Subclinical Cushing's syndrome

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

Objective

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

Background

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

Methods

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

Results

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

Conclusion

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

Unveiling the hidden impact: Subclinical hypercortisolism and its subtle influence on bone health

In recent years, advancements in imaging technologies have led to an increased detection rate of adrenal incidentalomas (AI), with age demonstrating a significant correlation with their incidence. Among the various forms of functional adrenal incidentalomas, subclinical hypercortisolism (SH) stands out as a predominant subtype. Despite the absence of typical symptoms associated with Cushing's syndrome, both domestic and international research consistently establishes a robust link between SH and diverse metabolic irregularities, including hypertension, lipid metabolism disorders, glucose metabolism abnormalities, and disruptions in bone metabolism. Individuals with SH face an elevated risk of cardiovascular events and mortality, highlighting the clinical significance of addressing this condition. Prolonged exposure to elevated cortisol levels poses a significant threat to bone health, contributing to bone loss, alterations in bone microstructure, and an increased susceptibility to fractures. However, comprehensive reviews addressing bone metabolism changes and associated mechanisms in SH patients are currently lacking. Furthermore, the profound impact of concurrent SH on the overall health of the elderly cannot be overstated. A comprehensive understanding of the skeletal health status in elderly individuals with concomitant SH is imperative. This article aims to fill this gap by offering a detailed review of bone metabolism changes and associated mechanisms in SH patients arising from AI. Additionally, it provides a forward-looking perspective on research concerning skeletal health in elderly individuals with concurrent SH.

Is Follow-up of Adrenal Incidentalomas Always Mandatory?

Adrenal masses are mainly detected unexpectedly by an imaging study performed for reasons unrelated to any suspect of adrenal diseases. Such masses are commonly defined as "adrenal incidentalomas" and represent a public health challenge because they are increasingly recognized in current medical practice. Management of adrenal incidentalomas is currently matter of debate. Although there is consensus on the need of a multidisciplinary expert team evaluation and surgical approach in patients with significant hormonal excess and/or radiological findings suspicious of malignancy demonstrated at the diagnosis or during follow-up, the inconsistency between official guidelines and the consequent diffuse uncertainty on management of small adrenal incidentalomas still represents a considerable problem in terms of clinical choices in real practice. The aim of the present work is to review the proposed strategies on how to manage patients with adrenal incidentalomas that are not candidates to immediate surgery. The recent European Society of Endocrinology/European Network for the Study of Adrenal Tumors guidelines have supported the view to avoid surveillance in patients with clear benign adrenal lesions <4 cm and/or without any hormonal secretion; however, newer prospective studies are needed to confirm safety of this strategy, in particular in younger patients.

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

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

Adrenalectomy for Cushing's syndrome: do's and don'ts

Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”).

Material and Method. This is a narrative review.

Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA.

Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women.

Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome

Prevalence of subclinical hypercortisolism in type 2 diabetic patients from the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS

Subclinical hypercortisolism was reported to be more prevalent among diabetic, obese and hypertensive patients. Our primary aim was to investigate the prevalence of subclinical hypercortisolism in patients from the Rio de Janeiro Type 2 Diabetes (RIO-T2D) Cohort; and secondarily to assess its associated factors.

METHODS

From May 2013 to August 2014, 393 diabetic outpatients underwent overnight 1mg dexamethasone suppression test (DST). Patients with non-suppressive morning cortisol (≥1.8μg/dl) were further evaluated with nocturnal salivary cortisol, two readings >0.35μg/dl were considered confirmatory for subclinical hypercortisolism.

RESULTS

One-hundred twenty-eight patients (32.6%) failed to suppress morning cortisol, and in 33 patients (8.6%) subclinical hypercortisolism was confirmed. Independent correlates of a positive DST were older age (OR: 1.04; 95% CI: 1.01-1.07; p=0.007), number of anti-hypertensive drugs in use (OR: 1.26; 95% CI: 1.05-1.50; p=0.012), longer diabetes duration (OR: 1.03; 95% CI: 1.004-1.06; p=0.023), and presence of diabetic nephropathy (OR: 1.70; 95% CI: 1.01-2.87; p=0.047). Independent correlates of confirmed subclinical hypercortisolism were a greater number of anti-hypertensive medications (OR: 1.54; 95% CI: 1.14-2.06; p=0.004), shorter diabetes duration (OR: 0.92; 95% CI: 0.87-0.98; p=0.006), and increased aortic stiffness (OR: 2.81; 95% CI: 1.20-6.57; p=0.017); metformin use was protective (OR: 0.27; 95% CI: 0.10-0.73; p=0.010).

CONCLUSION

Patients with type 2 diabetes had a high prevalence of subclinical hypercortisolism, and its presence was associated with more severe hypertension and increased aortic stiffness.

Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly

Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce-and regularly update-conflicts of interest. The authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.

Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly

BACKGROUND

Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels.

AIMS

The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess.

METHODOLOGY

Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce--and regularly update--conflicts of interest. The Authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.

Is it worthwhile to screen patients with type 2 diabetes mellitus for subclinical Cushing's syndrome?

Variable prevalence of subclinical Cushing's syndrome (SCS) has been reported in patients with type 2 diabetes mellitus (T2DM), making the need for screening in this population uncertain. It is unknown if this variability is solely due to study-related methodological differences or a reflection of true differences in ethnic predisposition. The objective of this study is to explore the prevalence of SCS in Asian Indian patients with T2DM. In this prospective single center study conducted in a tertiary care referral center, 993 T2DM outpatients without any discriminatory clinical features (easy bruising, facial plethora, proximal muscle weakness, and/or striae) of hypercortisolism underwent an overnight 1 mg dexamethasone suppression test (ODST). ODST serum cortisol ≥1.8 μg/dl was considered positive, and those with positive results were subjected to 48 h, 2 mg/day low dose DST (LDDST). A stepwise evaluation for endogenous hypercortisolism was planned for patients with LDDST serum cortisol ≥1.8 μg/dl. Patients with positive ODST and negative LDDST were followed up clinically and re-evaluated a year later for the development of clinically evident Cushing's syndrome (CS). In this largest single center study reported to date, we found 37 out of 993 (3.72%) patients had ODST serum cortisol ≥1.8 μg/dl. None of them had LDDST cortisol ≥1.8 μg/dl, nor did they develop clinically evident CS over a follow-up period of 1 year. Specificity of ODST for screening of CS was 96.3% in our cohort. None of the T2DM outpatients in our cohort had SCS, hence cautioning against routine biochemical screening for SCS in this cohort. We suggest screening be based on clinical suspicion only.

Laparoscopic adrenalectomy in patients with subclinical Cushing syndrome

BACKGROUND

Subclinical Cushing syndrome in patients with adrenal incidentalomas has been associated with an increased prevalence of the metabolic syndrome and cardiovascular risk. The management of these patients, be it conservative or surgical, is still debated, but there is accumulating evidence that surgery is best and that laparoscopic adrenalectomy, when possible, is the most preferred procedure. Here we present the short- and long-term results of laparoscopic adrenalectomy for subclinical Cushing syndrome and determine the effect of this procedure on components of the metabolic syndrome.

METHODS

Twenty-nine patients, 8 men and 21 women with adrenal incidentalomas and subclinical Cushing syndrome who underwent laparoscopic adrenalectomy, were studied retrospectively. They had undergone postoperative follow-up for improvement or worsening of their arterial blood pressure, body weight, and fasting glucose level for a mean period of 77 months.

RESULTS

Preoperatively, 17 patients (58.6 %) had arterial hypertension, 14 (48.3 %) had a body mass index exceeding 27 kg/m(2), and 12 (41.4 %) had diabetes mellitus. Postoperatively, a decrease in mean arterial pressure was found in 12 patients (70.6 %), a decrease in body mass index in 6 patients (42.9 %), and an improvement in glycemic control in 5 patients (41.7 %).

CONCLUSIONS

Laparoscopic adrenalectomy is beneficial in many patients with subclinical Cushing syndrome because it reduces arterial blood pressure, body weight, and fasting glucose levels. Prospective randomized studies are needed to compare laparoscopic adrenalectomy with a conservative approach and to confirm these results.

Homocysteine and alpha-1 antitrypsin concentration in patients with subclinical hypercortisolemia

PURPOSE

Glucocorticoids have particularly strong impact on the thromboembolic complications. A factor which increases the risk of thrombosis is hyperhomocysteinemia, observed in patients with hypercortisolemia. Proinflammatory factors also affect the haemostatic balance. There has been an extensive research which estimates hemostatic system in patients with Cushing's syndrome. Undoubtedly, much fewer publications are available on thromboembolic complications in patients with Subclinical Cushing's Syndrome (SCS). The purpose of this study was to estimate of homocysteine (HCY) and alpha-1 antitrypsin (α1ATp) concentrations in patients with SCS.

MATERIALS AND METHODS

We studied 35 patients (56.0 ± 15.0 years) with SCS and 33 healthy volunteers (53.3 ± 17.7 years). In all subjects the analysis of HCY and α1ATp concentration in serum was determined with an immunonephelometric method. P-values below 0.05 were considered statistically significant.

RESULTS

A comparison of HCY and α1ATp mean concentrations in patients with SCS and healthy representatives indicated statistically higher values of both analysed parameters in the sera of patients than in the healthy controls (p values were 0.018 and 0.008, respectively). In the patients with SCS a negative correlation between α1ATp and cortisol concentration in overnight dexamethasone test was found (p=0.017, R=-0.40). We did not reveal any statistically significant correlation between the concentrations of HCY and α1ATp, and coagulation parameters such as INR, APTT, fibrinogen concentration in patients with SCS.

CONCLUSIONS

On the basis of the obtained results, a slight increase in the concentration of homocysteine and α1ATp is observed in patients with SCS, which may influence vascular complications.

Do patients with type 2 diabetes mellitus have an increased prevalence of Cushing's syndrome?

Many clinical features are common for patients with type 2 diabetes mellitus (T2DM) and Cushing's syndrome (CS) such as central obesity, hypertension and dyslipidaemia. Patients with CS often have T2DM. Because T2DM is much more frequent than CS, it is possible that some patients with T2DM have increased production of cortisol and thus represent patients with CS. The aim of this review was to evaluate the prevalence of CS in patients with T2DM. A search was performed in PubMed and Medline. We found seven prospective studies, two case-control studies and two cross-sectional studies. The difficulties in diagnosing subclinical CS is discussed. The most frequent tests for diagnosing CS, late-night salivary cortisol, 1-mg dexamethasone suppression test and urinary free cortisol are discussed and put in relation to the results of the literature found. The observed prevalence of CS in patients with T2DM varies widely between the different studies, ranging from 0-9.4%. This may be due to patient selection, differences in test methodology (including choice of test), cutoff values and different cortisol assays. The true prevalence of CS in T2DM has not been determined. We need more studies investigating the prevalence of CS in T2DM patients. There is a need for developing more specific tests for diagnosing CS in patients with only slightly elevated cortisol secretion and subclinical CS. We suggest that examination for hypercortisolism should only be performed in T2DM patients with a cushingoid appearance and hypertension or truncal obesity or dyslipidaemia.

Treatment Options in Cushing's Disease

Endogenous Cushing’s syndrome is a grave disease that requires a multidisciplinary and individualized treatment approach for each patient. Approximately 80% of all patients harbour a corticotroph pituitary adenoma (Cushing’s disease) with excessive secretion of adrenocorticotropin-hormone (ACTH) and, consecutively, cortisol. The goals of treatment include normalization of hormone excess, long-term disease control and the reversal of comorbidities caused by the underlying pathology. The treatment of choice is neurosurgical tumour removal of the pituitary adenoma. Second-line treatments include medical therapy, bilateral adrenalectomy and radiation therapy. Drug treatment modalities target at the hypothalamic/pituitary level, the adrenal gland and at the glucocorticoid receptor level and are commonly used in patients in whom surgery has failed. Bilateral adrenalectomy is the second-line treatment for persistent hypercortisolism that offers immediate control of hypercortisolism. However, this treatment option requires a careful individualized evaluation, since it has the disadvantage of permanent hypoadrenalism which requires lifelong glucocorticoid and mineralocorticoid replacement therapy and bears the risk of developing Nelson’s syndrome. Although there are some very promising medical therapy options it clearly remains a second-line treatment option. However, there are numerous circumstances where medical management of CD is indicated. Medical therapy is frequently used in cases with severe hypercortisolism before surgery in order to control the metabolic effects and help reduce the anestesiological risk. Additionally, it can help to bridge the time gap until radiotherapy takes effect. The aim of this review is to analyze and present current treatment options in Cushing’s disease.

Diabetes in Cushing syndrome: basic and clinical aspects

Diabetes mellitus is a frequent complication of Cushing syndrome (CS) which is caused by chronic exposure to glucocorticoid excess, either endogenous or exogenous, and that is characterized by several clinical symptoms such as central obesity, purple striae, proximal muscle weakness, acne, hirsutism and neuropsychological disturbances. Diabetes occurs as a consequence of an insulin-resistant state together with impaired insulin secretion which are induced by glucocorticoid excess. The management of patients with CS and diabetes mellitus includes the treatment of hyperglycemia and, when possible, the correction of glucocorticoid excess. This review focuses on the disorders of glucose metabolism in patients exposed to glucocorticoid excess, addressing both the pathophysiological aspects and the clinical and therapeutic implications.

Management of adrenal incidentaloma

The term adrenal incidentaloma covers a wide spectrum of adrenal pathologies sharing the method of discovery. The management of adrenal incidentaloma is controversial, and clinicians should determine whether the patient's health is affected by the presence of a tumor. Critical points in management include differentiating benign from malignant and hormonally active from nonfunctional adrenal masses. The probability of malignancy is related to tumor size and imaging phenotype. Masses smaller than 4 cm in diameter that exhibit low attenuation by unenhanced CT scan and rapid contrast washout by delayed contrast-enhanced CT scan are probably benign. All patients with adrenal incidentaloma should undergo biochemical evaluations for pheochromocytoma and subclinical or overt Cushing's syndrome, and hypertensive patients should undergo biochemical testing for hyperaldosteronism. Laparoscopic adrenalectomy is the treatment of choice in all hypersecretory tumors. If adrenocortical carcinoma is suspected, an open adrenalectomy is recommended. Patients who are not candidates for surgical resection of the tumor should be monitored radiographically for 2 years, and hormonal follow-up should be performed annually for 4 years.

Clinically silent adrenal adenomas - their relation to the metabolic syndrome and to GNB3 C825T gene polymorphism

OBJECTIVES

Aim of the study was to assess the prevalence of C825T GNB3 gene polymorphism in patients with adrenal incidentaloma (AI) as well as its relation to the metabolic syndrome (MS) and cortisol status.

SUBJECT AND METHODS

Alltogether 82 subjects (50 patients with AI, mean age 57.9 + 15 years and 32 subjects without AI, mean age 53.8 + 6.9 years) were included in this study. Parameters of glucose and lipid metabolism, serum adiponectin and the single nucleotide polymorphism C825T in GNB3 gene using PCR-RFLP method were examined. To detect subclinical Cushing syndrome an overnight dexamethason test was performed in all patients with AI.

RESULTS

Patients with AI had signifcantly higher BMI, HOMA, triacylglycerols (p < 0.05) and significantly lower serum adiponectine (p < 0.05) than controls. There were no significant differences in metabolic parameters between group with and without subclinical Cushing syndrome (SCS). The prevalence of T allele of GNB3 gene in patients with AI was not significantly higher as compared with control group (32% vs. 47%). No significant differences in serum glucose and lipids between carriers of T and C alleles were detected. However carriers of T allele had significantly lower serum adiponectin than those with allele C (p < 0.01).

CONCLUSION

We conclude that patients with AI had significantly higher cardiovascular risk factors that is not related to the presence of SCS. Moreover patients with AI and TC or TT genotype have significantly lower serum adiponectin which may be an early symptom of metabolic syndrome in patients with AI.

Cohort study of patients with adrenal lesions discovered incidentally

Background

This prospective cohort study investigated the incidence, clinical features and natural history of incidentally discovered adrenal mass lesions (adrenal incidentaloma, AI) in an unselected population undergoing radiological examination.

Methods

During an 18-month period, all patients with AI were reported prospectively from all 19 radiology departments in western Sweden. Inclusion criteria were: incidentally discovered adrenal enlargement or mass lesion in patients without extra-adrenal malignancy on detection. Clinical and biochemical evaluation was performed on inclusion and after 24 months. Computed tomography (CT) of the adrenals was scheduled at 4, 12 and 24 months. Magnetic resonance imaging was performed for lesions larger than 20 mm. The indications for surgical excision were: hormone activity, lesion diameter more than 30 mm, lesion growth or other radiological features suspicious of malignancy.

Results

Of 534 patients assessed for eligibility, 226 (mean age 67 years, 62·4 per cent women; mean lesion diameter 23·9 mm, 22·6 per cent bilateral) fulfilled the inclusion criteria. Mean follow-up was 19·0 months. After baseline evaluation, 14 patients had surgery owing to primary hyperaldosteronism (3), catecholamine-producing tumour (1), tumour size (6), size and indication of subclinical hypercortisolism (3) and metastasis (1). No hypersecreting lesions were confirmed during follow-up; one patient underwent adrenalectomy for a suspected phaeochromocytoma (adrenocortical adenoma at histopathology). No primary adrenal malignancy was found.

Conclusion

In this prospective cohort study 6·6 per cent of patients with an AI had surgery and benign hormone-producing tumours were verified in 3·1 per cent. Repeat CT and hormone evaluation after 2 years did not increase the sensitivity for diagnosis of malignant or hormone-producing tumours.

Adrenal lesions in acromegaly: do metabolic aspects and aryl hydrocarbon receptor interacting protein gene have a role? Evaluation at baseline and after long-term follow-up

BACKGROUND

Adrenal lesions are discovered in acromegaly more frequently than in general population, without relationship with primary disease. Some patients, carriers of aryl hydrocarbon receptor interacting protein (AIP) gene mutations, developed an adrenal neoplasm.

AIM

To evaluate the role of metabolic and genetic aspects and the follow-up of adrenal nodules in acromegaly.

MATERIAL AND METHODS

We studied 69 acromegalic patients (30 male and 39 female, 56 ± 15 yr) who had been referred to the Endocrinology Unit of Padua. In all patients we determined body mass index (BMI) and waist-to-hip ratio (WHR); we performed an oral glucose tolerance test (OGTT) whenever possible. If adrenal computed tomography revealed a lesion, the patient underwent an endocrine and genetic study.

RESULTS

Adrenal lesions were identified in 14 patients and were not related to gender, duration of disease, GH or IGF-I concentrations, basal and after-OGTT glucose and insulin levels, log(HOMA-IR) and Quantitative Insulin Sensitivity Check Index (QUICKI) values, whereas BMI and WHR were higher in patients with adrenal lesions. Baseline endocrine and radiological study revealed benign lesions; during mean 4-yr follow-up none of the patients showed hormone excess, even though some lesions increased in size. We did not find any mutation in AIP gene, except heterozygous silent alteration (T48T).

CONCLUSIONS

The frequency of non-functioning adrenal lesions in acromegaly is not associated with the considered aspects, except BMI and WHR. The prolonged follow-up showed that these lesions have a tendency to increase in size independently of the control of acromegaly, so a morphological follow- up is recommended.

Is metabolic syndrome a mild form of Cushing's syndrome?

The Metabolic Syndrome is a diagnosis of increasing prevalence that is noted to share multiple clinical features with Cushing's syndrome. Several studies suggest abnormalities in the Hypothalamic-Pituitary-Adrenal axis to be associated with this disease and tissue-specific hypercortisolemia is being investigated as a possible contributing factor. More research is needed to explore the relation between cortisol and the metabolic syndrome which, if confirmed, will have major therapeutic and public health implications.

Utility of salivary cortisol measurements in Cushing's syndrome and adrenal insufficiency

CONTEXT

The measurement of cortisol in saliva is a simple, reproducible, and reliable test to evaluate the normal and disordered control of the hypothalamic-pituitary-adrenal (HPA) axis. There are a variety of simple methods to obtain saliva samples without stress, making this a robust test applicable to many different experimental and clinical situations.

EVIDENCE ACQUISITION

Ovid Medline and PubMed from 1950 to present were searched using the following strategies: [<saliva or salivary>and<cortisol or hydrocortisone>and<Cushing or Cushing's>] and [<saliva or salivary>and<cortisol or hydrocortisone>and<adrenal insufficiency or hypoadrenalism or hypopituitarism or Addison's disease>]. The bibliographies of all relevant citations were evaluated for any additional appropriate citations.

EVIDENCE SYNTHESIS

Measurement of an elevated late-night (2300 to 2400 h) salivary cortisol has a greater than 90% sensitivity and specificity for the diagnosis of endogenous Cushing's syndrome. Late-night salivary cortisol measurements are also useful to monitor patients for remission and/or recurrence after pituitary surgery for Cushing's disease. Because it is a surrogate for plasma free cortisol, the measurement of salivary cortisol may be useful during an ACTH stimulation test in patients with increased plasma binding protein concentrations due to increased estrogen, or decreased plasma binding protein concentrations during critical illness. Most reference laboratories now offer salivary cortisol testing.

CONCLUSIONS

It is expected that the use of the measurement of salivary cortisol will become routine in the evaluation of patients with disorders of the HPA axis.

Clinical review: The pathogenetic role of cortisol in the metabolic syndrome: a hypothesis

CONTEXT

The metabolic syndrome (MetS) is a cluster of metabolic abnormalities that increase the risk for type 2 diabetes mellitus and vascular disease. The common characteristics of MetS and hypercortisolemic conditions such as Cushing's syndrome (CS) suggest that the pathogenesis of MetS and central obesity might involve prolonged and excessive exposure to glucocorticoids. The present review summarizes the evidence on the potential role of cortisol in the pathogenesis of MetS and discusses new therapeutic approaches for these patients.

EVIDENCE ACQUISITION

Using PubMed, we searched for publications during the last 20 yr regarding the possible pathogenetic role of cortisol in the development of MetS.

EVIDENCE SYNTHESIS

Emerging data suggest that patients with MetS show hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, which leads to a state of "functional hypercortisolism." The cause for this activation of the HPA axis remains uncertain but may be partly associated with chronic stress and/or low birth weight, which are both associated with increased circulating cortisol levels and greater responsiveness of the HPA axis. Increased exposure to cortisol contributes to increased fat accumulation in visceral depots. However, cortisol metabolism is not only centrally regulated. The action of 11beta-hydroxysteroid dehydrogenase-1 at the tissue level also modulates cortisol metabolism. Increased 11beta-hydroxysteroid dehydrogenase-1 activity in adipose tissue and liver might contribute to the development of several features of the MetS.

CONCLUSIONS

MetS shares many characteristics of CS, and cortisol might play a role in the development of MetS at both a central and a peripheral level.

Adrenal incidentalomas and subclinical Cushing's syndrome: diagnosis and treatment

PURPOSE OF REVIEW

Adrenal incidentaloma has become a frequent clinical dilemma. Even in the absence of specific clinical features of Cushing's syndrome, adrenocortical incidentalomas may display steroid secretory activity at different degrees. The recognition of endocrine and metabolic dysfunctions associated with subclinical hypercortisolism leads to current awareness about its potential consequences.

RECENT FINDINGS

Different protocols and threshold values to define normal cortisol secretion and diagnosis of subclinical Cushing's syndrome have been proposed, including recent practice guidelines for the diagnosis of overt Cushing's syndrome. Follow-up studies have provided additional data about the natural course of the disease and related cardiovascular and metabolic consequences. The study of bilateral adrenocorticotropin-independent macronodular adrenocortical hyperplasia in some familial cases offers a new approach to understanding the spectrum of subclinical cortisol hypersecretion.

SUMMARY

The prevalence of subclinical hypercortisolism may be higher than previously reported as more sensitive diagnostic criteria are now recommended. The absence of a single gold standard test, the diversity of diagnostic criteria and the requirement of subsequent meticulous biochemical evaluations before a decision for treatment represent a challenge for the clinical management of this condition.

The urinary steroid profile in patients diagnosed with adrenal incidentaloma

OBJECTIVE

The aim of this study was to investigate the possible urinary markers of hormonal activity in patients with non-functioning adrenal incidentalomas. In order to evaluate the endocrine activity of aforementioned tumours, urinary steroid metabolite levels were analyzed in samples from patients and controls. Possible blocks in metabolic pathways of the examined hormones were determined by comparing selected urinary steroid metabolite sums and ratios in both groups of interest.

DESIGN

Urine samples were collected from 20 patients with non-functioning adrenal incidentalomas and from 25 controls matched in terms of age, sex and BMI. Excretion of 19 major urinary steroid metabolites was analyzed by gas chromatography. The results were subjected to statistical analysis.

RESULTS

In patients with adrenal incidentalomas sum of total urinary cortisol metabolites was significantly increased in respect to the control group. We also observed a shift towards tetrahydrocorticosterone, cortisol and etiocholanolone production in patients. No significant differences in production of other urinary steroid metabolites were noted in patients with adrenal incidentalomas in respect to control group.

CONCLUSIONS

Our data suggests that not only urinary free cortisol but also its metabolite such as tetrahydrocortisol and other steroids including etiocholanolone and corticosterone tetrahydrometabolite might be urinary markers for the endocrine activity of adrenal incidentalomas. Enhanced levels of these urinary steroid metabolites indicate an impairment of 11beta-hydroxysteroid dehydrogenase activity and slightly increased activity of 5beta-reductase in patients with adrenal incidentalomas.

Adrenal incidentalomas: experience from a retrospective study in a Chinese population

BACKGROUND

With no generally accepted criteria for preoperative differential diagnosis between benign and malignant adrenal lesions, management of adrenal incidentalomas, especially those between 4 and 6 cm, remains controversial.

PATIENTS AND METHODS

Clinical details, radiological diagnosis, laboratory examination, intervention measures, and follow-up data were noted in 152 patients with adrenal incidentaloma hospitalized at a tertiary referral hospital in eastern China between July 1999 and February 2008. Pathologic diagnoses were analyzed in surgical cases.

RESULTS

Of 143 surgical patients, the mean pathologic size of the tumors was 5.6 ± 3.2 cm (range 0.5 to 22.0 cm). The final benign pathologic diagnosis mainly included adrenocortical adenoma (31.3%), pheochromocytoma (18.8%), myelolipoma (16.7%), and ganglioneuromas (9.0%). The incidence of malignancy was 6.9%. Based on the size criterion of 6 cm, there was a significant difference between malignant and benign tumor groups (P=0.007), but based on the size criterion of 4 or 5 cm, there was no significant difference between the two groups.

CONCLUSIONS

In our experience, the incidence of malignancy in adrenal incidentalomas was generally low, but relatively high in adrenal incidentalomas >6 cm. Nerve cell tumors constitute a significant number of cases of adrenal incidentaloma. Overtreatment of nonfunctional incidentalomas <4 cm remains frequent in China, and close follow-up for this group is recommended. Factors such as radiologic characteristics and patient concern should be taken into account for nonfunctional incidentalomas between 4 and 6 cm (not including 6 cm), for which laparoscopic adrenalectomy is a reasonable option.