) after adjusting for age, gender, OB and DL. CONCLUSIONS In NFAT patients, F-1mgDST 1.2-1.79 µg/dL seems to be associated with a higher prevalence of HT and DM and a worse cardiometabolic profile, even if the poor accuracy of these associations suggests caution in interpreting these results.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Carmen Aresta
- Endocrinology Department & Lab of Endocrine and Metabolic Research, IRCCS - Istituto Auxologico Italiano, Milan, Italy
| | - Chiara Parazzoli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Elisa Cairoli
- Endocrinology Department & Lab of Endocrine and Metabolic Research, IRCCS - Istituto Auxologico Italiano, Milan, Italy
| | | | - Serena Palmieri
- Unit of Endocrinology, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Stefano Salcuni
- Unit of Endocrinology and Metabolism, University-Hospital S. Maria Della Misericordia, Udine, Italy
| | - Maura Arosio
- Unit of Endocrinology, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Endocrinology Department & Lab of Endocrine and Metabolic Research, IRCCS - Istituto Auxologico Italiano, Milan, Italy
| | - Alfredo Scillitani
- Ospedale "Casa Sollievo della Sofferenza" IRCCS, San Giovanni Rotondo, FG, Italy
| | - Valentina Morelli
- Endocrinology Department & Lab of Endocrine and Metabolic Research, IRCCS - Istituto Auxologico Italiano, Milan, Italy.
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Unit of Endocrinology, Ospedale Niguarda Cà Granda, Milan, Italy
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Sulu C, Koca O, Icli TB, Oz A, Kargin OA, Durcan E, Sahin S, Arslan S, Turan S, Kadioglu P, Ozkaya HM. Altered thalamic volume in patients with mild autonomous cortisol secretion: a structural brain MRI study. Neuroradiology 2023; 65:1037-1051. [PMID: 37121916 DOI: 10.1007/s00234-023-03156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE To compare thalamic volume and cognitive functions of patients with mild autonomous cortisol secretion (MACS) with control subjects and patients with overt Cushing's syndrome (CS). METHODS In this cross-sectional study, volumes of regions of interest were assessed using 3 T magnetic resonance imaging and a voxel-based morphometry approach in 23 patients with MACS, 21 patients with active CS, 27 patients with CS in remission, and 21 control subjects. Cognitive functions were assessed using validated questionnaires. RESULTS Patients with MACS had smaller left thalamic (F = 3.8, p = 0.023), left posterior thalamic (F = 4.9, p = 0.01), left medial thalamic (F = 4.7, p = 0.028), and right lateral thalamic (F = 4.1, p = 0.025) volumes than control subjects. Patients with active CS also had smaller left thalamic (F = 3.8, p = 0.044), left posterior thalamic (F = 4.9, p = 0.007), left medial thalamic (F = 4.7, p = 0.006), and right lateral thalamic (F = 4.1, p = 0.042) volumes compared to controls. Patients with CS in remission had smaller left medial (F = 4.7, p = 0.030) and right lateral thalamic (F = 4.1, p = 0.028) volumes than controls. Neuropsychological tests showed no difference between the groups. CONCLUSION MACS may decrease thalamic volume.
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Affiliation(s)
- Cem Sulu
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Oguzhan Koca
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Tevhide Betul Icli
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Ahmet Oz
- Department of Radiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Osman Aykan Kargin
- Department of Radiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | | | - Serdar Sahin
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Serdar Arslan
- Department of Radiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Senol Turan
- Department of Psychiatry, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Hande Mefkure Ozkaya
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Türkiye.
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Türkiye.
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Araujo-Castro M, García Cano AM, Escobar-Morreale HF, Valderrabano P. Predictive model for autonomous cortisol secretion development in non-functioning adrenal incidentalomas. Hormones (Athens) 2023; 22:51-59. [PMID: 36279032 DOI: 10.1007/s42000-022-00406-6] [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: 01/06/2022] [Accepted: 10/07/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to develop a predictive model able to stratify patients with non-functioning adrenal incidentalomas (AIs), according to their risk for developing autonomous cortisol secretion (ACS) during follow-up. METHODS This was a retrospective study of patients with non-functioning AIs consecutively evaluated at a single institution between 2013 and 2019 in whom hormonal follow-up information was available for at least 1 year. Clinical, biochemical, and radiological features were used to build a multivariate Cox regression model using the estimation of all possible equations. RESULTS We included 331 patients with non-functioning AIs. ACS (post-dexamethasone suppression test (DST) serum cortisol > 1.8 µg/dL) developed in 73 patients during a median follow-up time of 35.7 months [range 12.8-165.4]. The best predictive model for ACS development during follow-up combined age, post-DST serum cortisol, and bilaterality at presentation and showed good diagnostic accuracy (AUC-ROC 0.70 [95% CI 0.65-0.75]). The lowest risk for ACS development was found among patients < 50 years old with cortisol post-DST values < 0.45 µg/dL and with unilateral tumors (risk 2.42%). Baseline post-DST serum cortisol levels at diagnosis were the most important factor for the development of ACS during follow-up (hazard ratio 3.56 for each µg/dL, p < 0.001). The rate of ACS development was associated with post-DST cortisol levels, being 19.2, 32.3, and 68.1 cases/10,000 person-years for patients with baseline post-DST cortisol < 0.9 µg/dL, 0.9-1.3 µg/dL, and > 1.3 µg/dL, respectively. CONCLUSION After ruling out malignancy, follow-up visits for patients < 50 years old with unilateral non-functioning AIs and post-DST serum cortisol < 0.45 µg/dL are considered unnecessary given the low risk of developing ACS during follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
- Universidad de Alcalá, Madrid, Spain.
| | - Ana M García Cano
- Department of Biochemistry, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas, Madrid, Spain
| | - Pablo Valderrabano
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
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9
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Johnson PC, Thompson SM, Adamo D, Fleming CJ, Bancos I, McKenzie TJ, Cheville J, Young WF, Andrews JC. Adrenal venous sampling for lateralization of cortisol hypersecretion in patients with bilateral adrenal masses. Clin Endocrinol (Oxf) 2023; 98:177-189. [PMID: 36263687 DOI: 10.1111/cen.14833] [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: 04/13/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the role of adrenal venous sampling (AVS) in guiding the management of patients with corticotropin (ACTH)-independent glucocorticoid secretory autonomy and bilateral adrenal masses. DESIGN AND PATIENTS A cohort with 25 patients underwent AVS and surgical management. MEASUREMENTS Cortisol was measured from the adrenal veins (AVs) and inferior vena cava (IVC). AV/IVC cortisol ratio and cortisol lateralization ratio (CLR) (dominant AV cortisol concentration divided by the nondominant AV cortisol concentration) were calculated. Posthoc receiver-operating characteristic curves were generated to determine the specificity of revised AV/IVC cortisol ratio and CLR in differentiating unilateral from bilateral disease. RESULTS Patients underwent unilateral (n = 21) or bilateral (n = 4) adrenalectomy. The mean AV/IVC cortisol ratio for unilateral adrenalectomy was 12.1 ± 9.6 (dominant) and 4.7 ± 3.8 (contralateral) with a mean CLR of 3.6 ± 3.5. The mean AV/IVC cortisol ratio for bilateral adrenalectomy was 7.5 ± 2.1, with a mean CLR of 1.1 ± 0.6. At a mean follow-up of 22 months, one patient who underwent unilateral adrenalectomy for the predicted bilateral disease developed recurrent mild autonomous cortisol secretion. Posthoc analyses demonstrated a specificity of 95%-100% for unilateral disease with AV/IVC cortisol ratio >9 for one side, <2.0 for the opposite side and a CLR > 2.3. The specificity was 80%-90% for bilateral disease with AV/IVC cortisol ratio >5.1 bilaterally and a CLR < 1.1. CONCLUSIONS Among patients with bilateral adrenal masses and ACTH-independent autonomous cortisol secretion, AVS can distinguish between unilateral and bilateral disease with high specificity and may guide surgical management.
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Affiliation(s)
- Paige C Johnson
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott M Thompson
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Adamo
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad J Fleming
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis J McKenzie
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - James C Andrews
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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10
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Kalara N, Manzano A. Mifepristone-Induced Hypothyroidism. J Investig Med High Impact Case Rep 2023; 11:23247096231191874. [PMID: 37565673 PMCID: PMC10422905 DOI: 10.1177/23247096231191874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/05/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023] Open
Abstract
Medications are known to affect the thyroid physiology and are a known cause of hypothyroidism. There is an ever-growing list of medications that affect the thyroid by 1 or more mechanisms. Mifepristone is presently used for the treatment of mild autonomous cortisol secretion (MACS). Hypothyroidism is not a known side effect of this medication. We present a 71-year-old woman with newly diagnosed impaired fasting glucose, dyslipidemia, and osteopenia presenting with a 3-year history of unintentional 15-pound weight gain (despite exercise and a good diet) and increased anxiety. Her physical examination was pertinent for mild lower extremity edema, easy bruising, and skin thinning. Workup revealed adrenocorticotropic hormone (ACTH)-independent MACS from bilateral micronodular hyperplasia of the adrenals. Since she was not a surgical candidate, medical management with mifepristone was chosen. While on mifepristone, she complained of excessive fatigue, a workup done revealed new-onset hypothyroidism. Given her symptoms and bloodwork, she was started on levothyroxine. After stopping mifepristone, she was biochemically and clinically euthyroid and was eventually off levothyroxine. The mechanism by which mifepristone induces hypothyroidism is unknown. Except for a multicenter case series suggesting that mifepristone increases thyroid hormone requirements in patients with central hypothyroidism, to the best of our knowledge, the literature on euthyroid patients developing hypothyroidism secondary to mifepristone is scarce. In conclusion, while the hypothyroidism seems reversible our case highlights the importance of getting baseline thyroid function tests (TFTs) and repeating them while on the medication. Treatment of hypothyroidism is based on symptoms and bloodwork.
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Affiliation(s)
- Niketa Kalara
- Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Alex Manzano
- Mount Sinai Medical Center, Miami Beach, Florida, USA
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11
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Chang YY, Lee BC, Chen ZW, Tsai CH, Chang CC, Liao CW, Pan CT, Peng KY, Chou CH, Lu CC, Wu VC, Hung CS, Lin YH. Cardiovascular and metabolic characters of KCNJ5 somatic mutations in primary aldosteronism. Front Endocrinol (Lausanne) 2023; 14:1061704. [PMID: 36950676 PMCID: PMC10025475 DOI: 10.3389/fendo.2023.1061704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is the leading cause of curable endocrine hypertension, which is associated with a higher risk of cardiovascular and metabolic insults compared to essential hypertension. Aldosterone-producing adenoma (APA) is a major cause of PA, which can be treated with adrenalectomy. Somatic mutations are the main pathogenesis of aldosterone overproduction in APA, of which KCNJ5 somatic mutations are most common, especially in Asian countries. This article aimed to review the literature on the impacts of KCNJ5 somatic mutations on systemic organ damage. EVIDENCE ACQUISITION PubMed literature research using keywords combination, including "aldosterone-producing adenoma," "somatic mutations," "KCNJ5," "organ damage," "cardiovascular," "diastolic function," "metabolic syndrome," "autonomous cortisol secretion," etc. RESULTS APA patients with KCNJ5 somatic mutations are generally younger, female, have higher aldosterone levels, lower potassium levels, larger tumor size, and higher hypertension cure rate after adrenalectomy. This review focuses on the cardiovascular and metabolic aspects of KCNJ5 somatic mutations in APA patients, including left ventricular remodeling and diastolic function, abdominal aortic thickness and calcification, arterial stiffness, metabolic syndrome, abdominal adipose tissue, and correlation with autonomous cortisol secretion. Furthermore, we discuss modalities to differentiate the types of mutations before surgery. CONCLUSION KCNJ5 somatic mutations in patients with APA had higher left ventricular mass (LVM), more impaired diastolic function, thicker aortic wall, lower incidence of metabolic syndrome, and possibly a lower incidence of concurrent autonomous cortisol secretion, but better improvement in LVM, diastolic function, arterial stiffness, and aortic wall thickness after adrenalectomy compared to patients without KCNJ5 mutations.
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Affiliation(s)
- Yi-Yao Chang
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Graduate Institute of Medicine, Yuan Ze University, Taoyuan, Taiwan
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Cheng-Hsuan Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Che-Wei Liao
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chien-Ting Pan
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Kang-Yung Peng
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Hung Chou
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- *Correspondence: Yen-Hung Lin,
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12
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Vosseler A, Machann J, Fritsche L, Prystupa K, Kübler C, Häring HU, Birkenfeld AL, Stefan N, Peter A, Fritsche A, Wagner R, Heni M. Interscapular fat is associated with impaired glucose tolerance and insulin resistance independent of visceral fat mass. Obesity (Silver Spring) 2022; 30:2233-2241. [PMID: 36192827 DOI: 10.1002/oby.23554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Dysregulated body fat distribution is a major determinant of various diseases. In particular, increased visceral fat mass and ectopic lipids in the liver are linked to metabolic disorders such as insulin resistance and type 2 diabetes. Furthermore, interscapular fat is considered to be a metabolically active fat compartment. METHODS This study measured interscapular fat mass and investigated its relationship with glucose metabolism in 822 individuals with a wide range of BMI values and different glucose tolerance statuses. Magnetic resonance imaging was used to quantify body fat depots, and an oral glucose tolerance test was performed to determine glucose metabolism. RESULTS Elevated interscapular fat mass was positively associated with age, BMI, and total body, visceral, and subcutaneous adipose tissue mass. High interscapular fat mass associated with elevated fasting glucose levels, glucose levels at 2 hours during the oral glucose tolerance test, glycated hemoglobin, and insulin resistance, independent of sex, age, and total body and visceral fat mass. CONCLUSIONS In conclusion, interscapular fat might be a highly specific fat compartment with a potential impact on glucose metabolism and the pathogenesis of diabetes mellitus.
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Affiliation(s)
- Andreas Vosseler
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Jürgen Machann
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Section of Experimental Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany
| | - Louise Fritsche
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Katsiaryna Prystupa
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Kübler
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Hans-Ulrich Häring
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Andreas L Birkenfeld
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Norbert Stefan
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Andreas Peter
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Fritsche
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Robert Wagner
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Heni
- Department of Internal Medicine, Division of Diabetology, Endocrinology and Nephrology, University Hospital Tübingen, Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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13
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Liu MS, Lou Y, Chen H, Wang YJ, Zhang ZW, Li P, Zhu DL. Performance of DHEAS as a Screening Test for Autonomous Cortisol Secretion in Adrenal Incidentalomas: A Prospective Study. J Clin Endocrinol Metab 2022; 107:e1789-e1796. [PMID: 35137142 DOI: 10.1210/clinem/dgac072] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Autonomous cortisol secretion (ACS) affects up to 30% of patients with adrenal incidentalomas (AIs). The current guidelines for ACS diagnosis are not decisive. A lower dehydroepiandrosterone sulfate (DHEAS) level is a potential biomarker, but the evidence is conflicting. OBJECTIVE This prospective study aimed to evaluate and validate the ACS screening and diagnostic accuracy of DHEAS. METHODS AND PATIENTS Recruited patients with AI were screened for adrenal medullary and cortisol hypersecretion. The diagnosis of ACS was based on a serum cortisol level ≥ 50 nmol/L following a 1-mg dexamethasone suppression test (DST) and a low-dose DST. Age- and sex-specific DHEAS ratios were also calculated. RESULTS In the development cohort (45 ACS and 242 non-ACS patients), the areas under the receiver operator characteristic curves (AUCs) of DHEAS and the DHEAS ratio were 0.869 (95% CI 0.824-0.906) and 0.799 (95% CI 0.748-0.844), respectively. The optimal DHEAS cutoff for diagnosing ACS was 60 μg/dL, with a sensitivity of 75.6% (95% CI 60.5-87.1) and a specificity of 81.4% (95% CI 76.4-86.5). The midnight serum cortisol level had moderate diagnostic accuracy [AUC 0.875 (95% CI 0.831-0.911)]. Suppressed adrenocorticotropic hormone (≤2.2 pmol/L) had a lower sensitivity (55.6%), and the 24-hour urinary free cortisol lacked sensitivity and specificity [AUC 0.633 (95% CI 0.603-0.721)]. In the validation cohort (14 ACS and 45 non-ACS patients), the sensitivity and specificity of the optimized DHEAS cutoff were 71.4% (95% CI 41.9-91.6) and 82.2% (95% CI 68.0-92.0), respectively. CONCLUSIONS A single basal measurement of DHEAS is valuable for identifying ACS. Because of its stability and ease of use, the DHEAS level could be used as an ACS screening test.
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Affiliation(s)
- Meng-Si Liu
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, People's Republic of China
- Department of Endocrinology, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, People's Republic of China
| | - Yuan Lou
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, People's Republic of China
| | - Huan Chen
- Department of Endocrinology, Nanjing Drum Tower Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Nanjing, People's Republic of China
| | - Yi-Jie Wang
- Department of Endocrinology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, People's Republic of China
| | - Zi-Wei Zhang
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, People's Republic of China
| | - Ping Li
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, People's Republic of China
- Department of Endocrinology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, People's Republic of China
| | - Da-Long Zhu
- Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, People's Republic of China
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14
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Rege J, Hoxie J, Liu CJ, Cash MN, Luther JM, Gellert L, Turcu AF, Else T, Giordano TJ, Udager AM, Rainey WE, Nanba K. Targeted Mutational Analysis of Cortisol-Producing Adenomas. J Clin Endocrinol Metab 2022; 107:e594-e603. [PMID: 34534321 PMCID: PMC8764218 DOI: 10.1210/clinem/dgab682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Somatic gene mutations have been identified in only about half of cortisol-producing adenomas (CPAs). Affected genes include PRKACA, GNAS, PRKAR1A, and CTNNB1. OBJECTIVE This work aims to expand our understanding of the prevalence of somatic mutations in CPAs from patients with overt Cushing syndrome (OCS) and "subclinical" mild autonomous cortisol excess (MACE), with an immunohistochemistry (IHC)‒guided targeted amplicon sequencing approach using formalin-fixed paraffin-embedded (FFPE) tissue. METHODS We analyzed FFPE adrenal tissue from 77 patients (n = 12 men, 65 women) with either OCS (n = 32) or MACE (n = 45). Using IHC for 17α-hydroxylase/17,20-lyase (CYP17A1) and 3β-hydroxysteroid dehydrogenase (HSD3B2), we identified 78 CPAs (32 OCS CPAs and 46 MACE CPAs). Genomic DNA was isolated from the FFPE CPAs and subjected to targeted amplicon sequencing for identification of somatic mutations. RESULTS Somatic mutations were identified in 71.8% (56/78) of the CPAs. While PRKACA was the most frequently mutated gene in OCS CPAs (14/32, 43.8%), somatic genetic aberrations in CTNNB1 occurred in 56.5% (26/46) of the MACE CPAs. Most GNAS mutations were observed in MACE CPAs (5/7, 71.4%). No mutations were observed in PRKAR1A. In addition to the known mutations, we identified one previously unreported mutation in PRKACA. Two patients with MACE harbored 2 adjacent tumors within the same adrenal gland - one patient had 2 CPAs, and the other patient had a CPA and an aldosterone-producing adenoma (identified by IHC for aldosterone synthase). CONCLUSION A comprehensive FFPE IHC-guided gene-targeted sequencing approach identified somatic mutations in 71.8% of the CPAs. OCS CPAs demonstrated a distinct mutation profile compared to MACE CPAs.
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Affiliation(s)
- Juilee Rege
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jessie Hoxie
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Chia-Jen Liu
- Department of Pathology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Morgan N Cash
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - James M Luther
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Lan Gellert
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Thomas J Giordano
- Department of Pathology, University of Michigan, Ann Arbor, Michigan 48109, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan 48109, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Aaron M Udager
- Department of Pathology, University of Michigan, Ann Arbor, Michigan 48109, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan 48109, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109, USA
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
- Correspondence: William E. Rainey, PhD, Department of Molecular and Integrative Physiology, University of Michigan, Room 2560C, MSRB II, 1150 W Medical Center Dr, Ann Arbor, MI 48109-5622, USA.
| | - Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109, USA
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
- Kazutaka Nanba, MD, Department of Molecular and Integrative Physiology, University of Michigan, 1150 W Medical Center Dr, Ann Arbor, MI, 48109, USA; Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan.
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15
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Pathophysiology of Mild Hypercortisolism: From the Bench to the Bedside. Int J Mol Sci 2022; 23:ijms23020673. [PMID: 35054858 PMCID: PMC8775422 DOI: 10.3390/ijms23020673] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 02/07/2023] Open
Abstract
Mild hypercortisolism is defined as biochemical evidence of abnormal cortisol secretion without the classical detectable manifestations of overt Cushing’s syndrome and, above all, lacking catabolic characteristics such as central muscle weakness, adipose tissue redistribution, skin fragility and unusual infections. Mild hypercortisolism is frequently discovered in patients with adrenal incidentalomas, with a prevalence ranging between 5 and 50%. This high variability is mainly due to the different criteria used for defining this condition. This subtle cortisol excess has also been described in patients with incidentally discovered pituitary tumors with an estimated prevalence of 5%. To date, the mechanisms responsible for the pathogenesis of mild hypercortisolism of pituitary origin are still not well clarified. At variance, recent advances have been made in understanding the genetic background of bilateral and unilateral adrenal adenomas causing mild hypercortisolism. Some recent data suggest that the clinical effects of glucocorticoid (GC) exposure on peripheral tissues are determined not only by the amount of the adrenal GC production but also by the peripheral GC metabolism and by the GC sensitivity. Indeed, in subjects with normal cortisol secretion, the combined estimate of cortisol secretion, cortisone-to-cortisol peripheral activation by the 11 beta-hydroxysteroid dehydrogenase enzyme and GC receptor sensitizing variants have been suggested to be associated with the presence of hypertension, diabetes and bone fragility, which are three well-known consequences of hypercortisolism. This review focuses on the pathophysiologic mechanism underlying both the different sources of mild hypercortisolism and their clinical consequences (bone fragility, arterial hypertension, subclinical atherosclerosis, cardiovascular remodeling, dyslipidemia, glucose metabolism impairment, visceral adiposity, infections, muscle damage, mood disorders and coagulation).
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16
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Sagmeister MS, Harper L, Hardy RS. Cortisol excess in chronic kidney disease - A review of changes and impact on mortality. Front Endocrinol (Lausanne) 2022; 13:1075809. [PMID: 36733794 PMCID: PMC9886668 DOI: 10.3389/fendo.2022.1075809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023] Open
Abstract
Chronic kidney disease (CKD) describes the long-term condition of impaired kidney function from any cause. CKD is common and associated with a wide array of complications including higher mortality, cardiovascular disease, hypertension, insulin resistance, dyslipidemia, sarcopenia, osteoporosis, aberrant immune function, cognitive impairment, mood disturbances and poor sleep quality. Glucocorticoids are endogenous pleiotropic steroid hormones and their excess produces a pattern of morbidity that possesses considerable overlap with CKD. Circulating levels of cortisol, the major active glucocorticoid in humans, are determined by a complex interplay between several processes. The hypothalamic-pituitary-adrenal axis (HPA) regulates cortisol synthesis and release, 11β-hydroxysteroid dehydrogenase enzymes mediate metabolic interconversion between active and inactive forms, and clearance from the circulation depends on irreversible metabolic inactivation in the liver followed by urinary excretion. Chronic stress, inflammatory states and other aspects of CKD can disturb these processes, enhancing cortisol secretion via the HPA axis and inducing tissue-resident amplification of glucocorticoid signals. Progressive renal impairment can further impact on cortisol metabolism and urinary clearance of cortisol metabolites. Consequently, significant interest exists to precisely understand the dysregulation of cortisol in CKD and its significance for adverse clinical outcomes. In this review, we summarize the latest literature on alterations in endogenous glucocorticoid regulation in adults with CKD and evaluate the available evidence on cortisol as a mechanistic driver of excess mortality and morbidity. The emerging picture is one of subclinical hypercortisolism with blunted diurnal decline of cortisol levels, impaired negative feedback regulation and reduced cortisol clearance. An association between cortisol and adjusted all-cause mortality has been reported in observational studies for patients with end-stage renal failure, but further research is required to assess links between cortisol and clinical outcomes in CKD. We propose recommendations for future research, including therapeutic strategies that aim to reduce complications of CKD by correcting or reversing dysregulation of cortisol.
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Affiliation(s)
- Michael S. Sagmeister
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- *Correspondence: Michael S. Sagmeister,
| | - Lorraine Harper
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rowan S. Hardy
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Research into Inflammatory Arthritis Centre Versus Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- Institute of Clinical Science, University of Birmingham, Birmingham, United Kingdom
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Ouyang R, Yin Y, Wang J, Su W, Zang L, Chen K, Du J, Lyu Z, Dou J, Mu Y, Gu W. Sex Differences in Hypercortisolism and Glucose-Metabolism Disturbances in Patients with Mild Autonomous Cortisol Secretion: Findings From a Single Center in China. Front Endocrinol (Lausanne) 2022; 13:857947. [PMID: 35757395 PMCID: PMC9218075 DOI: 10.3389/fendo.2022.857947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Mild autonomous cortisol secretion (MACS) presents with a marked female preponderance, but whether the sex difference in its distribution has any relevance to the presentation and outcome of the disease is unknown. The aim of this study was therefore to compare biochemical indices of hypercortisolism and impaired glucose metabolism between male and female patients with MACS. METHOD We enrolled a total of 98 patients with autonomous/possible autonomous cortisol secretion in our study, and indices of hypercortisolism and glucose metabolism were collected and compared between the male and female patients. Logistic regression models were used to evaluate the association between sex and cortisol-secretory ability, as well as between the latter and glucose metabolism. In addition, we conducted further stratified analyses according to the degree of autonomous cortisol secretion and menopausal status. RESULTS Cortisol levels at 00:00 and 08:00 h after a 1-mg dexamethasone suppression test (DST) and low-dose DST were significantly higher in female than in male MACS patients, and the inhibition rate of 1-mg DST was lower in the women than in the men. This significant difference still remained after adjusting for age, BMI, and the course of the disease. Logistic regression analysis revealed a significant association between autonomous cortisol secretion and fasting C-peptide, as well as with the C-peptide-to-glucose ratio in females relative to male patients. In addition, stratified analyses indicated that this association was observed only among women with autonomous cortisol secretion and who were premenopausal. CONCLUSION The level of autonomic cortisol secretion in female patients with MACS was higher than in male patients, and the association between autonomous cortisol secretory ability and glucose homeostasis was only noted in patients with autonomous cortisol secretion and in premenopausal women. This phenomenon will, however, require closer follow-up.
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Affiliation(s)
- Ru Ouyang
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
- Department of Endocrinology, Sanya Central Hospital, Sanya, China
- Department of Endocrinology, Hainan Affiliated Hospital of Hainan Medical University, Hainan General Hospital, Haikou, China
| | - Yaqi Yin
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jie Wang
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
- Department of Endocrinology, Beijing Chao-yang Hospital, Beijing, China
| | - Wanlu Su
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Li Zang
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Kang Chen
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Zhaohui Lyu
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Weijun Gu,
| | - Weijun Gu
- Department of Endocrinology, the First Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
- *Correspondence: Yiming Mu, ; Weijun Gu,
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18
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Antonić T, Petrović-Mucok A, Stefanović A. Current challenges in laboratory diagnostics of autonomous cortisol secretion in adrenal incidentalomas. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-36043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Adrenal incidentalomas are unexpectedly identified adrenal masses without prior suspicion of the existence of adrenal disease. The majority of adrenal incidentalomas are benign adrenal adenomas (80-90%), and they are non-functioning adrenocortical adenomas in more than 70% of cases. Mild hypercortisolemia is the most common finding in hormonally active adrenal incidentalomas. It is defined as autonomous cortisol secretion in up to 15% of patients. Despite a lot of research that anticipated higher cardiometabolic risk in patients with autonomous cortisol secretion, there is still no clear consensus on biochemical criteria for an autonomous cortisol secretion diagnosis in patients with adrenal incidentalomas. This review delineates the advantages and limitations of different laboratory tests recommended for the diagnosis of autonomous cortisol secretion in adrenal incidentalomas.
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Ceccato F, Barbot M, Scaroni C, Boscaro M. Frequently asked questions and answers (if any) in patients with adrenal incidentaloma. J Endocrinol Invest 2021; 44:2749-2763. [PMID: 34160793 PMCID: PMC8572215 DOI: 10.1007/s40618-021-01615-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 06/14/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Adrenal incidentalomas (AIs) are incidentally discovered adrenal masses, during an imaging study undertaken for other reasons than the suspicion of adrenal disease. Their management is not a minor concern for patients and health-care related costs, since their increasing prevalence in the aging population. The exclusion of malignancy is the first question to attempt, then a careful evaluation of adrenal hormones is suggested. Surgery should be considered in case of overt secretion (primary aldosteronism, adrenal Cushing's Syndrome or pheochromocytoma), however the management of subclinical secretion is still a matter of debate. METHODS The aim of the present narrative review is to offer a practical guidance regarding the management of AI, by providing evidence-based answers to frequently asked questions. CONCLUSION The clinical experience is of utmost importance: a personalized diagnostic-therapeutic approach, based upon multidisciplinary discussion, is suggested.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy.
- Department of Neuroscience DNS, University of Padova, Padova, Italy.
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
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20
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Araujo-Castro M, Robles Lázaro C, Parra Ramírez P, García Centeno R, Gracia Gimeno P, Fernández-Ladreda MT, Sampedro Núñez MA, Marazuela M, Escobar-Morreale HF, Valderrabano P. Maximum adenoma diameter, regardless of uni- or bilaterality, is a risk factor for autonomous cortisol secretion in adrenal incidentalomas. J Endocrinol Invest 2021; 44:2349-2357. [PMID: 33683661 DOI: 10.1007/s40618-021-01539-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/17/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate differences between patients with unilateral and bilateral adrenal incidentalomas (AIs) in the prevalence of autonomous cortisol secretion (ACS) and related comorbidities. METHODS In this multicentre retrospective study, AIs ≥ 1 cm without overt hormonal excess were included in the study. ACS was defined by a post-dexamethasone suppression test (DST) serum cortisol ≥ 5.0 µg/dl, in the absence of signs of hypercortisolism. For the association of ACS with the prevalence of comorbidities, post-DST serum cortisol was also analysed as a continuous variable. RESULTS Inclusion criteria were met by 823 patients, 66.3% had unilateral and 33.7% bilateral AIs. ACS was demonstrated in 5.7% of patients. No differences in the prevalence of ACS and related comorbidities were found between bilateral and unilateral AIs (P > 0.05). However, we found that tumour size was a good predictor of ACS (OR = 1.1 for each mm, P < 0.001), and the cut-off of 25 mm presented a good diagnostic accuracy to predict ACS (sensitivity of 69.4%, specificity of 74.1%). During a median follow-up time of 31.2 (IQR = 14.4-56.5) months, the risk of developing dyslipidaemia was increased in bilateral compared with unilateral AIs (HR = 1.8, 95% CI = 1.1-3.0 but, this association depended on the tumour size observed at the end of follow-up (HR adjusted by last visit-tumour size = 0.9, 95% CI = 0.1-16.2). CONCLUSIONS Tumour size, not bilaterality, is associated with a higher prevalence of ACS. During follow-up, neither tumour size nor bilaterality were associated with the development of new comorbidities, yet a larger tumour size after follow-up explained the association of bilateral AIs with the risk of dyslipidaemia.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition. Hospital, Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS. Madrid, Madrid, Spain.
| | - C Robles Lázaro
- Department of Endocrinology and Nutrition, Hospital Virgen de la Concha, Zamora, Spain
| | - P Parra Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario la Paz, Madrid, Spain
| | - R García Centeno
- Department of Endocrinology and Nutrition, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - P Gracia Gimeno
- Department of Endocrinology and Nutrition, Hospital Royo Villanova, Zaragoza, Spain
| | - M T Fernández-Ladreda
- Department of Endocrinology and Nutrition, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - M A Sampedro Núñez
- Department of Endocrinology and Nutrition, Hospital Universitario de la Princesa, Madrid, Spain
| | - M Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de la Princesa, Madrid, Spain
| | - H F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, University of Alcalá, Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas CIBERDEM, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - P Valderrabano
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
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Favero V, Cremaschi A, Falchetti A, Gaudio A, Gennari L, Scillitani A, Vescini F, Morelli V, Aresta C, Chiodini I. Management and Medical Therapy of Mild Hypercortisolism. Int J Mol Sci 2021; 22:ijms222111521. [PMID: 34768949 PMCID: PMC8584167 DOI: 10.3390/ijms222111521] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/30/2022] Open
Abstract
Mild hypercortisolism (mHC) is defined as an excessive cortisol secretion, without the classical manifestations of clinically overt Cushing's syndrome. This condition increases the risk of bone fragility, neuropsychological alterations, hypertension, diabetes, cardiovascular events and mortality. At variance with Cushing's syndrome, mHC is not rare, with it estimated to be present in up to 2% of individuals older than 60 years, with higher prevalence (up to 10%) in individuals with uncontrolled hypertension and/or diabetes or with unexplainable bone fragility. Measuring cortisol after a 1 mg overnight dexamethasone suppression test is the first-line test for searching for mHC, and the degree of cortisol suppression is associated with the presence of cortisol-related consequences and mortality. Among the additional tests used for diagnosing mHC in doubtful cases, the basal morning plasma adrenocorticotroph hormone, 24-h urinary free cortisol and/or late-night salivary cortisol could be measured, particularly in patients with possible cortisol-related complications, such as hypertension and diabetes. Surgery is considered as a possible therapeutic option in patients with munilateral adrenal incidentalomas and mHC since it improves diabetes and hypertension and reduces the fracture risk. In patients with mHC and bilateral adrenal adenomas, in whom surgery would lead to persistent hypocortisolism, and in patients refusing surgery or in whom surgery is not feasible, medical therapy is needed. Currently, promising though scarce data have been provided on the possible use of pituitary-directed agents, such as the multi-ligand somatostatin analog pasireotide or the dopamine agonist cabergoline for the-nowadays-rare patients with pituitary mHC. In the more frequently adrenal mHC, encouraging data are available for metyrapone, a steroidogenesis inhibitor acting mainly against the adrenal 11-βhydroxylase, while data on osilodrostat and levoketoconazole, other new steroidogenesis inhibitors, are still needed in patients with mHC. Finally, on the basis of promising data with mifepristone, a non-selective glucocorticoid receptor antagonist, in patients with mild cortisol hypersecretion, a randomized placebo-controlled study is ongoing for assessing the efficacy and safety of relacorilant, a selective glucocorticoid receptor antagonist, for patients with mild adrenal hypercortisolism and diabetes mellitus/impaired glucose tolerance and/or uncontrolled systolic hypertension.
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Affiliation(s)
- Vittoria Favero
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Arianna Cremaschi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, 95123 Catania, Italy;
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy;
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology “Casa Sollievo della Sofferenza” Hospital, IRCCS, 71013 San Giovanni Rotondo (FG), Italy;
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. M. Misericordia of Udine, 33100 Udine, Italy;
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
- Correspondence: ; Tel.: +39-02-61911-2738
| | - Iacopo Chiodini
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20133 Milan, Italy; (V.F.); (A.C.); (I.C.)
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, 20149 Milan, Italy;
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22
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Oda S, Ashida K, Uchiyama M, Sakamoto S, Hasuzawa N, Nagayama A, Wang L, Nagata H, Sakamoto R, Kishimoto J, Todaka K, Ogawa Y, Nakanishi Y, Nomura M. An Open-label Phase I/IIa Clinical Trial of 11β-HSD1 Inhibitor for Cushing's Syndrome and Autonomous Cortisol Secretion. J Clin Endocrinol Metab 2021; 106:e3865-e3880. [PMID: 34143883 DOI: 10.1210/clinem/dgab450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) inhibitors demonstrate antimetabolic and antisarcopenic effects in Cushing's syndrome (CS) and autonomous cortisol secretion (ACS) patients. OBJECTIVE To confirm the efficacy and safety of S-707106 (11β-HSD1 inhibitor) administered to CS and ACS patients. DESIGN A 24-week single-center, open-label, single-arm, dose-escalation, investigator-initiated clinical trial on a database. SETTING Kyushu University Hospital, Kurume University Hospital, and related facilities. PATIENTS Sixteen patients with inoperable or recurrent CS and ACS, with mildly impaired glucose tolerance. INTERVENTION Oral administration of 200 mg S-707106 after dinner, daily, for 24 weeks. In patients with insufficient improvement in oral glucose tolerance test results at 12 weeks, an escalated dose of S-707106 (200 mg twice daily) was administered for the residual 12 weeks. MAIN OUTCOME MEASURES The rate of participants responding to glucose tolerance impairment, defined as those showing a 25% reduction in the area under the curve (AUC) of plasma glucose during the 75-g oral glucose tolerance test at 24 weeks. RESULTS S-707106 administration could not achieve the primary endpoint of this clinical trial (>20% of responsive participants). AUC glucose decreased by -7.1% [SD, 14.8 (90% CI -14.8 to -1.0), P = 0.033] and -2.7% [14.5 (-10.2 to 3.4), P = 0.18] at 12 and 24 weeks, respectively. S-707106 administration decreased AUC glucose significantly in participants with a high body mass index. Body fat percentage decreased by -2.5% [1.7 (-3.3 to -1.8), P < 0.001] and body muscle percentage increased by 2.4% [1.6 (1.7 to 3.1), P < 0.001]. CONCLUSIONS S-707106 is an effective insulin sensitizer and antisarcopenic and antiobesity medication for these patients.
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Affiliation(s)
- Satoko Oda
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
| | - Kenji Ashida
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume-city, Japan
| | - Makiko Uchiyama
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka-city, Japan
| | - Shohei Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
| | - Nao Hasuzawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume-city, Japan
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume-city, Japan
| | - Lixiang Wang
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
- Department of Medical Biochemistry, Kurume University School of Medicine, Kurume-city, Japan
| | - Hiromi Nagata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
| | - Ryuichi Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
| | - Junji Kishimoto
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka-city, Japan
| | - Koji Todaka
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka-city, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
| | - Yoichi Nakanishi
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka-city, Japan
| | - Masatoshi Nomura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-city, Japan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume-city, Japan
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23
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Inoue K, Horwich T, Bhatnagar R, Bhatt K, Goldwater D, Seeman T, Watson KE. Urinary Stress Hormones, Hypertension, and Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis. Hypertension 2021; 78:1640-1647. [PMID: 34510914 DOI: 10.1161/hypertensionaha.121.17618] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Kosuke Inoue
- Department of Epidemiology, UCLA Fielding School of Public Health (K.I., T.S.).,Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Japan (K.I.)
| | - Tamara Horwich
- Division of Cardiology (T.H., D.G., K.E.W.), Department of Medicine, University of California, Los Angeles
| | - Roshni Bhatnagar
- Department of Medicine, University of California, Los Angeles (R.B., K.B.)
| | - Karan Bhatt
- Department of Medicine, University of California, Los Angeles (R.B., K.B.)
| | - Deena Goldwater
- Division of Cardiology (T.H., D.G., K.E.W.), Department of Medicine, University of California, Los Angeles.,Division of Geriatrics (D.G., T.S.), Department of Medicine, University of California, Los Angeles
| | - Teresa Seeman
- Department of Epidemiology, UCLA Fielding School of Public Health (K.I., T.S.).,Division of Geriatrics (D.G., T.S.), Department of Medicine, University of California, Los Angeles
| | - Karol E Watson
- Division of Cardiology (T.H., D.G., K.E.W.), Department of Medicine, University of California, Los Angeles
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Teuber JP, Nanba K, Turcu AF, Chen X, Zhao L, Else T, Auchus RJ, Rainey WE, Rege J. Intratumoral steroid profiling of adrenal cortisol-producing adenomas by liquid chromatography- mass spectrometry. J Steroid Biochem Mol Biol 2021; 212:105924. [PMID: 34089832 PMCID: PMC8734951 DOI: 10.1016/j.jsbmb.2021.105924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022]
Abstract
Endogenous Cushing syndrome (CS) is an endocrine disorder marked by excess cortisol production rendering patients susceptible to visceral obesity, dyslipidemia, hypertension, osteoporosis and diabetes mellitus. Adrenal CS is characterized by autonomous production of cortisol from cortisol-producing adenomas (CPA) via adrenocorticotropic hormone-independent mechanisms. A limited number of studies have quantified the steroid profiles in sera from patients with CS. To understand the intratumoral steroid biosynthesis, we quantified 19 steroids by mass spectrometry in optimal cutting temperature compound (OCT)-embedded 24 CPA tissue from patients with overt CS (OCS, n = 10) and mild autonomous cortisol excess (MACE, n = 14). Where available, normal CPA-adjacent adrenal tissue (AdjN) was also collected and used for comparison (n = 8). Immunohistochemistry (IHC) for CYP17A1 and HSD3B2, two steroidogenic enzymes required for cortisol synthesis, was performed on OCT sections to confirm the presence of tumor tissue and guided subsequent steroid extraction from the tumor. LC-MS/MS was used to quantify steroids extracted from CPA and AdjN. Our data indicated that CPA demonstrated increased concentrations of cortisol, cortisone, 11-deoxycortisol, corticosterone, progesterone, 17OH-progesterone and 16OH-progesterone as compared to AdjN (p < 0.05). Compared to OCS, MACE patient CPA tissue displayed higher concentrations of corticosterone, 18OH-corticosterone, 21-deoxycortisol, progesterone, and 17OH-progesterone (p < 0.05). These findings also demonstrate that OCT-embedded tissue can be used to define intra-tissue steroid profiles, which will have application for steroid-producing and steroid-responsive tumors.
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Affiliation(s)
- James P Teuber
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Kazutaka Nanba
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA; Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555, Japan
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Xuan Chen
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, 48109, USA
| | - Lili Zhao
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, 48109, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Richard J Auchus
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, 48109, USA; Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William E Rainey
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Juilee Rege
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA.
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Ognjanović S, Antić J, Pekmezović T, Popović B, Isailović T, Antić IB, Bogavac T, Kovačević VE, Ilić D, Opalić M, Macut D. The association of glucocorticoid receptor polymorphism with metabolic outcomes in menopausal women with adrenal incidentalomas. Maturitas 2021; 151:15-21. [PMID: 34446274 DOI: 10.1016/j.maturitas.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/21/2021] [Accepted: 06/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To investigate whether BclI polymorphism in the glucocorticoid receptor gene influences hypothalamic-pituitary-adrenal (HPA) axis regulation, body composition and metabolic parameters in women with adrenal incidentalomas (AIs). STUDY DESIGN A cross-sectional study. MAIN OUTCOME MEASURES We analyzed 106 women with AIs. Insulin resistance was assessed using a homeostasis model while HPA activity was assessed using dexamethasone suppression tests (DST), basal ACTH, urinary free cortisol, and midnight serum cortisol level. Body composition was analyzed using dual-energy X-ray absorptiometry. DNA was obtained from peripheral blood leucocytes and BclI polymorphism was detected using PCR, RFLP and DNA sequencing. RESULTS BclI carriers in comparison with those with wild-type BclI had less suppressed cortisol after DST-0.5 mg (126.4 ± 111.4 vs 80.9 ± 75.7 nmol/l, p = 0.026) and had a lower prevalence of impaired glucose tolerance and of type 2 diabetes mellitus (T2DM). BclI carriers had a higher percentage of leg fat mass (FM), lower left-sided limb muscle mass and a decline in total lean body mass. Duration of menopause remained a strong predictor of appendicular lean mass index (ALMI) (β=-0.125, p = 0.034). BclI polymorphism was significantly associated with sum of legs FM percentage (β=0.327, p = 0.048). T2DM was negatively associated with BclI polymorphism, after adjusting for age, truncal FM, ALMI, and sum of legs FM (OR=0.158, 95%CI 0.031-0.806, p = 0.027). CONCLUSIONS BclI polymorphism is associated with tissue-specific glucocorticoid sensitivity, relative glucocorticoid resistance of the HPA axis and peripheral adipose tissue, and glucocorticoid hypersensitivity at the muscle level. By modulating glucocorticoid and insulin sensitivity, BclI polymorphism appears to reduce the risk of T2DM in women with AIs.
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Affiliation(s)
- Sanja Ognjanović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jadranka Antić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Pekmezović
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bojana Popović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Isailović
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Božić Antić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tamara Bogavac
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Dušan Ilić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Belgrade, Serbia
| | - Milica Opalić
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Belgrade, Serbia
| | - Djuro Macut
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
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Giovanelli L, Aresta C, Favero V, Bonomi M, Cangiano B, Eller-Vainicher C, Grassi G, Morelli V, Pugliese F, Falchetti A, Gennari L, Scillitani A, Persani L, Chiodini I. Hidden hypercortisolism: a too frequently neglected clinical condition. J Endocrinol Invest 2021; 44:1581-1596. [PMID: 33394454 DOI: 10.1007/s40618-020-01484-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/07/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Classic Cushing's syndrome (CS) is a severe disease characterized by central obesity, hypertension, easy bruising, striae rubrae, buffalo hump, proximal myopathy and hypertricosis. However, several CS cases have also been reported with unusual or camouflaged manifestations. In recent years, several authors investigated the prevalence of "hidden hypercortisolism" (HidHyCo) among subjects affected with bone fragility, hypertension and type 2 diabetes mellitus (DM2). The prevalence of the HidHyCo is estimated to be much higher than that of classic CS. However, similarly to classic CS, HidHyCo is known to increase the risk of fractures, cardiovascular disease and mortality. METHODS We reviewed all published cases of unusual presentations of hypercortisolism and studies specifically assessing the HidHyCo prevalence in diabetic, osteoporotic and hypertensive patients. RESULTS We found 49 HidHyCo cases, in whom bone fragility, hypertension and diabetes were the presenting manifestations of an otherwise silent hypercortisolism. Amongst these cases, 34.7%, 32.7%, 6.1% and 19.0%, respectively, had bone fragility, hypertension, DM2 or hypertension plus DM2 as the sole clinical manifestations of HidHyCo. Overall, 25% of HidHyCo cases were of pituitary origin, and bone fragility was the very prevalent first manifestation among them. In population studies, it is possible to estimate that 1-4% of patients with apparent primary osteoporosis has a HidHyCo and the prevalence of this condition among diabetics ranges between 3.4 and 10%. CONCLUSION These data indicate that patients with resistant or suddenly worsening hypertension or DM2 or unexplainable bone fragility should be screened for HidHyCo using the most recently approved sensitive cut-offs.
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Affiliation(s)
- L Giovanelli
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Aresta
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - V Favero
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Bonomi
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - B Cangiano
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - G Grassi
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - F Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - A Falchetti
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
| | - L Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - A Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, FG, Italy
| | - L Persani
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - I Chiodini
- Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano, IRCCS, Via Magnasco 2, 20149, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Aresta C, Soranna D, Giovanelli L, Favero V, Parazzoli C, Gennari L, Persani L, Scillitani A, Blevins LS, Brown D, Einhorn D, Pivonello R, Pantalone KM, Jørgensen JOL, Zambon A, Chiodini I. When to suspect hidden hypercortisolism in type 2 diabetes: a meta-analysis. Endocr Pract 2021; 27:1216-1224. [PMID: 34325041 DOI: 10.1016/j.eprac.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Among patients with type 2 diabetes (T2D), the prevalence of hidden hypercortisolism (HidHyCo, formally called subclinical hypercortisolism or mild autonomous cortisol secretion) was estimated to be 2.2-12.1%. The aim of this study was to investigate whether the available literature helps to identify the characteristics of T2D patients more frequently associated with HidHyCo. METHODS A meta-analysis was performed using studies that assessed both the prevalence of HidHyCo in patients with T2D and the characteristics of these patients with and without HidHyCo. The DerSimonian and Laird (DSL) and the Hartung, Knapp, Sidik and Jonkman (HKSJ) methods were utilized. RESULTS Among the 18 available studies, 6 studies provided the necessary data. The association between HidHyCo and advanced T2D (based on the patients' description given in each study in presence of micro/ microvascular complications, or insulin treatment plus hypertension, or hypertension treated with ≥2 drugs), hypertension, insulin treatment and dyslipidemia was reported in 5 (2184 patients), 6 (2283 patients), 3 (1440 patients), and 3 (987 patients) studies, respectively. HidHyCo was associated with advanced T2D as assessed with both DSL (odds ratio, OR, 3.47, 95% Confidence Interval, 95%CI, 2.12-5.67) and HKSJ method (OR 3.60, 95%CI 2.03-6.41) and with the prevalence of hypertension or of insulin treatment as assessed by the DSL approach (OR 1.92, 95%CI 1.05-3.50 and OR 2.29, 95%CI 1.07-4.91, respectively), but not as assessed with HKSJ method. CONCLUSIONS Patients with advanced T2D have a higher prevalence of HidHyCo. These data inform about the selection of T2D patients for HidHyCo screening.
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Affiliation(s)
- Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico Italiano, Biostatistic Unit, Milan, Italy
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Chiara Parazzoli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy
| | - Lewis S Blevins
- Department of Neurosurgery, University of California San Francisco, California Center for Pituitary Disorders, San Francisco, California
| | | | - Dan Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, CA, USA
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Staff of UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | | | | | - Antonella Zambon
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy.
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Glucocorticoids: Fuelling the Fire of Atherosclerosis or Therapeutic Extinguishers? Int J Mol Sci 2021; 22:ijms22147622. [PMID: 34299240 PMCID: PMC8303333 DOI: 10.3390/ijms22147622] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 01/21/2023] Open
Abstract
Glucocorticoids are steroid hormones with key roles in the regulation of many physiological systems including energy homeostasis and immunity. However, chronic glucocorticoid excess, highlighted in Cushing's syndrome, is established as being associated with increased cardiovascular disease (CVD) risk. Atherosclerosis is the major cause of CVD, leading to complications including coronary artery disease, myocardial infarction and heart failure. While the associations between glucocorticoid excess and increased prevalence of these complications are well established, the mechanisms underlying the role of glucocorticoids in development of atheroma are unclear. This review aims to better understand the importance of glucocorticoids in atherosclerosis and to dissect their cell-specific effects on key processes (e.g., contractility, remodelling and lesion development). Clinical and pre-clinical studies have shown both athero-protective and pro-atherogenic responses to glucocorticoids, effects dependent upon their multifactorial actions. Evidence indicates regulation of glucocorticoid bioavailability at the vasculature is complex, with local delivery, pre-receptor metabolism, and receptor expression contributing to responses linked to vascular remodelling and inflammation. Further investigations are required to clarify the mechanisms through which endogenous, local glucocorticoid action and systemic glucocorticoid treatment promote/inhibit atherosclerosis. This will provide greater insights into the potential benefit of glucocorticoid targeted approaches in the treatment of cardiovascular disease.
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Pugliese F, Salcuni AS, Battista C, Carnevale V, Guglielmi G, Columbu C, Velluzzi F, Giovanelli L, Eller-Vainicher C, Scillitani A, Chiodini I. Prevalence of less severe hypercortisolism in fractured patients admitted in an outpatient clinic for metabolic bone diseases. Endocrine 2021; 73:203-208. [PMID: 33484412 DOI: 10.1007/s12020-021-02616-1] [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: 11/24/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the prevalence of less severe hypercortisolism (LSH) in fractured patients, and its association with hypertension, hyperglicemia, dyslipidemia, and obesity. METHOD From July 2015 to October 2018 we enrolled all fractured patients admitted in our outpatient center for metabolic bone diseases, after exclusion of patients with secondary osteoporosis apart from diabetes and taking drugs known to affect bone metabolism. In all enrolled patients we collected data regarding gonadal status, history of diabetes, high blood pressure, dyslipidemia, and measured blood pressure, lipid profile, fasting glycaemia. Bone mass was measured with DXA at lumbar spine and femoral neck and the presence of fractures was evaluated with X-ray of thoracic and lumbar spine. All patients performed twice, 1 mg overnight dexametasone suppression test (DST) and, as confirmatory, 2day low-dose DST for diagnosing hypercortisolism. RESULTS We enrolled 101 fractured patients (75 females, 26 males), aged 65 ± 10.3 years. Five out of 101 (5.0%) patients were diagnosed as LSH. Fifty-five (54.5%) out of 101 were hypertensive, 57 (56.4%) dyslipidemic, 17 (16.8%) hyperglicaemic, 28(27.7%) obese patients. LSH tended to be associated to blood hypertension [5/5 vs 50/96 (Fisher exact test, p = 0.06) hypertensive patients]. Four out five LSH patients were hypogonadic. CONCLUSIONS Our study confirms that a nonnegligible percentage of fractured subjects actually presents an unrecognized hypercortisolism. Accordingly, regardless of age, we suggest to screen for hypercortisolism all patients with established osteoporosis and in particular hypertensive subjects.
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Affiliation(s)
- F Pugliese
- Units of Endocrinology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy
| | - A S Salcuni
- Units of Endocrinology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy
| | - C Battista
- Units of Endocrinology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy
| | - V Carnevale
- Unit of Internal Medicine, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy
| | - G Guglielmi
- Unit of Radiology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy
| | - C Columbu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - F Velluzzi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - L Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - C Eller-Vainicher
- Unit of Endocrinology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Scillitani
- Units of Endocrinology, Ospedale "Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, FG, Italy.
| | - I Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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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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Carton T, Mathieu E, Wolff F, Bouziotis J, Corvilain B, Driessens N. Two-day low-dose dexamethasone suppression test more accurate than overnight 1-mg in women taking oral contraceptives. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00255. [PMID: 34277979 PMCID: PMC8279609 DOI: 10.1002/edm2.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 11/06/2022]
Abstract
Introduction Late-night salivary cortisol (LSaC) and 24-h urinary free cortisol measurement, and overnight 1-mg dexamethasone suppression test (1 mg-DST) are the first-line screening tests recommended for Cushing's syndrome. Through elevations in the level of cortisol-binding globulin, oral contraceptive agents lead to increases in the total plasma cortisol concentration, yielding false-positive 1 mg-DST results. Objective To compare the accuracy of the overnight 1-mg DST and two-day low-dose DST (2d-DST) in female volunteers taking combined oestrogen-progestin oral contraceptives (COCs). Methods This prospective study enrolled 30 healthy participants. Their plasma cortisol response levels were compared after the 1-mg DST and 2d-DST and classified into three categories: normal (≤50 nmol/L), doubtful (51-138 nmol/L) and abnormal (>138 nmol/L). Salivary cortisol was also measured at late night and after the DSTs. Results Following the 1-mg DST and 2d-DST, the plasma cortisol concentrations decreased to a median of 69 nmol/L and 37 nmol/L, respectively (p < 0.001). A statistically significant higher proportion of unclear or abnormal results were observed after the 1-mg DST (63%) than after the 2d-DST (27%) (p = 0.004). None of the values were >138 nmol/L after the 2d-DST, while 11% of them were abnormal after the 1-mg DST (p = 0.25). No LSaC value was abnormal. Conclusion Our results suggest that, when late-night salivary cortisol is not available, the 2d-DST could be a better screening option than the 1-mg DST for women taking oral contraceptive agents who are reluctant to stop them. This finding requires confirmation in those with a suspicion of hypercortisolism.
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Affiliation(s)
- Tiphaine Carton
- Department of Endocrinology Cliniques Universitaires de Bruxelles Hôpital Erasme Université Libre de Bruxelles (ULB) Brussels Belgium
| | - Elise Mathieu
- Department of Clinical Chemistry Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB) Université Libre de Bruxelles (ULB) Brussels Belgium
| | - Fleur Wolff
- Department of Clinical Chemistry Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB) Université Libre de Bruxelles (ULB) Brussels Belgium
| | - Jason Bouziotis
- Service de la Recherche Biomédicale Cliniques Universitaires de Bruxelles Hôpital Erasme Université Libre de Bruxelles (ULB) Brussels Belgium
| | - Bernard Corvilain
- Department of Endocrinology Cliniques Universitaires de Bruxelles Hôpital Erasme Université Libre de Bruxelles (ULB) Brussels Belgium
| | - Natacha Driessens
- Department of Endocrinology Cliniques Universitaires de Bruxelles Hôpital Erasme Université Libre de Bruxelles (ULB) Brussels Belgium
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Aouinati Y, Mjabber A, Haraj NE, Aziz SE, Chadli A. Adrenocorticotropic hormone (ACTH) independent Cushing's syndrome due to unilateral adrenocortical hyperplasia: two case reports. Pan Afr Med J 2021; 38:367. [PMID: 34367446 PMCID: PMC8308852 DOI: 10.11604/pamj.2021.38.367.26040] [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: 09/12/2020] [Accepted: 01/20/2021] [Indexed: 11/23/2022] Open
Abstract
Adrenal unilateral macronodular hyperplasia is a rare cause of Cushing's syndrome. We discuss the case of two patients who present Cushing syndrome due to unilateral adrenal hyperplasia. They presented the signs of clinical hypercorticism as well as metabolic, cardiovascular and osteoporotic complications. Both patients presented clinical and laboratory signs of adrenocorticotropic hormone (ACTH)-independent Cushing syndrome with elevated urinary free cortisol (UFC) levels, adrenal computed tomography (CT) scan revealed the appearance of unilateral adrenal adenoma and normal contralateral adrenal gland. Adrenalectomy was performed under laparoscopic surgery; the resected mass was pathologically diagnosed as unilateral nodular adrenal hyperplasia. Unilateral adrenal hyperplasia is a very rare etiology of ACTH-independent Cushing syndrome, often mistaken for adenoma on CT and only pathological examination can confirm the diagnosis.
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Affiliation(s)
- Yousra Aouinati
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Amal Mjabber
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Nassim Essabah Haraj
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Siham El Aziz
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
| | - Asmaa Chadli
- Department of Endocrinology, Diabetology and Metabolic Diseases, University Hospital Center Ibn ROCHD, Casablanca, Morocco
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Ishida A, Igarashi K, Ruike Y, Ishiwata K, Naito K, Kono S, Deguchi H, Fujimoto M, Shiga A, Suzuki S, Yoshida T, Tanaka T, Tatsuno I, Yokote K, Koide H. Association of urinary free cortisol with bone formation in patients with mild autonomous cortisol secretion. Clin Endocrinol (Oxf) 2021; 94:544-550. [PMID: 33296503 DOI: 10.1111/cen.14385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/10/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
CONTEXT Mild autonomous cortisol secretion (ACS) is associated with an increased risk of vertebral fractures (VFx). However, the influence of this condition on bone turnover or its association with mild ACS is still controversial. OBJECTIVE This study aimed to evaluate the impact of mild ACS on bone quality among patients living with the disease. DESIGN AND SETTING A retrospective study was conducted using data from 55 mild ACS and 12 nonfunctioning adrenal tumour (NFT) patients who visited Chiba University Hospital, Japan, from 2006 to 2018. PATIENTS AND MAIN OUTCOME MEASURES We analysed clinical features and bone-related factors, including bone mineral density (BMD) and VFx, performed blood tests to assess bone metabolism markers in patients with mild ACS and NFT, and assessed the associations between bone-related markers and endocrinological parameters in patients with mild ACS. RESULTS No significant differences between mild ACS and NFT patients were observed with respect to the presence or absence of VFx and BMD. Urinary free cortisol (UFC) was higher in mild ACS patients with VFx than those without (p = .037). The T-score and young adult mean (YAM) of the BMD of the femoral neck in mild ACS patients with a body mass index <25 were positively correlated with dehydroepiandrosterone sulphate levels (ρ: 0.42, p = .017; ρ: 0.40, p = .024, respectively). Pearson's correlation analysis showed that bone-specific alkaline phosphatase was negatively correlated with UFC in the patients with mild ACS (ρ: -0.37, p = .026). CONCLUSIONS These results suggest that urinary free cortisol may be useful for predicting bone formation in mild ACS patients.
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Affiliation(s)
- Akiko Ishida
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Katsushi Igarashi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Yutaro Ruike
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Kazuki Ishiwata
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Kumiko Naito
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Satomi Kono
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Hanna Deguchi
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Masanori Fujimoto
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Akina Shiga
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Sawako Suzuki
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Tomohiko Yoshida
- Department of Diabetes, Metabolism and Endocrinology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Tomoaki Tanaka
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Endocrinology, and Metabolism, Toho University Sakura Medical Center, Chiba, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
| | - Hisashi Koide
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Diabetes, Endocrinology and Metabolism, Chiba University Hospital, Chiba, Japan
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Araujo-Castro M, Valderrábano P, Escobar-Morreale HF, Hanzu FA, Casals G. Urine steroid profile as a new promising tool for the evaluation of adrenal tumors. Literature review. Endocrine 2021; 72:40-48. [PMID: 33219921 DOI: 10.1007/s12020-020-02544-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/31/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To review the literature assessing the diagnostic performance of urinary steroid profiling (USP) by high-performance liquid chromatography (LC-MS) or gas chromatography (GC) coupled to mass spectrometry (MS) in the evaluation of adrenal lesions, both in terms of functionality and malignancy. RESULTS The evaluation of adrenal incidentalomas (AI) aims to rule out malignancy and hormone excess. Current diagnostic protocols have several limitations and include time consuming and relatively complicated multi-step processes in most cases. On the contrary, USP by LC-MS/MS or LC-GC/MS offer an easy, comprehensive and non-invasive assessment of adrenal steroid secretion. USP complements current workups used in the evaluation of AIs by improving our ability to identify malignancy and/or autonomous hormone secretion. CONCLUSIONS Urine steroid profiling by LC-MS/MS and GC-MS allows a thorough, non-invasive, assessment of adrenal steroidogenesis as a whole which complement the current evaluation of AIs, and holds a promising role in the diagnosis of autonomous cortisol secretion, primary aldosteronism, and adrenal malignancy.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
| | - Pablo Valderrábano
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology & Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Felicia A Hanzu
- Department of Endocrinology & Metabolism, Hospital Clinic, Barcelona, Spain
| | - Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, Barcelona, Spain.
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Aresta C, Favero V, Morelli V, Giovanelli L, Parazzoli C, Falchetti A, Pugliese F, Gennari L, Vescini F, Salcuni A, Scillitani A, Persani L, Chiodini I. Cardiovascular complications of mild autonomous cortisol secretion. Best Pract Res Clin Endocrinol Metab 2021; 35:101494. [PMID: 33814301 DOI: 10.1016/j.beem.2021.101494] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentalomas (AI) may be associated with a mild autonomous cortisol secretion (MACS) in up to one third of cases. There is growing evidence that MACS patients actually present increased risk of cardiovascular disease and higher mortality rate, driven by increased prevalence of known cardiovascular risk factors, as well as accelerated cardiovascular remodelling. Adrenalectomy seems to have cardiometabolic beneficial effects in MACS patients but their management is still a debated topic due to the lack of high-quality studies. Several studies suggested that so called "non-functioning" AI may be actually "functioning" with an associated increased cardiovascular risk. Although the individual cortisol sensitivity and peripheral activation have been recently suggested to play a role in influencing the cardiovascular risk even in apparently eucortisolemic patients, to date the degree of cortisol secretion, as mirrored by the cortisol levels after dexamethasone suppression test remains the best predictor of an increased cardiovascular risk in AI patients. However, whether or not the currently used cut-off set at 50 nmol/L for cortisol levels after dexamethasone suppression could be considered completely reliable in ruling out hypercortisolism remains unclear.
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Affiliation(s)
- Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Vittoria Favero
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy.
| | - Luca Giovanelli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Chiara Parazzoli
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Alberto Falchetti
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy.
| | - Flavia Pugliese
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Italy.
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Antonio Salcuni
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia, Udine, Italy.
| | - Alfredo Scillitani
- Unit of Endocrinology and Diabetology "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo (FG), Italy.
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy; Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy.
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Raj R, Kern PA, Ghanta N, Uy EM, Asadipooya K. Adrenal Vein Cortisol to Metanephrine Ratio for Localizing ACTH-Independent Cortisol-Producing Adenoma: A Case Report. J Endocr Soc 2021; 5:bvab009. [PMID: 33644621 DOI: 10.1210/jendso/bvab009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 11/19/2022] Open
Abstract
Context Finding the source of adrenocorticotropic hormone (ACTH)-independent cortisol-producing adenoma in the patients with subclinical Cushing syndrome (SCS) and bilateral adrenal nodules is sometimes challenging. Computed tomography (CT) and positron emission tomography are helpful, but adrenal venous sampling (AVS) is the gold standard approach. However, interpretation of AVS is important to improve the accuracy of decision-making for surgery. We report a case and review of the literature to assess the benefit of using adrenal vein cortisol to metanephrine ratio to determine the source of cortisol production in SCS and bilateral nodules. Evidence Acquisition Three authors searched PubMed for data on patients with SCS who had AVS procedure and measurements of cortisol and catecholamines. Case Description A 51-year-old woman with SCS and hypertension crisis presented to our clinic. Paraclinical investigations revealed that she had an ACTH-independent cortisol-producing adenoma and her CT scan showed bilateral adrenal nodules. After AVS, cortisol (high to low) lateralization ratio could not determine the source of cortisol production but the cortisol to metanephrine ratio localized the source to the left side, which included the larger nodule according to CT measurements. Left adrenalectomy led to clinical and paraclinical improvement. Conclusion There is a possibility of co-secretion of other steroids accompanied with cortisol in the setting of ACTH-independent SCS. Moreover, cortisol measurement alone and interpretation of AVS results based on cortisol values may not help lateralizing the source of cortisol production with bilateral adrenal nodules. Therefore, we suggest applying cortisol to metanephrine ratio with the same gradient (gradient > 2.3, highest to lowest concentration) when the source of cortisol production cannot be determined by cortisol lateralization ratio.
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Affiliation(s)
- Rishi Raj
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Pikeville Medical Center, Pikeville, KY, USA
| | - Philip A Kern
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
| | - Neelima Ghanta
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
| | - Edilfavia M Uy
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Highlands Appalachian Regional Health Care Medical Center, Prestonsburg, KY, USA
| | - Kamyar Asadipooya
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, USA
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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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Yozamp N, Vaidya A. Assessment of mild autonomous cortisol secretion among incidentally discovered adrenal masses. Best Pract Res Clin Endocrinol Metab 2021; 35:101491. [PMID: 33593680 DOI: 10.1016/j.beem.2021.101491] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Incidentally discovered adrenal masses are common and mostly benign and non-functioning adenomas. However, evolving evidence suggests that a notable proportion of these adrenal adenomas may demonstrate mild autonomous cortisol secretion (MACS), which has been associated with an increased risk for hypertension, hyperglycemia, obesity, dyslipidemia, vertebral fractures, adverse cardiovascular events, and mortality. Therefore, it is advised that all patients with an incidentally discovered adrenal mass be tested for MACS. When there is convincing evidence for MACS, surgical adrenalectomy has been associated with an improvement in certain metabolic parameters and a reduction in vertebral fractures; however, conclusive evidence demonstrating decreased cardiovascular outcomes or mortality are not yet available. Future studies with adequate randomization and follow-up to assess adverse clinical endpoints are needed to determine the optimal management and follow-up of patients with MACS.
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Affiliation(s)
- Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Morelli V, Ghielmetti A, Caldiroli A, Grassi S, Siri FM, Caletti E, Mucci F, Aresta C, Passeri E, Pugliese F, Di Giorgio A, Corbetta S, Scillitani A, Arosio M, Buoli M, Chiodini I. Mental Health in Patients With Adrenal Incidentalomas: Is There a Relation With Different Degrees of Cortisol Secretion? J Clin Endocrinol Metab 2021; 106:e130-e139. [PMID: 33017843 PMCID: PMC7765655 DOI: 10.1210/clinem/dgaa695] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/24/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT Cushing's syndrome frequently causes mental health impairment. Data in patients with adrenal incidentaloma (AI) are lacking. OBJECTIVE We aimed to evaluate psychiatric and neurocognitive functions in AI patients, in relation to the presence of subclinical hypercortisolism (SH), and the effect of adrenalectomy on mental health. DESIGN We enrolled 62 AI patients (64.8 ± 8.9 years) referred to our centers. Subclinical hypercortisolism was diagnosed when cortisol after 1mg-dexamethasone suppression test was >50 nmol/L, in the absence of signs of overt hypercortisolism, in 43 patients (SH+). INTERVENTIONS The structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders-5, and 5 psychiatric scales were performed. The Brief Assessment of Cognition in Schizophrenia (Verbal and Working Memory, Token and Symbol Task, Verbal Fluency, Tower of London) was explored in 26 patients (≤65 years). RESULTS The prevalence of psychiatric disorders was 27.4% (SH+ 30.2% vs SH- 21.1%, P = 0.45). SH+ showed a higher prevalence of middle insomnia (by the Hamilton Depression Rating Scale) compared with SH- (51% vs 22%, P = 0.039). Considering the Sheehan Disability Scale, SH+ showed a higher disability score (7 vs 3, P = 0.019), higher perceived stress (4.2 ± 1.9 vs 2.9 ± 1.9, P = 0.015), and lower perceived social support (75 vs 80, P = 0.036) than SH-. High perceived stress was independently associated with SH (odds ratio [OR] = 5.46, confidence interval 95% 1.4-21.8, P = 0.016). Interestingly, SH+ performed better in verbal fluency (49.5 ± 38.9 vs 38.9 ± 9.0, P = 0.012), symbol coding (54.1 ± 6.7 vs 42.3 ± 15.5, P = 0.013), and Tower of London (15.1 vs 10.9, P = 0.009) than SH-. In 8 operated SH+, no significant changes were found. CONCLUSIONS Subclinical hypercortisolism may influence patients' mental health and cognitive performances, requiring an integrated treatment.
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Affiliation(s)
- Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Correspondence and Reprint Requests: Valentina Morelli, Endocrinology Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy. E-mail:
| | - Alberto Ghielmetti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Alice Caldiroli
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Grassi
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Marzia Siri
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisabetta Caletti
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Mucci
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carmen Aresta
- Unit for Bone Metabolism Diseases and Diabetes, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Elena Passeri
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Flavia Pugliese
- Unit of Endocrinology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Annabella Di Giorgio
- Liaison Psychiatric Service, Unit of Neurology, Department of Emergency and Critical Areas, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Sabrina Corbetta
- Endocrinology and Diabetology Service, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Alfredo Scillitani
- Unit of Endocrinology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Massimiliano Buoli
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Iacopo Chiodini
- Unit for Bone Metabolism Diseases and Diabetes, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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Casals G, Hanzu FA. Cortisol Measurements in Cushing's Syndrome: Immunoassay or Mass Spectrometry? Ann Lab Med 2020; 40:285-296. [PMID: 32067427 PMCID: PMC7054699 DOI: 10.3343/alm.2020.40.4.285] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 11/19/2022] Open
Abstract
Determination of cortisol levels in the urine (24 hours urine free cortisol), saliva (late-night), or serum (total cortisol after dexamethasone suppression) is recommended to screen for Cushing's syndrome (CS). This review focuses on the differences between the frequently used cortisol-antibody immunoassay-based methods and the highly specific mass-spectrometry-based methods that are progressively being employed in clinical laboratories for CS screening. The particular characteristics of cortisol metabolism and the lack of specificity of the immunoassays cause marked differences between both methods that are in turn highly dependent on the biological matrix, in which the cortisol is measured. Understanding the origin of these differences is essential for the interpretation of these results. Although cross-reactivity with endogenous steroids leads to grossly inaccurate results of immunoassay measurements of cortisol in the saliva and urine, preliminary evidence suggests that the clinical sensitivity of CS screening using immunoassays may be similar to CS screening using mass spectrometry. However, mass spectrometry offers more accurate results and considerably reduced variation across laboratories, while avoiding false-positive results. Moreover, mass spectrometry can overcome some common diagnostic challenges, such as identification of exogenous corticosteroids or simultaneous assessment of appropriate dexamethasone levels in suppression tests. Further, comprehensive mass spectrometry-based profiling of several steroid metabolites may be useful for discriminating among different subtypes of CS. Finally, this review discusses the main preanalytical factors that could cause variations in cortisol measurements and their influence on the reliability of the results.
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Affiliation(s)
- Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centrode Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), ISCIII, Madrid, Spain.
| | - Felicia Alexandra Hanzu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain.,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Kim JH, Kim MJ, Lee JH, Yoon JW, Shin CS. Nonfunctioning Adrenal Incidentalomas are not Clinically Silent: A Longitudinal Cohort Study. Endocr Pract 2020; 26:1406-1415. [PMID: 33471732 DOI: 10.4158/ep-2020-0182] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The association between nonfunctioning adrenal incidentalomas (NFAIs) and cardiometabolic diseases remains controversial. This retrospective cohort study investigated whether NFAIs are related with prevalent and incident cardiometabolic diseases. METHODS This study included 154 patients with biochemically confirmed NFAIs and 1:3 age and sex-matched controls without adrenal incidentalomas (n = 462) among subjects who underwent abdominal computed tomography at a single healthcare center in 2003-2012. Electronic medical records were reviewed for comorbidities at baseline and during a mean follow-up of 7.5 years. The logistic regression analysis for prevalent cardiometabolic diseases and the survival analysis for incident cardiometabolic diseases were performed. RESULTS The subjects were 55.7±8.8 years of age and predominantly male (73.1%). The NFAI group had a higher body mass index compared to the age and sex-matched control group (25.1±2.8 vs. 24.0±2.8 kg/m2; P<.001). In a cross-sectional design, covariate-adjusted logistic regression showed significantly higher odds ratios (ORs) for diabetes mellitus and hypertension in the NFAI group (adjusted OR [95% confidence interval [CI]], 1.89 [1.17 to 3.06] and 2.26 [1.47 to 3.50], respectively). The NFAI group had a 2-fold higher risk of insulin resistance (adjusted ORs [95% CI], 2.03 [1.06 to 3.90]). Moreover, NFAI subjects with diabetes mellitus had a greater increase in size of adrenal lesions than those without diabetes mellitus (3.4±5.5 vs. 1.4±5.5 mm; P =.048). However, in the survival analysis, the incidence of any cardiometabolic diseases did not differ between the NFAI and control groups. CONCLUSION NFAIs are related to prevalent diabetes mellitus or hypertension in our cross-sectional study. However, the presence of NFAIs did not affect the development of cardiometabolic diseases. ABBREVIATIONS ACTH = adrenocorticotropic hormone; AI = adrenal incidentaloma; BMI = body mass index; CI = confidence interval; CT = computed tomography; HbA1c = hemoglobin A1c; HOMA-IR = homeostasis model assessment of insulin resistance; HU = Hounsfield units; MACE = mild autonomous cortisol excess; NFAI = nonfunctioning adrenal incidentaloma; OR = odds ratio.
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Affiliation(s)
- Jung Hee Kim
- From the (1)Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Min Joo Kim
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea..
| | - Jung Hyun Lee
- From the (1)Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Ji Won Yoon
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Chan Soo Shin
- From the (1)Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
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Peng KY, Liao HW, Chan CK, Lin WC, Yang SY, Tsai YC, Huang KH, Lin YH, Chueh JS, Wu VC. Presence of Subclinical Hypercortisolism in Clinical Aldosterone-Producing Adenomas Predicts Lower Clinical Success. Hypertension 2020; 76:1537-1544. [PMID: 32921192 DOI: 10.1161/hypertensionaha.120.15328] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The clinical characteristics and outcomes in patients with clinical aldosterone-producing adenomas harboring KCNJ5 mutations with or without subclinical hypercortisolism remain unclear. This prospective study is aimed at determining factors associated with subclinical hypercortisolism in patients with clinical aldosterone-producing adenomas. Totally, 82 patients were recruited from November 2016 to March 2018 and underwent unilateral laparoscopic adrenalectomy with at least a 12-month follow-up postoperatively. Standard subclinical hypercortisolism (defined as cortisol >1.8 μg/dL after 1 mg dexamethasone suppression test [DST]) was detected in 22 (26.8%) of the 82 patients. Intriguingly, a generalized additive model identified the clinical aldosterone-producing adenoma patients with 1 mg DST>1.5 μg/dL had significantly larger tumors (P=0.02) than those with 1 mg DST<1.5 μg/dL. Multivariable logistic regression showed that the presence of KCNJ5 mutations (odds ratio, 0.22, P=0.010) and body mass index (odds ratio, 0.87, P=0.046) were negatively associated with 1 mg DST>1.5 μg/dL, whereas tumor size was positively associated with it (odds ratio, 2.85, P=0.014). Immunohistochemistry revealed a higher degree of immunoreactivity for CYP11B1 in adenomas with wild-type KCNJ5 (P=0.018), whereas CYP11B2 was more commonly detected in adenomas with KCNJ5 mutation (P=0.007). Patients with wild-type KCNJ5 and 1 mg DST>1.5 μg/dL exhibited the lowest complete clinical success rate (36.8%) after adrenalectomy. In conclusion, subclinical hypercortisolism is common in clinical aldosterone-producing adenoma patients without KCNJ5 mutation or with a relatively larger adrenal tumor. The presence of serum cortisol levels >1.5 μg/dL after 1 mg DST may be linked to a lower clinical complete success rate.
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Affiliation(s)
- Kang-Yung Peng
- From the Departments of Internal Medicine (K.-Y.P., S.-Y.Y., Y.-H.L., V.-C.W.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
| | | | - Chieh-Kai Chan
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu County (C.-K.C.)
| | - Wei-Chou Lin
- Department of Pathology (W.-C.L.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
| | - Shao-Yu Yang
- From the Departments of Internal Medicine (K.-Y.P., S.-Y.Y., Y.-H.L., V.-C.W.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
| | - Yao-Chou Tsai
- Department of Urology, Taipei Medical University Hospital, Taipei Medical University, Taiwan (Y.-C.T.)
| | - Kuo-How Huang
- Department of Urology (K.-H.H.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
| | - Yen-Hung Lin
- From the Departments of Internal Medicine (K.-Y.P., S.-Y.Y., Y.-H.L., V.-C.W.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
| | - Jeff S Chueh
- Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, OH (J.S.C.)
| | - Vin-Cent Wu
- From the Departments of Internal Medicine (K.-Y.P., S.-Y.Y., Y.-H.L., V.-C.W.), National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei
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Podbregar A, Janez A, Goricar K, Jensterle M. The prevalence and characteristics of non-functioning and autonomous cortisol secreting adrenal incidentaloma after patients' stratification by body mass index and age. BMC Endocr Disord 2020; 20:118. [PMID: 32736549 PMCID: PMC7395413 DOI: 10.1186/s12902-020-00599-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The escalating prevalence of adrenal incidentaloma (AI) has been associated with the improvement of radiologic techniques and widespread imaging in aging population. It is currently unclear whether patients with obesity more likely develop AI and the current rise in the prevalence of AI could be at least partly associated with the respective rise in obesity. We compared the prevalence and characteristics of non-functional (NF) and autonomous cortisol secreting (ACS) adrenal incidentalomas (AIs) after the study population was stratified by different body mass indexes (BMI) and age groups. METHODS Retrospective cross-sectional study comprising of 432 patients (40.6% male, 59.4% female) with NFAI (N = 290) and ACS (N = 142), of median age 63.4 (54.0-71.6) years and median BMI 28.6 (25.5-31.7) kg/m2. The data collection contained 11.132 points including demographic, anthropometric, radiologic, hormonal and metabolic parameters. RESULTS We observed 68-87% higher prevalence of AI across different age groups in NFAI and ACS in obese/overweight compared to normal weight subjects. Patients with ACS were older (P = 0.008), with higher basal cortisol (P < 0.001), lower basal DHEAS (P = 0.001), lower suppression DHEAS (P = 0.027) and higher aldosterone (P = 0.039). AIs with ACS were larger than NFAI (P < 0.001). Interestingly, ACS group had lower body mass (P = 0.023) and did not differ in BMI, blood pressure, heart rate, lipid profile, fasting glucose and presence of diabetes mellitus type 2 when compared to NFAI., By contrast to the similarity of metabolic profiles in ACS and NFAI, some components of adverse metabolic traits were rather associated with higher BMI and older age, in particular in NFAI. CONCLUSION The prevalence of NFAI and ACS were significantly higher in overweight/obese subgroup across the age distribution. Stratification by age and BMI displayed significant differences in some metabolic traits, in particular in NFAI.
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Affiliation(s)
- Ana Podbregar
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- University Rehabilitation Institute Republic of Slovenia, Ljubljana, Slovenia
| | - Andrej Janez
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Katja Goricar
- Pharmacogenetics Laboratory, Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Jensterle
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Ljubljana, Slovenia.
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Foster T, Bancos I, McKenzie T, Dy B, Thompson G, Lyden M. Early assessment of postoperative adrenal function is necessary after adrenalectomy for mild autonomous cortisol secretion. Surgery 2020; 169:150-154. [PMID: 32693952 DOI: 10.1016/j.surg.2020.05.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/26/2020] [Accepted: 05/27/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The diagnostic threshold for mild autonomous cortisol secretion using low dose, overnight, dexamethasone suppression testing is recognized widely as a serum cortisol ≥1.8 mcg/dL. The degree to which these patients require postoperative glucocorticoid replacement is unknown. METHODS We reviewed adult patients with corticotropin (ACTH)-independent hypercortisolism who underwent unilateral laparoscopic adrenalectomy for benign disease with a dexamethasone suppression testing ≥1.8 mcg/dL at our institution from 1996 to 2018. Patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL were compared with those with a dexamethasone suppression testing >5 mcg/dL. RESULTS We compared 68 patients with a preoperative dexamethasone suppression testing of 1.8 to 5 mcg/dL to 53 patients with a preoperative dexamethasone suppression testing >5 mcg/dL. Preoperative serum ACTH (mean 10.0 vs 9.2 pg/mL), adenoma size (mean 3.4 vs 3.5 cm), and side of adrenalectomy (37 and 47% right) were similar between groups (P > .05 each). Patients with a dexamethasone suppression testing 1.8 to 5 mcg/dL were older (mean values 58 ± 11 vs 52 ± 16 years ; P = .01), less likely to be female (63 vs 81%; P = .03), had greater body mass indexes (33.1 ± 8.4 vs 29.1 ± 5.6; P = .01), and had lesser 24 hour preoperative urine cortisol excretions (32.6 ± 26.7 vs 76.1 ± 129.4 mcg; P = .03). Postoperative serum cortisol levels were compared in 22 patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL to 14 patients with a dexamethasone suppression testing >5 mcg/dL. Those with dexamethasone suppression testing 1.8 to 5 mcg/dL had greater postoperative serum cortisol levels (8.0 ± 5.7 vs 5.0 ± 2.6 mcg/dL; P = .03), were less likely to be discharged on glucocorticoid replacement (59% vs 89%; P = .003), and had a decreased duration of treatment (4.4 ± 3.8 vs 10.7 ± 18.0 months; P = .04). CONCLUSION Assessment of early postoperative adrenal function with mild autonomous cortisol secretion is necessary to minimize unnecessary glucocorticoid replacement.
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Affiliation(s)
| | - Irina Bancos
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Benzon Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
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Inoue S, Hayashi T, Teishima J, Matsubara A. Impact of Adrenalectomy on Cortisol-Producing Adenoma: Longitudinal Evaluation of Health-Related Quality of Life following Laparoscopic Adrenalectomy. Urol Int 2020; 104:789-796. [PMID: 32645700 DOI: 10.1159/000508765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION There is increasing interest in evaluating the quality of life of patients with cortisol-producing adrenocortical adenoma (CPA). Our objective was to assess patient-reported health-related quality of life (HRQOL) in patients with CPA compared to non-CPA. METHODS Between January 2012 and September 2015, a total of 24 and 62 patients who had laparoscopic adrenalectomy with CPA and non-CPA, respectively, were included in the study. General HRQOL was evaluated on Short Form 8 (SF-8) questionnaire. The SF-8 questionnaire was administered at preoperative baseline and at 3, 6, 9, 12, 18, and 24 months after adrenalectomy. The impact of changing 2 measures of the summary score on the physical component summary (PCS) and mental component summary (MCS) score of SF-8 was evaluated in prospective and longitudinal studies. RESULTS The baseline PCS score was significantly lower in the CPA than in the non-CPA group (43.6 vs. 49.0; p = 0.0075). Thereafter, the PCS score was significantly lower in the CPA group at 3, 6, 9, and 12 months postoperatively. The PCS score increased in the CPA group with no significant difference between both groups at 18 months (48.1 vs. 50.2; p = 0.1202) and 24 months (48.0 vs. 50.8; p = 0.3625) postoperatively. However, the baseline MCS score was not significantly different between the CPA and non-CPA group. The MCS score in both groups gradually increased with no significant differences between the groups at any time points after surgery. The PCS score was not significantly improved at all postoperative points than the baseline score in the CPA and non-CPA group. The MCS score was significantly improved than the baseline score from 6 months postoperatively only in the CPA group. CONCLUSION Our research suggests that laparoscopic adrenalectomy may contribute to improving the physical and mental function in HRQOL.
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Affiliation(s)
- Shogo Inoue
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan,
| | - Tetsutaro Hayashi
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Jun Teishima
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Akio Matsubara
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
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Chiodini I, Falchetti A, Merlotti D, Eller Vainicher C, Gennari L. Updates in epidemiology, pathophysiology and management strategies of glucocorticoid-induced osteoporosis. Expert Rev Endocrinol Metab 2020; 15:283-298. [PMID: 32584619 DOI: 10.1080/17446651.2020.1772051] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Endogenous or exogenous (corticosteroid-induced) glucocorticoids (GCs) excess represents, together with diabetes, the most common cause of secondary osteoporosis. AREAS COVERED We present a comprehensive overview about the pathophysiology, clinical management and treatment of GCs induced osteoporosis (GIOP). According to PRISMA guidelines, a literature search identifying articles about bone and GCs was done. EXPERT OPINION Despite the progress over the years and the increase in therapeutic options, there still are controversial issues about the management of GIOP. These mainly include the failure of BMD or FRAX to completely account for the rapid increase in fracture risk of most GC-treated patients, the understanding about the independent contribution on bone fragility of the underlying disease requiring GCs therapy, and the necessity of clearer information about the anti-fracture efficacy and long term-safety of most therapeutic options. Moreover, there are no specific indications for the management of bone fragility in endogenous hypercortisolism. Notwithstanding the above limitations there is a general consensus to recommend an assessment of fracture risk in all individuals >40 years committed to receive (or continuing) high dose (>7.5 mg of prednisone equivalent) GCs for ≥3 months and in all patients with fragility fracture history.
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Affiliation(s)
- Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan , Italy
| | - Daniela Merlotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
| | - Cristina Eller Vainicher
- Endocrinology and Diabetology Units, Department of Medical Sciences and Community, Fondazione Ca'Granda Ospedale Maggiore Policlinico IRCCS , Milan, Italy
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena , Italy
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Eller-Vainicher C, Morelli V, Aresta C, Salcuni AS, Falchetti A, Carnevale V, Persani L, Scillitani A, Chiodini I. Defining Nonfunctioning Adrenal Adenomas on the Basis of the Occurrence of Hypocortisolism after Adrenalectomy. J Endocr Soc 2020; 4:bvaa079. [PMID: 32699828 PMCID: PMC7365697 DOI: 10.1210/jendso/bvaa079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/12/2020] [Indexed: 01/06/2023] Open
Abstract
Background In patients with adrenal incidentalomas (AIs), there is uncertainty on how to rule out hypercortisolism. The occurrence of postsurgical (unilateral adrenalectomy) hypocortisolism (PSH) has been proposed as a proof of the presence of presurgical hypercortisolism in AI patients. The aim of this study was to define the thresholds of cortisol level after the 1 mg overnight dexamethasone suppression test (F-1mgDST), urinary free cortisol (UFC), midnight serum cortisol (MSC), and adrenocorticotropin (ACTH) to predict the absence of PSH in AI patients undergoing surgery. Methods In 60 patients who underwent AI excision, cortisol secretion was assessed by a low-dose corticotropin stimulation test or insulin tolerance test when needed. We searched for the lowest presurgical value of F-1mgDST, UFC, and MSC and the highest value for ACTH in AI patients with PSH as indexes of normal cortisol secretion. Results The lowest values of F-1mgDST, UFC, and MSC and the highest value for ACTH in PSH patients were 1.2 µg/dL (33 nmol/L), 10.4 µg/24 hours (29 nmol/24 hours), 1.2 µg/dL (33 nmol/L), and 26.9 pg/mL (6 pmol/L), respectively, but only F-1mgDST <1.2 µg/dL (33 nmol/L) was able to predict the absence of PSH. Among AI patients with F-1mgDST <1.2 µg/dL (33 nmol/L) no subjects had diabetes mellitus and/or metabolic syndrome, and these subjects tended to have a better metabolic profile than those with F-1mgDST ≥1.2 µg/dL (33 nmol/L). Conclusion In AI patients a F-1mgDST <1.2 µg/dL (33 nmol/L) rules out PSH and could be used to exclude hypercortisolism in AI patients.
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Affiliation(s)
| | - Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico Milan, Italy
| | - Carmen Aresta
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
| | - Antonio Stefano Salcuni
- Endocrinology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | - Alberto Falchetti
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy
| | - Vincenzo Carnevale
- Unit of Internal Medicine, Ospedale "Casa Sollievo della soffererenza" IRCCS, San Giovanni Rotondo (FG), Italy
| | - Luca Persani
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
| | - Alfredo Scillitani
- Endocrinology and Diabetology, Ospedale "Casa Sollievo della soffererenza" IRCCS, San Giovanni Rotondo (FG), Italy
| | - Iacopo Chiodini
- Istituto Auxologico Italiano, IRCCS, Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research, Milan, Italy.,Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
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Practical guide on the initial evaluation, follow-up, and treatment of adrenal incidentalomas Adrenal Diseases Group of the Spanish Society of Endocrinology and Nutrition. ACTA ACUST UNITED AC 2020; 67:408-419. [PMID: 32349941 DOI: 10.1016/j.endinu.2020.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 12/16/2022]
Abstract
Initial evaluation of adrenal incidentalomas should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion. Our recommendation is that, except when cortisol levels <1.8μg/dL in the dexamethasone suppression test rule out diagnosis and levels ≥5μg/dL establish the presence of autonomous cortisol secretion, diagnosis should be based on a combined definition of dexamethasone suppression test ≥3μg/dL and at least one of the following: elevated urinary free cortisol, ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, dexamethasone suppression test should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism. The initial radiographic test of choice for characterization of adrenal incidentalomas is a computed tomography scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6-12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed. We think that patients with autonomous cortisol secretion with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy. The indication for unilateral adrenalectomy is clear in patients with overt hormonal syndromes or suspected malignancy. In conclusion, adrenal incidentalomas require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.
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KIRNAP NG, ÖZTEKİN S, TÜTÜNCÜ NB. Adrenal İnsidentaloma ve Otonom Kortizol Sekresyonu Vakalarının İzlemi: 14 Yıllık Tek Merkez Çalışması- Retrospektif Kohort. DICLE MEDICAL JOURNAL 2020. [DOI: 10.5798/dicletip.706119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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