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He C, Li R, Yang J, Shen H, Wang Y, Chen X, Luo W, Zeng Q, Ma L, Song Y, Cheng Q, Wang Z, Wu FF, Li Q, Yang S, Hu J. Optimizing the aldosterone-to-renin ratio cut-off for screening primary aldosteronism based on cardiovascular risk: a collaborative study. Clin Exp Hypertens 2024; 46:2301571. [PMID: 38270079 DOI: 10.1080/10641963.2023.2301571] [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: 07/24/2023] [Accepted: 12/28/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES Aldosterone-to-renin ratio (ARR) based screening is the first step in the diagnosis of primary aldosteronism (PA). However, the guideline-recommended ARR cutoff covers a wide range, from the equivalent of 1.3 to 4.9 ng·dl-1/mIU∙l-1. We aimed to optimize the ARR cutoff for PA screening based on the risk of cardiovascular diseases (CVD). METHODS Longitudinally, we included hypertensive participants from the Framingham Offspring Study (FOS) who attended the sixth examination cycle and followed up until 2014. At baseline (1995-1998), we used circulating concentrations of aldosterone and renin to calculate ARR (unit: ng·dl-1/mIU∙l-1) among 1,433 subjects who were free of CVD. We used spline regression to calculate the ARR threshold based on the incident CVD. We used cross-sectional data from the Chongqing Primary Aldosteronism Study (CONPASS) to explore whether the ARR cutoff selected from FOS is applicable to PA screening. RESULTS In FOS, CVD risk increased with an increasing ARR until a peak of ARR 1.0, followed by a plateau in CVD risk (hazard ratio 1.49, 95%CI 1.19-1.86). In CONPASS, when compared to essential hypertension with ARR < 1.0, PA with ARR ≥ 1.0 carried a higher CVD risk (odds ratio 2.24, 95%CI 1.41-3.55), while essential hypertension with ARR ≥ 1.0 had an unchanged CVD risk (1.02, 0.62-1.68). Setting ARR cutoff at 2.4 ~ 4.9, 10% ~30% of PA subjects would be unrecognized although they carried a 2.45 ~ 2.58-fold higher CVD risk than essential hypertension. CONCLUSIONS The CVD risk-based optimal ARR cutoff is 1.0 ng·dl-1/mIU∙l-1 for PA screening. The current guideline-recommended ARR cutoff may miss patients with PA and high CVD risk. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT03224312).
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Affiliation(s)
- Chunxue He
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ruolin Li
- Department of Dermatology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Hang Shen
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiangjun Chen
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjin Luo
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qinglian Zeng
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linqiang Ma
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Song
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingfeng Cheng
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhihong Wang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fei-Fei Wu
- Department of Endocrinology, Affiliated Heping Hospital, Changzhi Medical College, Changzhi, China
| | - Qifu Li
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shumin Yang
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinbo Hu
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Wei X, Wu F, Dong H, Jing Y, Song Y, Pang H, Chen J, Du Z, He W, Ma L, Wang Y, Hu J, Li Q, Yang S. 68Ga-pentixafor PET/CT in the localization diagnosis of primary aldosteronism concurrent subclinical cushing's syndrsome: two case reports. Endocrine 2024; 85:1398-1406. [PMID: 38914747 DOI: 10.1007/s12020-024-03865-6] [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: 11/02/2023] [Accepted: 11/28/2023] [Indexed: 06/26/2024]
Abstract
PURPOSE Adrenal venous sampling (AVS) is recommended for subtyping primary aldosteronism (PA). However, in cases of PA, concurrent subclinical Cushing's syndrome (SCS) has the potential to confound AVS results. Pentixafor, a CXC chemokine receptor type 4-specific ligand, has been reported as a promising marker to evaluate functional nature of adrenal adenomas. This study aims to investigate the clinical value of Gallium-68 Pentixafor Positron Emission Tomography-Computed Tomography (68Ga-Pentixafor PET/CT) in the localization diagnosis of patients with PA plus SCS. METHODS Two patients with a confirmed diagnosis of PA plus SCS underwent AVS and 68Ga-Pentixafor PET/CT. RESULTS AVS results revealed no lateralization for both patients while 68Ga-Pentixafor PET/CT showed a unilateral adrenal nodule with increased uptake of 68Ga-Pentixafor. Unilateral adrenalectomy was performed based on the results of 68Ga-Pentixafor PET/CT. Subsequently, complete biochemical remission of autonomous aldosterone and cortisol secretion were achieved in both cases. CONCLUSIONS 68Ga-Pentixafor PET/CT shows promising potential for the localization of aldosterone and cortisol co-secreting adrenal adenoma in patients with PA plus SCS.
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Affiliation(s)
- Xin Wei
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feifei Wu
- Department of Endocrinology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Haoyu Dong
- Department of Endocrinology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Ying Jing
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Pang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Chen
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenwen He
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linqiang Ma
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Sweeney AT, Hamidi O, Dogra P, Athimulam S, Correa R, Blake MA, McKenzie T, Vaidya A, Pacak K, Hamrahian AH, Bancos I. Clinical Review: The Approach to the Evaluation and Management of Bilateral Adrenal Masses. Endocr Pract 2024:S1530-891X(24)00642-6. [PMID: 39103149 DOI: 10.1016/j.eprac.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVE This white paper provides practical guidance for clinicians encountering bilateral adrenal masses. METHODS A case-based approach to the evaluation and management of bilateral adrenal masses. Specific clinical scenarios presented here include cases of bilateral adrenal adenomas, hemorrhage, pheochromocytomas, metastatic disease, myelolipomas, as well as primary bilateral macronodular adrenal hyperplasia. RESULTS Bilateral adrenal masses represent approximately 10% to 20% of incidentally discovered adrenal masses. The general approach to the evaluation and management of bilateral adrenal masses follows the same protocol as the evaluation of unilateral adrenal masses, determined based on the patient's clinical history and examination as well as the imaging characteristics of each lesion, whether the lesions could represent a malignancy, demonstrate hormone excess, or possibly represent a familial syndrome. Furthermore, there are features unique to bilateral adrenal masses that must be considered, including the differential diagnosis, the evaluation, and the management depending on the etiology. Therefore, considerations for the optimal imaging modality, treatment (medical vs surgical therapy), and surveillance are included. These recommendations were developed through careful examination of existing published studies as well as expert clinical opinion consensus. CONCLUSION The evaluation and management of bilateral adrenal masses require a comprehensive systematic approach which includes the assessment and interpretation of the patient's clinical history, physical examination, dynamic hormone evaluation, and imaging modalities to determine the key radiographic features of each adrenal nodule. In addition, familial syndromes should be considered. Any final treatment options and approaches should always be considered individually.
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Affiliation(s)
- Ann T Sweeney
- Division of Endocrinology, Department of Medicine, St Elizabeth's Medical Center, Brighton, Massachusetts.
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prerna Dogra
- Division of Endocrinology, Diabetes and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health, Detroit, Michigan
| | - Ricardo Correa
- Division of Endocrinology, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Blake
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Travis McKenzie
- Division of Endocrine Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Amir H Hamrahian
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, Maryland
| | - Irina Bancos
- Division of Endocrinology, Joint appointment Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Altieri B, Secener AK, Sai S, Fischer C, Sbiera S, Arampatzi P, Kircher S, Herterich S, Landwehr L, Vitcetz SN, Braeuning C, Fassnacht M, Ronchi CL, Sauer S. Single-nucleus and spatial transcriptome reveal adrenal homeostasis in normal and tumoural adrenal glands. Clin Transl Med 2024; 14:e1798. [PMID: 39167619 PMCID: PMC11338279 DOI: 10.1002/ctm2.1798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 07/11/2024] [Accepted: 07/26/2024] [Indexed: 08/23/2024] Open
Abstract
The human adrenal gland is a complex endocrine tissue. Studies on adrenal renewal have been limited to animal models or human foetuses. Enhancing our understanding of adult human adrenal homeostasis is crucial for gaining insights into the pathogenesis of adrenal diseases, such as adrenocortical tumours. Here, we present a comprehensive cellular genomics analysis of the adult human normal adrenal gland, combining single-nuclei RNA sequencing and spatial transcriptome data to reconstruct adrenal gland homeostasis. As expected, we identified primary cells of the various zones of the adrenal cortex and medulla, but we also uncovered additional cell types. They constitute the adrenal microenvironment, including immune cells, mostly composed of a large population of M2 macrophages, and new cell populations, including different subpopulations of vascular-endothelial cells and cortical-neuroendocrine cells. Utilizing spatial transcriptome and pseudotime trajectory analysis, we support evidence of the centripetal dynamics of adrenocortical cell maintenance and the essential role played by Wnt/β-catenin, sonic hedgehog, and fibroblast growth factor pathways in the adult adrenocortical homeostasis. Furthermore, we compared single-nuclei transcriptional profiles obtained from six healthy adrenal glands and twelve adrenocortical adenomas. This analysis unveiled a notable heterogeneity in cell populations within the adenoma samples. In addition, we identified six distinct adenoma-specific clusters, each with varying distributions based on steroid profiles and tumour mutational status. Overall, our results provide novel insights into adrenal homeostasis and molecular mechanisms potentially underlying early adrenocortical tumorigenesis and/or autonomous steroid secretion. Our cell atlas represents a powerful resource to investigate other adrenal-related pathologies.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and DiabetesDepartment of Internal Medicine IUniversity HospitalUniversity of WürzburgWürzburgGermany
| | - A. Kerim Secener
- Max Delbrück Center for Molecular MedicineBerlinGermany
- Berlin Institute of HealthBerlinGermany
- Department of BiologyChemistry and PharmacyInstitute of BiochemistryFree University BerlinBerlinGermany
| | - Somesh Sai
- Max Delbrück Center for Molecular MedicineBerlinGermany
- Berlin Institute of HealthBerlinGermany
- Department of BiologyChemistry and PharmacyInstitute of BiochemistryFree University BerlinBerlinGermany
| | - Cornelius Fischer
- Max Delbrück Center for Molecular MedicineBerlinGermany
- Berlin Institute of HealthBerlinGermany
| | - Silviu Sbiera
- Division of Endocrinology and DiabetesDepartment of Internal Medicine IUniversity HospitalUniversity of WürzburgWürzburgGermany
| | | | - Stefan Kircher
- Institute of PathologyUniversity of WürzburgWürzburgGermany
| | | | - Laura‐Sophie Landwehr
- Division of Endocrinology and DiabetesDepartment of Internal Medicine IUniversity HospitalUniversity of WürzburgWürzburgGermany
| | - Sarah N. Vitcetz
- Max Delbrück Center for Molecular MedicineBerlinGermany
- Berlin Institute of HealthBerlinGermany
| | | | - Martin Fassnacht
- Division of Endocrinology and DiabetesDepartment of Internal Medicine IUniversity HospitalUniversity of WürzburgWürzburgGermany
- Central Laboratory University Hospital WürzburgWürzburgGermany
| | - Cristina L. Ronchi
- Division of Endocrinology and DiabetesDepartment of Internal Medicine IUniversity HospitalUniversity of WürzburgWürzburgGermany
- Institute of Metabolism and System ResearchUniversity of BirminghamEdgabston, BirminghamUK
| | - Sascha Sauer
- Max Delbrück Center for Molecular MedicineBerlinGermany
- Berlin Institute of HealthBerlinGermany
- Core Unit SysMedUniversity of WürzburgWürzburgGermany
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Yu Y, Yang M, Gong M, Zhang Y, Jiang Y, Song W. Evaluation of adrenal vein anatomy by adrenal venous sampling in patients with primary aldosteronism in Chinese. J Clin Hypertens (Greenwich) 2024; 26:912-920. [PMID: 38937885 PMCID: PMC11301435 DOI: 10.1111/jch.14860] [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: 02/07/2024] [Revised: 04/03/2024] [Accepted: 05/27/2024] [Indexed: 06/29/2024]
Abstract
Accurate cannulation of the adrenal vein is challenging during adrenal venous sampling (AVS) because of the variations in adrenal vein anatomy. This study aimed to investigate the adrenal venous morphology in Chinese and improve the success rate of AVS. A total of 221 participants with primary aldosteronism (PA) who underwent AVS were enrolled. Compare the morphology among subgroups divided according to sex, body mass index (BMI), and with or without adenoma. The success rate of right, left, and bilateral AVS was 98.60%, 97.20%, and 96.85%, respectively. The triangular pattern was the most common (39.37%) on the right side, while the glandlike pattern (70.14%) on the left. The proportion of adrenal venous morphology varies among patients with different sexes (χ2 = 21.335, P < .001), BMI (χ2 = 10.642 P = .031), and with or without adenoma (χ2 = 10.637, P = .031) on the right side, and the male, obese and adenoma group showed a higher proportion of glandlike pattern than triangular pattern. If only dependent on computed tomography, 9.05% of patients incorrectly diagnose the dominant side, 14.48% of patients would have inappropriate surgery meanwhile 25.34% of patients would miss the surgical opportunity. In conclusion, the most common types of right and left adrenal venous morphology were triangular pattern and glandlike pattern, respectively. Sex, BMI, and the presence of adenoma affected right adrenal venous morphology. Adequate knowledge of the adrenal venous morphology is critical for improving the success rate of AVS and making an appropriate treatment for PA.
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Affiliation(s)
- Yang Yu
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Minghui Yang
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Minghui Gong
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Ying Zhang
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Yinong Jiang
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
| | - Wei Song
- Department of CardiologyFirst Affiliated Hospital of Dalian Medical UniversityDalianLiaoningChina
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Prete A, Bancos I. Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches. Nat Rev Endocrinol 2024; 20:460-473. [PMID: 38649778 DOI: 10.1038/s41574-024-00984-y] [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] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1-7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20-50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Guo L, Yang L, Wang X, Bai X, Tuoheti K, Yisha Z, Hu D, Liu T. Impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors: a retrospective study. World J Urol 2024; 42:441. [PMID: 39046549 DOI: 10.1007/s00345-024-05134-7] [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: 02/02/2024] [Accepted: 06/19/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVE To investigate the impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors. SUBJECTS AND METHODS Between January 2020 and October 2022, patients with adrenal lesions were retrospectively screened for nonfunctional adrenal tumors at the Zhongnan Hospital of Wuhan University. All patients underwent detailed endocrinological examination and computed tomography to characterize the lesions. One year after discharge, follow-up blood pressure (BP) was assessed and compared to the blood pressure on admission. Univariate analysis and multivariate regression analysis were performed to determine factors predicting favorable hypertension outcomes after adrenalectomy. RESULTS A total of 309 patients were found to be eligible, including 123 who underwent adrenalectomy. Patients who underwent adrenalectomy were stratified into two groups: (Bancos I (2022) Adrenal Incidentalomas: Insights Into Prevalence. Ann Intern Med 175:1481-1482. https://doi.org/10.7326/M22-2600 ) those with improved hypertension (n = 71), and (Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J et al. (2023) European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 189:G1-42. https://doi.org/10.1093/ejendo/lvad066 ) those without improved hypertension (n = 52). In contrast, the blood pressure levels of conservatively treated patients remained relatively stable 1 year after discharge. Univariate analysis and multivariate regression analysis showed that body mass index (BMI) and duration of hypertension were significantly different between the hypertension improvement group and the non-improvement group (p < 0.05). CONCLUSION Adrenalectomy has been shown to be effective in improving hypertension in certain patients with nonfunctional adrenal tumors. BMI and duration of hypertension were independent factors associated with favorable hypertension outcomes after adrenalectomy.
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Affiliation(s)
- Linfa Guo
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Lijie Yang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Xiaolong Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Xiaojie Bai
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Kuerban Tuoheti
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Zuhaer Yisha
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Dongliang Hu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China.
| | - Tongzu Liu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China.
- Cancer Precision Diagnosis and Treatment and Translational Medicine Hubei Engineering Research Center, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China.
- Hubei Province Key Laboratory of Urinary System Diseases, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China.
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Vassiliadi DA, Delivanis DA, Papalou O, Tsagarakis S. Approach to the Patient With Bilateral Adrenal Masses. J Clin Endocrinol Metab 2024; 109:2136-2148. [PMID: 38478374 DOI: 10.1210/clinem/dgae164] [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: 12/29/2023] [Indexed: 07/13/2024]
Abstract
Bilateral adrenal masses, increasingly encountered in clinical practice, manifest across diverse contexts, including incidental discovery, malignancy staging, and targeted imaging after hormonal diagnosis of adrenal disorders. The spectrum encompasses various pathologies, such as cortical adenomas, macronodular adrenal disease, pheochromocytomas, myelolipomas, infiltrative disorders, and primary and secondary malignancies. Notably, not all masses in both adrenal glands necessarily share the same etiology, often exhibiting diverse causes. Recently, the European Society of Endocrinology and the European Network for the Study of Adrenal Tumors updated guidelines, introduced a 4-option schema based on imaging, aiding in targeted hormonal testing and management. This "Approach to the Patient" review delves into the latest advancements in imaging, biochemical, and genetic approaches for the diagnostic and management nuances of bilateral adrenal masses. It provides insights and a contemporary framework for navigating the complexities associated with this clinical entity.
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Affiliation(s)
- Dimitra Argyro Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
| | - Danae Anastasia Delivanis
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Olga Papalou
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, European Reference Network on Rare Endocrine Conditions (ENDO-ERN), Evangelismos Hospital, 10676, Athens, Greece
- Private Practice, 10675, Athens, Greece
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Fuß CT, Megerle F, Fassnacht M. [Adrenal tumors: current standards in clinical management]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:632-641. [PMID: 38864873 DOI: 10.1007/s00108-024-01727-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
Adrenal tumors are among the most common tumors in humans. They are most frequently discovered incidentally during abdominal imaging for other reasons or due to clinical symptoms (e.g. Conn's or Cushing's syndrome, pheochromocytoma or androgen excess). Although over 80% of adrenal tumors are benign, in cases of hormone excess, they are associated with significantly increased morbidity. In highly malignant adrenocortical carcinoma (ACC), early diagnosis is of particular prognostic relevance. Therefore, this review presents the diagnostic procedure for what are referred to as adrenal incidentalomas and provide recommendations for the management of ACC and pheochromocytomas/paragangliomas (PPGL). In primary diagnosis, sufficient hormone diagnostics is required for all adrenal tumors, as this is the only way to identify all patients with relevant hormone excess. Imaging has increasingly improved in recent years and allows a reliable assessment of the tumor's malignancy in most cases. Imaging of first choice is unenhanced computed tomography (CT), while magnetic resonance imaging (MRI) and fluorodeoxyglucose-18 positron emission tomography (FDG-PET/CT) are reserved for special situations, as published evidence on these procedures is more limited. The treatment of ACC and PPGL is complex and is carried out on an interdisciplinary basis at specialized centers. In the case of localized disease, surgery is the only curative treatment option. There are now clear recommendations for individualized adjuvant therapy for ACC. In metastatic disease, mitotane with or without platinum-containing chemotherapy is the standard. Other lines of therapy should be discussed with a reference center. Over 35% of PPGL have a germline mutation; therefore, genetic testing should be offered. In metastatic PPGL, an individual decision is required between active surveillance, radionuclide therapy, sunitinib or chemotherapy.
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Affiliation(s)
- Carmina Teresa Fuß
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Felix Megerle
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - Martin Fassnacht
- Medizinische Klinik und Poliklinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
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Reimondo G, Solitro F, Puglisi S, Balbi M, Tiranti GM, Perini AME, Cultrera A, Brero D, Botto C, Perotti P, Caramello V, Boccuzzi A, Pia A, Veltri A, Terzolo M. Serendipitous Adrenal Hyperplasia in Patients Admitted to the Emergency Department for Suspected SARS-CoV-2 Infection is Linked to Increased Mortality. Arch Med Res 2024; 55:103010. [PMID: 38805767 DOI: 10.1016/j.arcmed.2024.103010] [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: 11/24/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Few data are available on adrenal morphology in patients with acute diseases, although it is known that endogenous glucocorticoids are essential for survival under stress conditions and that an adequate response is driven by activation of the hypothalamic-pituitary-adrenal (HPA) axis. AIMS The aim of this study was to assess adrenal morphology in patients with acute disease compared with patients with non-acute disease. METHODS This cross-sectional study included: 402 patients admitted to the emergency department (ED) for suspected SARS-CoV-2 infection (March-May, 2020) [main cohort]; 200 patients admitted to the ED for acute conditions (December 2018-February 2019) [control group A]; 200 outpatients who underwent radiological evaluation of non-acute conditions (January-February 2019) [control group B]. Chest and/or abdominal CT scans were reviewed to identify adrenal nodules or hyperplasia. RESULTS In the main cohort, altered adrenal morphology was found in 24.9% of the patients (15.4% adrenal hyperplasia; 9.5% adrenal nodules). The frequency of adrenal hyperplasia was higher both in the main cohort (15.4%) and control group A (15.5%) compared to control group B (8.5%; p = 0.02 and p = 0.03, respectively). In the main cohort, 14.9% patients died within 30 d. According to a multivariate analysis, adrenal hyperplasia was an independent risk factor for mortality (p = 0.04), as were older age (p <0.001) and active cancer (p = 0.01). CONCLUSIONS The notable frequency of adrenal hyperplasia in patients with acute diseases suggests an exaggerated activation of the HPA axis due to stressful conditions. The increased risk of short-term mortality found in patients with adrenal hyperplasia suggests that it may be a possible hallmark of worse prognosis.
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Affiliation(s)
- Giuseppe Reimondo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Federica Solitro
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Soraya Puglisi
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
| | - Maurizio Balbi
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Giorgio Maria Tiranti
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Anna Maria Elena Perini
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Alessandra Cultrera
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Dalila Brero
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Cristina Botto
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Paola Perotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | | | - Adriana Boccuzzi
- Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Anna Pia
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Andrea Veltri
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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11
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Woods AP, Feeney T, Gupta A, Knapp PE, McAneny D, Drake FT. Prospective Study of a System-Wide Adrenal Incidentaloma Quality Improvement Initiative. J Am Coll Surg 2024; 238:961-970. [PMID: 38116951 DOI: 10.1097/xcs.0000000000000930] [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: 12/21/2023]
Abstract
BACKGROUND Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs. STUDY DESIGN This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral. RESULTS The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517). CONCLUSIONS This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.
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Affiliation(s)
- Alison P Woods
- From the Departments of Surgery (Woods, McAneny, Drake), Boston University School of Medicine and Boston Medical Center, Boston, MA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Timothy Feeney
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC (Feeney)
| | - Avneesh Gupta
- Radiology (Gupta), Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Philip E Knapp
- Medicine (Knapp), Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - David McAneny
- From the Departments of Surgery (Woods, McAneny, Drake), Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Frederick Thurston Drake
- From the Departments of Surgery (Woods, McAneny, Drake), Boston University School of Medicine and Boston Medical Center, Boston, MA
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12
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Lindh JD, Patrova J, Mannheimer B, Falhammar H. Prevalence and Incidence of Fractures in Patients With Nonfunctional Adrenal Tumors. JAMA Netw Open 2024; 7:e246453. [PMID: 38619841 PMCID: PMC11019395 DOI: 10.1001/jamanetworkopen.2024.6453] [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: 12/18/2023] [Accepted: 02/15/2024] [Indexed: 04/16/2024] Open
Abstract
Importance It is unclear whether nonfunctional adrenal tumors (NFATs) are associated with fractures. Objective To analyze fracture frequencies in individuals with NFATs. Design, Setting, and Participants A national retrospective cohort study was conducted in patients with NFATs diagnosed in Sweden between January 1, 2005, and December 31, 2019, and control participants without adrenal tumors followed up until death or the end of 2019. Individuals with a diagnosis of adrenal hormonal excess or previous malignant tumors were excluded. Sensitivity analyses were performed in subgroups of individuals with a combination of gallbladder, biliary tract, and pancreas diseases (for whom it was assumed that controls would also have undergone computed tomography) and 3- and 12-month survival free of malignant tumors after the NFAT diagnosis. The data were analyzed from September to November 2023. Exposures Diagnosis of NFATs. Main Outcomes and Measures Main study outcomes were prevalence and incidence of fractures after adjustment for sex, age, and comorbidities. Secondary outcomes were fragility fractures, fractures with fall on the same level, and fracture locations (distal arm and vertebral and hip fractures). Fracture incidence after adrenalectomy was also studied. Results Among 20 390 patients, 12 120 (59.4%) were women, and the median (IQR) age was 66 (57-73) years; among 125 392 controls, 69 994 (55.8%) were women, and the median (IQR) age was 66 (57-73) years. Previous fractures were more common in patients diagnosed with NFATs compared with controls (4310 of 20 390 [21.1%] vs 20 323 of 125 392 [16.2%]; odds ratio [OR], 1.39; 95% CI, 1.34-1.45; adjusted OR [AOR], 1.27; 95% CI, 1.23-1.33). During the follow-up period (median [IQR], 4.9 [2.2-8.2] years), incident fractures were more common in patients with NFATs (3127 of 20 390 [15.3%] vs 16 086 of 125 392 [12.8%]; hazard ratio [HR], 1.40; 95% CI, 1.34-1.45; adjusted HR [AHR], 1.27; 95% CI, 1.22-1.33). An association between NFATs and vertebral fractures was found (AOR, 1.51; 95% CI, 1.33-1.72; AHR, 1.83; 95% CI, 1.60-2.09). In men younger than 50 years, NFATs were associated with fractures (AOR, 1.45; 95% CI, 1.21-1.74; AHR, 1.48; 95% CI, 1.20-1.82). There was no association among individuals who had undergone adrenalectomy (AHR, 1.12; 95% CI, 0.90-1.38). The association between NFATs and fractures remained significant and of similar magnitude in all sensitivity analyses. Conclusions and Relevance In this cohort study, NFATs were associated with fractures, particularly among younger men; thus, patients with NFATs should have bone health evaluation with appropriate treatment and monitoring, especially in younger men.
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Affiliation(s)
- Jonatan D. Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jekaterina Patrova
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Södersjukhuset, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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13
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Chen T, Wang Y, Chen X, Zheng W, Guo W, Liang Q, Wang J, Chen Z, Zhou Y, Xiao L. The MQRG score: a novel prognostic tool for adrenocortical carcinoma patients based on mitochondrial quality. Front Endocrinol (Lausanne) 2024; 15:1222281. [PMID: 38505747 PMCID: PMC10948487 DOI: 10.3389/fendo.2024.1222281] [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: 05/14/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
Objectives Adrenal tumors are common, but adrenocortical carcinomas (ACCs) are a rare and challenging form of cancer to diagnose and manage.This study aimed to explore the critical role of mitochondrial quality in maintaining cellular function and the implications of the abnormal expression of mitochondrial metabolism-related proteins observed in ACC patients. We focused on identifying the connection between mitochondrial quality and the development of ACC at molecular and genomic levels. Methods We compared mitochondrial quality-related genes (MQRGs) across ACC subtypes using overall survival (OS) and disease-free survival (DFS) as evaluation indicators. Furthermore, a novel MQRG score was developed to predict clinical prognosis and guide immunotherapy responses accurately. Results The majority of MQRGs were upregulated in the ACC samples, correlating to poor prognosis. The MQRG score was confirmed as an independent prognostic factor for ACC, with the high-risk MQRG score group showing a significantly shorter overall survival period. Conclusions Multilayer alterations in MQRGs are associated with patient prognosis and immune cell infiltration characteristics. This comprehensive analysis of MQRGs can contribute to a deeper understanding of potential differences in ACC patients' tumor microenvironment. This can influence clinical decision-making and advanced prognosis prediction, thereby offering new insights into personalized treatments in ACC.
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Affiliation(s)
- Tao Chen
- Shenzhen Key Laboratory of Viral Oncology, The Clinical Innovation & Research Centre, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
- The Third School of Clinical Medicine, Southern Medical University, Shenzhen, Guangdong, China
| | - Yifan Wang
- Department of Neurology, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Xue Chen
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Wenbin Zheng
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Weiquan Guo
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Qi Liang
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Jing Wang
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Zhongbiao Chen
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Yiwen Zhou
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Lijia Xiao
- Department of Clinical Laboratory Medicine Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
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14
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Ginzberg SP, Gasior JA, Kelz LR, Passman JE, Soegaard Ballester JM, Roses RE, Fraker DL, Wachtel H. Adrenalectomy approach and outcomes according to surgeon volume. Am J Surg 2024; 229:44-49. [PMID: 37940441 PMCID: PMC10922122 DOI: 10.1016/j.amjsurg.2023.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND This study assessed the relationship between surgeon volume, operative management, and resource utilization in adrenalectomy. METHODS Isolated adrenalectomies performed within our health system were identified (2016-2021). High-volume surgeons were defined as those performing ≥6 cases/year. Outcomes included indication for surgery, perioperative outcomes, and costs. RESULTS Of 476 adrenalectomies, high-volume surgeons (n = 3) performed 394, while low-volume surgeons (n = 12) performed 82. High-volume surgeons more frequently operated for pheochromocytoma (19% vs. 16%, p < 0.001) and less frequently for metastasis (6.4% vs. 23%, p < 0.001), more frequently used laparoscopy (95% vs. 80%, p < 0.001), and had lower operative supply costs ($1387 vs. $1,636, p = 0.037). Additionally, laparoscopic adrenalectomy was associated with shorter length of stay (-3.43 days, p < 0.001), lower hospitalization costs (-$72,417, p < 0.001), and increased likelihood of discharge to home (OR 17.03, p = 0.008). CONCLUSIONS High-volume surgeons more often resect primary adrenal pathology and utilize laparoscopy. Laparoscopic adrenalectomy is, in turn, associated with decreased healthcare resource utilization.
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Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Center for Healthcare Improvement and Patient Safety, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Julia A Gasior
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jesse E Passman
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Robert E Roses
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Shakir MN, Woods AL, Sun KA, Goldman RE, Campbell MJ, Corwin MT, Graves CE. Incidence, Presentation, and Natural History of Adrenal Hemorrhage: An Institutional Analysis. J Surg Res 2024; 295:53-60. [PMID: 37988907 DOI: 10.1016/j.jss.2023.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/08/2023] [Accepted: 09/24/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Adrenal hemorrhage (AH) can occur due to multiple etiologies with variable radiographic appearance, often indistinguishable from underlying adrenal neoplasms. There is a lack of AH literature and evidence-based guidelines. Our study aimed to understand the prevalence and etiology of AH, follow-up, and incidence of underlying neoplasm. METHODS An institutional database was queried from January 2006 to October 2021 for patients with AH on imaging, excluding patients with known malignancies, adrenal masses, or prior adrenal surgery. Demographics, medical history, hematoma size, laterality, biochemical evaluation, intervention, and additional imaging were reviewed. RESULTS Of 490,301 imaging reports queried, 530 (0.11%) with AH met inclusion criteria. Most imaging (n = 485, 91.5%) was performed during trauma evaluation. Two patients underwent dedicated intervention at presentation. Interval imaging was performed in 114 (21.5%) patients at a median of 2.6 (interquartile range 0.99-13.4) mo, with resolution (n = 84, 73.7%) or decreased size of AH (n = 21, 18.4%) in most patients. Only 10 patients (1.9%) saw an outpatient provider in our system to address AH or evaluate for underlying mass, and 9 (1.7%) underwent biochemical screening. Thirteen patients (11% of 118 patients with any follow-up) had evidence of an adrenal mass, confirmed on serial imaging (n = 10) or adrenalectomy (n = 3). Scans performed for nontrauma indications were significantly more likely to have an underlying mass (n = 6/26 [23.1%]) than those performed for trauma evaluation (n = 7/92 [7.6%], P = 0.04). CONCLUSIONS AH is a rare finding associated with an increased rate of underlying adrenal mass, particularly when unrelated to trauma. Most AH resolves spontaneously without intervention. Follow-up imaging at 6 mo can help distinguish mass-associated AH from simple hemorrhage.
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Affiliation(s)
- Mustafa N Shakir
- University of California Davis School of Medicine, Sacramento, California
| | - Alexis L Woods
- Department of Surgery, University of California Davis, Sacramento, California
| | - Kiyomi A Sun
- Department of Surgery, University of California Davis, Sacramento, California
| | - Roger E Goldman
- Department of Radiology, University of California Davis, Sacramento, California
| | - Michael J Campbell
- Department of Surgery, University of California Davis, Sacramento, California
| | - Michael T Corwin
- Department of Radiology, University of California Davis, Sacramento, California
| | - Claire E Graves
- Department of Surgery, University of California Davis, Sacramento, California.
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16
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Zhang X, Shu X, Wu F, Yang J, Cheng Q, Du Z, Song Y, Yang Y, Hu J, Wang Y, Li Q, Yang S. Treatment decision based on unilateral index from nonadrenocorticotropic hormone-stimulated and adrenocorticotropic hormone-stimulated adrenal vein sampling in primary aldosteronism. J Hypertens 2024; 42:450-459. [PMID: 37937517 DOI: 10.1097/hjh.0000000000003612] [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: 11/09/2023]
Abstract
OBJECTIVE Adrenal venous sampling (AVS) is recommended for identifying the subtype of primary aldosteronism before making a surgical treatment decision, but failed cannulation of one adrenal vein is common. To evaluate whether using results of one adrenal vein during AVS could accurately predict unilateral primary aldosteronism. METHODS A retrospective study was conducted in primary aldosteronism patients receiving bilaterally or unilaterally successful AVS. The aldosterone-cortisol ratio from the adrenal vein divided by the aldosterone-cortisol ratio from the inferior vena cava (IVC) was calculated as the AV/IVC index. RESULTS The study examined 455 patients with primary aldosteronism, including 347 patients with unilateral primary aldosteronism. Among them, 250 and 125 patients received non- adrenocorticotropic hormone (ACTH) and ACTH-stimulated AVS, respectively, and 80 patients received both forms of AVS. Under non-ACTH-stimulated AVS, AUC of the AV/IVC index to diagnose ipsilateral and contralateral primary aldosteronism were 0.778 and 0.924, respectively. The specificity was 100% for both, with sensitivities of 5 and 26%, respectively, when using cutoffs of 17.05 to diagnose ipsilateral primary aldosteronism and 0.15 to diagnose contralateral primary aldosteronism. When using cutoffs of 3.60 and 0.70, the specificity decreased, but if combined with CT results (ipsilateral or contralateral adrenal nodules larger than 10 mm), the specificity could be maintained at 99%, with sensitivities of 33 and 45%, respectively. Under ACTH-stimulated AVS, the AV/IVC index showed similar accuracy to diagnose ipsilateral and contralateral primary aldosteronism. CONCLUSION The unilateral AV/IVC index can be used to diagnose unilateral primary aldosteronism during AVS. Combining CT results can increase the accuracy further.
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Affiliation(s)
- Xizi Zhang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Xiaoyu Shu
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing
| | - Feifei Wu
- Department of Endocrinology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Jun Yang
- Department of Medicine, Monash University
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Qingfeng Cheng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Yi Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Yue Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
| | - Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing
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17
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Amar L, Harbuz-Miller I, Turcu AF. Adrenal Incidentaloma-Innocent Bystander or Intruder? J Clin Endocrinol Metab 2024; 109:e1303-e1304. [PMID: 37622650 PMCID: PMC10876404 DOI: 10.1210/clinem/dgad504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Laurence Amar
- Centre de Soins, de Recherche et Enseignement en Hypertension Artérielle, Hôpital Européen Georges Pompidou, Université de Paris, 75015 Paris, France
| | - Inga Harbuz-Miller
- Department of Medicine, Endocrine/Metabolism, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Adina F Turcu
- Division of Endocrinology, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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18
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José Vallejo Herrera M, González Romero S, Vallejo Herrera V. [Primary adrenal carcinoma: Experience of 8 cases]. Med Clin (Barc) 2024; 162:83-85. [PMID: 37833105 DOI: 10.1016/j.medcli.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023]
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19
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Li X, Liang J, Hu J, Ma L, Yang J, Zhang A, Jing Y, Song Y, Yang Y, Feng Z, Du Z, Wang Y, Luo T, He W, Shu X, Yang S, Li Q. Screening for primary aldosteronism on and off interfering medications. Endocrine 2024; 83:178-187. [PMID: 37796417 DOI: 10.1007/s12020-023-03520-6] [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: 07/11/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVE To determine whether antihypertensives will affect diagnostic accuracy of the aldosterone-to-renin ratio (ARR) to an extent that is clinically relevant. METHODS Confirmatory tests were used to confirm or exclude PA diagnosis. Area under the receiver operating characteristic curve (AUC), specificity and sensitivity of ARR performance in different conditions were calculated. RESULTS 208 PA and 78 essential hypertension (EH), and 125 PA and 206 EH patients, were included in the retrospective and prospective cohort, respectively. AUC of ARR on interfering medications was comparable to ARR off interfering medications (retrospective: 0.82 vs. 0.87, p = 0.20; prospective: 0.78 vs. 0.84, p = 0.07). At a threshold of 20 pg/μIU, the sensitivity of ARR on interfering medications was lower (11.1-23.2%) while the specificity was higher (10.2-15.2%) than ARR off interfering medications. However, when the ARR threshold on interfering medications was lowered to 10 pg/μIU, both the sensitivity (retrospective: 0.91 vs. 0.90, p = 0.61; prospective: 0.86 vs. 0.82, p = 0.39) and specificity (retrospective: 0.49 vs. 0.59, p = 0.20; prospective: 0.58 vs. 0.66, p = 0.10) were comparable to the ARR threshold off interfering medications. CONCLUSION Using ARR to screen for PA whilst taking interfering antihypertensive drugs is feasible in most cases, but the ARR threshold needs to be reduced. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04991961.
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Affiliation(s)
- Xiaoyu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayu Liang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinbo Hu
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linqiang Ma
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Yang
- Department of Medicine, Monash University, Clayton, VIC, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Aipin Zhang
- Graduate Administration Office, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Jing
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Song
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengping Feng
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhipeng Du
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ting Luo
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenwen He
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyu Shu
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China.
| | - Shumin Yang
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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20
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Charoensri S, Turcu AF. Primary Aldosteronism Prevalence - An Unfolding Story. Exp Clin Endocrinol Diabetes 2023; 131:394-401. [PMID: 36996879 DOI: 10.1055/a-2066-2696] [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] [Indexed: 04/01/2023]
Abstract
Primary aldosteronism (PA) is characterized by dysregulated, renin-independent aldosterone excess. Long perceived as rare, PA has emerged as one of the most common causes of secondary hypertension. Failure to recognize and treat PA results in cardiovascular and renal complications, through processes mediated by both direct target tissue insults and indirectly, by hypertension. PA spans a continuum of dysregulated aldosterone secretion, which is typically recognized in late stages after treatment-resistant hypertension and cardiovascular and/or renal complications develop. Determining the precise disease burden remains challenging due to heterogeneity in testing, arbitrary thresholds, and populations studied. This review summarizes the reports on PA prevalence among the general population and in specific high-risk subgroups, highlighting the impact of rigid versus permissive criteria on PA prevalence perception.
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Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
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21
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Parazzoli C, Favero V, Aresta C, Morelli V. Predicting morphological and functional variations of benign adrenal incidentalomas in relation to initial characteristics. Front Endocrinol (Lausanne) 2023; 14:1179817. [PMID: 37347112 PMCID: PMC10280065 DOI: 10.3389/fendo.2023.1179817] [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: 03/04/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
The follow-up strategy for unresected non-functional adrenal tumors (NFAT) is a major controversial issue in endocrinological clinical practice, as the natural history of adrenal incidentalomas (AI) is partially unknown and a consensus on their adequate management is lacking. In a recent longitudinal study by Ceccato et al., a large cohort of patients with conservatively treated AI were evaluated for possible radiological variations over time and their relationship with autonomous cortisol secretion (ACS). Starting from this paper, we performed a literature review of available longitudinal studies focus on the same issue. Notwithstanding the high variability in the duration of follow-up and in the criteria used to define ACS in the included studies, our findings support the idea that there is a not negligible risk of morphological and functional changes, which may have metabolic implications, especially after 5-10 years of follow-up. Unfortunately, these variations seem to be scarcely predictable. Therefore, it may be risky to interrupt the follow-up in patients with NFAT, in particular in the presence of larger diameter of the adenoma and higher cortisol levels at diagnosis. These results should be considered in defining the optimal management of these patients.
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Affiliation(s)
- Chiara Parazzoli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - 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
| | - Valentina Morelli
- Endocrinology Department & Lab of Endocrine and Metabolic Research, IRCCS-Istituto Auxologico Italiano, Milan, Italy
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22
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Yu H, Wang Y, Li Y, Du J, Guo Q, Gu W, Lyu Z, Dou J, Mu Y, Zang L. Analysis of characteristics of four patients with adrenal unicentric Castleman disease. Front Endocrinol (Lausanne) 2023; 14:1181929. [PMID: 37265694 PMCID: PMC10230092 DOI: 10.3389/fendo.2023.1181929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 06/03/2023] Open
Abstract
Background Castleman Disease (CD) is a group of diseases with characteristic lymph node histopathology, characterized by marked enlargement of deep or superficial lymph nodes. Adrenal CD is rarely reported, and an accurate preoperative diagnosis of adrenal CD is difficult. Method We report four cases of CD in the adrenal gland confirmed by pathology and review the characteristics of this rare disease, highlighting the necessity of diagnostic evaluation and follow-up of the patients. Results All of the patients sought medical advice because of adrenal incidentalomas. No significant abnormalities were presented in the biochemistry or endocrine systems. The imaging suggested a moderate-to-large mass with uneven moderate contrast enhancement of the adrenal region, similar to a pheochromocytoma. All cases were misdiagnosed as pheochromocytomas before operation and finally confirmed by histopathology. Three cases were pathologically diagnosed as hyaline vascular CD, and one case was diagnosed as plasma cell CD. All the patients are alive without recurrence after a median follow-up of 8 years. Conclusion The adrenal CD should be considered after excluding pheochromocytoma and malignancy in the adrenal region. The long-term prognosis of patients with complete resection of the mass is excellent.
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Affiliation(s)
- Hao Yu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yuepeng Wang
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology, General Hospital of Northern Theater Command, Shenyang, China
- School of Medicine, Nankai University, Tianjin, China
| | - Yijun Li
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qinghua Guo
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhaohui Lyu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Zang
- Department of Endocrinology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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23
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Vogg N, Müller T, Floren A, Dandekar T, Riester A, Dischinger U, Kurlbaum M, Kroiss M, Fassnacht M. Simplified urinary steroid profiling by LC-MS as diagnostic tool for malignancy in adrenocortical tumors. Clin Chim Acta 2023; 543:117301. [PMID: 36948238 DOI: 10.1016/j.cca.2023.117301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Preoperative identification of malignant adrenal tumors is challenging. 24-h urinary steroid profiling by LC-MS/MS and machine learning has demonstrated high diagnostic power, but the unavailability of bioinformatic models for public use has limited its routine application. We here aimed to increase usability with a novel classification model for the differentiation of adrenocortical adenoma(ACA) and adrenocortical carcinoma(ACC). METHODS Eleven steroids (5-pregnenetriol, dehydroepiandrosterone, cortisone, cortisol, α-cortolone, tetrahydro-11-deoxycortisol, etiocholanolone, pregnenolone, pregnanetriol, pregnanediol, and 5-pregnenediol) were quantified by LC-MS/MS in 24-h urine samples from 352 patients with adrenal tumor (281 ACA,71 ACC). Random forest modelling and decision tree algorithms were applied in training (n=188) and test sets (n=80) and independently validated in 84 patients with paired 24-h and spot urine. RESULTS After examining different models, a decision tree using excretions of only 5-pregnenetriol and tetrahydro-11-deoxycortisol classified three groups with low, intermediate, and high risk for malignancy. 148/217 ACA were classified as being at low, 67 intermediate, and 2 high risk of malignancy. Conversely, none of the ACC demonstrated a low-risk profile leading to a negative predictive value of 100% for malignancy. In the independent validation cohort, the negative predictive value was again 100% in both 24-h urine and spot urine with a positive predictive value of 87.5% and 86.7%, respectively. CONCLUSIONS This simplified LC-MS/MS-based classification model using 24-h-urine provided excellent results for exclusion of ACC and can help to avoid unnecessary surgeries. Analysis of spot urine led to similarly satisfactory results suggesting that cumbersome 24-h urine collection might be dispensable after future validation.
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Affiliation(s)
- Nora Vogg
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany
| | - Tobias Müller
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Andreas Floren
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Thomas Dandekar
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Anna Riester
- Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany.
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Cuthbertson DJ, Alam U, Davison AS, Belfield J, Shore SL, Vinjamuri S. Investigation and assessment of adrenal incidentalomas. Clin Med (Lond) 2023; 23:135-140. [PMID: 36958837 PMCID: PMC11046519 DOI: 10.7861/clinmed.2023-0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
With the increasing volume of diagnostic imaging undertaken in an ageing population, adrenal incidentalomas (AIs) are increasingly commonly seen. These masses are most likely to be benign, but a small proportion may be malignant. Similarly, they are usually non-functional, but ∼14% are functional, ie hormone-secreting tumours. Clinical, biochemical and radiological assessment is mandated to stratify patients into those requiring radiological surveillance, medical management or surgical intervention or who can be discharged. Mass characteristics on cross-sectional (CT/MRI) imaging influence the need for radiological surveillance. Functional tumours where excess cortisol, aldosterone or catecholamine are secreted should be excluded, with mild autonomous cortisol secretion (MACS) and primary aldosteronism (PA) as the two most common functional states. MACS and PA are associated with an increased risk of cardiometabolic disease (eg hypertension, type 2 diabetes) and cardiovascular morbidity/mortality (eg coronary heart disease). Multidisciplinary management is critical for selected cases; the majority of adrenal incidentalomas only require a single assessment.
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Affiliation(s)
- Daniel J Cuthbertson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK and professor of medicine, University of Liverpool, Liverpool, UK
| | - Uazman Alam
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK and senior clinical lecturer in medicine, University of Liverpool, Liverpool, UK
| | - Andrew S Davison
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jane Belfield
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Susannah L Shore
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sobhan Vinjamuri
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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25
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Possible, probable, and certain hypercortisolism: A continuum in the risk of comorbidity. ANNALES D'ENDOCRINOLOGIE 2023; 84:272-284. [PMID: 36736771 DOI: 10.1016/j.ando.2023.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
Hypercortisolism may be considered as a continuum in terms of both hormonal and cardiometabolic abnormalities. It ranges from cases with "normal" hormonal profile and low to intermediate risk of comorbidity to florid cases with clear clinical and hormonal evidence of glucocorticoid excess and clearly increased cardiometabolic risk. Even in patients with nonfunctioning adrenal incidentaloma (NFAI), defined as adrenal incidentaloma with normal results on the currently available hormonal test for evaluation of hypercortisolism, cardiometabolic and mortality risk is higher than in the general population without adrenal lesions. Mild hypercortisolism or autonomous cortisol secretion (ACS) is a term used for patients with adrenal incidentaloma and pathological dexamethasone suppression test (DST) results, but without specific clinical signs of hypercortisolism. It is widely known that this condition is linked to higher prevalence of several cardiometabolic comorbidities, including diabetes, hypertension, osteoporosis and metabolic syndrome, than in patients with NFAI or without adrenal tumor. In case of overt Cushing's syndrome, cardiovascular risk is extremely high, and standard mortality ratio is high, cardiovascular disease being the leading cause of death. The present review summarizes the current evidence for a detrimental cardiometabolic profile in patients with possible (NFAI), probable (ACS) and certain hypercortisolism (overt Cushing's syndrome).
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26
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Chen AX, Burt MG. Cardio-metabolic pathophysiology in mild glucocorticoid excess: Potential implications for management of adrenal incidentaloma. Clin Endocrinol (Oxf) 2023; 98:153-164. [PMID: 36367077 DOI: 10.1111/cen.14850] [Citation(s) in RCA: 3] [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: 06/13/2022] [Revised: 10/13/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Adrenal adenomas are incidentally identified in up to 5% of computer tomography scans performed for unrelated indications. A proportion of these adrenal incidentalomas are found to autonomously secrete cortisol based on definitions in current guidelines. Epidemiological studies suggest that chronic exposure to mild glucocorticoid excess from adrenal incidentalomas is associated with significantly increased cardiometabolic risk. However, current management guidelines adopt a conservative approach as no large prospective randomized studies have demonstrated that these patients benefit from surgery. This narrative review examines the epidemiological and mechanistic studies related to three common clinical settings of mild glucocorticoid excess to gain further insight into the potential benefits of treating patients with adrenal incidentaloma and possible autonomous cortisol secretion.
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Affiliation(s)
- Angela X Chen
- Department of Endocrinology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Morton G Burt
- Department of Endocrinology, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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27
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Wise J. Most incidentally found adrenal tumours are non-functioning, regardless of age, study finds. BMJ 2022; 378:o2233. [PMID: 36104071 DOI: 10.1136/bmj.o2233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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