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Subclinical hypercortisolism and CT appearance in adrenal incidentalomas: a multicenter study from Southern Sweden

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Abstract

Evaluation of subclinical hypercortisolism (SH) in patients with adrenal incidentaloma (AI) including its correlation to size, attenuation at unenhanced computed tomography (CT) and unilateral or bilateral adrenal disease. Nine hospitals in Southern Sweden investigated during 2005–2007 consecutively patients with AI with hormonal and CT examinations according a regional protocol. Two hundred and twenty-eight patients with AI with median size 2.0 cm were included. One mg overnight dexamethasone suppression test (DST) was performed in 223 patients and basal P-ACTH measured in 146 patients. SH was defined as cortisol ≥50 nmol/l at DST in combination with basal ACTH <2 pmol/l. In patients with unilateral AI 42% (76/180) had inadequate suppression at DST and 23% (27/115) had SH. The probability for SH and inadequate suppression at DST correlated positively to size and inversely to attenuation at CT. Bilateral AI were found in 43 patients and of these 70% (30/43) had inadequate suppression at DST and 42% (13/31) SH. The patients with SH or inadequate suppression at DST had increased frequency of hypertension which increased further in patients with post-DST cortisol ≥140 nmol/l. The applied criterion for SH is useful for initial evaluation of patients with AI. SH is common in patients with AI, particular in bilateral disease. In patients with unilateral AI the probability for SH correlated positively to size and inversely to attenuation at CT. Furthermore, SH and the post-DST cortisol concentration was associated with hypertension.

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References

  1. S. Bovio, A. Cataldi, G. Reimondo, P. Sperone, S. Novello, A. Berruti, P. Borasio, C. Fava, L. Dogliotti, G.V. Scagliotti, A. Angeli, M. Terzolo, Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J. Endocrinol. Invest. 29(4), 298–302 (2006)

    PubMed  CAS  Google Scholar 

  2. R.T. Kloos, M.D. Gross, I.R. Francis, M. Korobkin, B. Shapiro, Incidentally discovered adrenal masses. Endocr. Rev. 16(4), 460–484 (1995)

    PubMed  CAS  Google Scholar 

  3. W.F. Young Jr, Clinical practice. The incidentally discovered adrenal mass. N. Engl. J. Med. 356(6), 601–610 (2007). doi:10.1056/NEJMcp065470

    Article  PubMed  CAS  Google Scholar 

  4. F. Mantero, M. Terzolo, G. Arnaldi, G. Osella, A.M. Masini, A. Ali, M. Giovagnetti, G. Opocher, A. Angeli, A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. J. Clin. Endocrinol. Metab. 85(2), 637–644 (2000)

    Article  PubMed  CAS  Google Scholar 

  5. B. Bulow, B. Ahren, Adrenal incidentaloma—experience of a standardized diagnostic programme in the Swedish prospective study. J. Intern. Med. 252(3), 239–246 (2002)

    Article  PubMed  CAS  Google Scholar 

  6. J.H. Song, F.S. Chaudhry, W.W. Mayo-Smith, The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR Am. J. Roentgenol. 190(5), 1163–1168 (2008). doi:10.2214/AJR.07.2799

    Article  PubMed  Google Scholar 

  7. S. Tsagarakis, D. Vassiliadi, N. Thalassinos, Endogenous subclinical hypercortisolism: diagnostic uncertainties and clinical implications. J. Endocrinol. Invest. 29(5), 471–482 (2006)

    PubMed  CAS  Google Scholar 

  8. L.K. Nieman, B.M. Biller, J.W. Findling, J. Newell-Price, M.O. Savage, P.M. Stewart, V.M. Montori, The diagnosis of Cushing’s syndrome: an Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 93(5), 1526–1540 (2008). doi:10.1210/jc.2008-0125

    Article  PubMed  CAS  Google Scholar 

  9. G.P. Piaditis, G.A. Kaltsas, I.I. Androulakis, A. Gouli, P. Makras, D. Papadogias, K. Dimitriou, D. Ragkou, A. Markou, K. Vamvakidis, G. Zografos, G. Chrousos, High prevalence of autonomous cortisol and aldosterone secretion from adrenal adenomas. Clin. Endocrinol. (Oxf.) 71(6), 772–778 (2009). doi:10.1111/j.1365-2265.2009.03551.x

    Article  CAS  Google Scholar 

  10. E. Vassilatou, A. Vryonidou, S. Michalopoulou, J. Manolis, J. Caratzas, C. Phenekos, I. Tzavara, Hormonal activity of adrenal incidentalomas: results from a long-term follow-up study. Clin. Endocrinol. (Oxf.) 70(5), 674–679 (2009). doi:10.1111/j.1365-2265.2008.03492.x

    Article  CAS  Google Scholar 

  11. I. Chiodini, Clinical review: diagnosis and treatment of subclinical hypercortisolism. J Clin. Endocrinol. Metab. 96(5), 1223–1236 (2011). doi:10.1210/jc.2010-2722

    Article  PubMed  CAS  Google Scholar 

  12. G.G. Garrapa, P. Pantanetti, G. Arnaldi, F. Mantero, E. Faloia, Body composition and metabolic features in women with adrenal incidentaloma or Cushing’s syndrome. J. Clin. Endocrinol. Metab. 86(11), 5301–5306 (2001)

    Article  PubMed  CAS  Google Scholar 

  13. L. Tauchmanova, R. Rossi, B. Biondi, M. Pulcrano, V. Nuzzo, E.A. Palmieri, S. Fazio, G. Lombardi, Patients with subclinical Cushing’s syndrome due to adrenal adenoma have increased cardiovascular risk. J. Clin. Endocrinol. Metab. 87(11), 4872–4878 (2002)

    Article  PubMed  CAS  Google Scholar 

  14. M. Terzolo, A. Pia, A. Ali, G. Osella, G. Reimondo, S. Bovio, F. Daffara, M. Procopio, P. Paccotti, G. Borretta, A. Angeli, Adrenal incidentaloma: a new cause of the metabolic syndrome? J. Clin. Endocrinol. Metab. 87(3), 998–1003 (2002)

    Article  PubMed  CAS  Google Scholar 

  15. I. Chiodini, V. Morelli, B. Masserini, A.S. Salcuni, C. Eller-Vainicher, R. Viti, F. Coletti, G. Guglielmi, C. Battista, V. Carnevale, L. Iorio, P. Beck-Peccoz, M. Arosio, B. Ambrosi, A. Scillitani, Bone mineral density, prevalence of vertebral fractures, and bone quality in patients with adrenal incidentalomas with and without subclinical hypercortisolism: an Italian multicenter study. J. Clin. Endocrinol. Metab. 94(9), 3207–3214 (2009). doi:10.1210/jc.2009-0468

    Article  PubMed  CAS  Google Scholar 

  16. G. Bernini, A. Moretti, P. Iacconi, P. Miccoli, R. Nami, B. Lucani, A. Salvetti, Anthropometric, haemodynamic, humoral and hormonal evaluation in patients with incidental adrenocortical adenomas before and after surgery. Eur. J. Endocrinol. 148(2), 213–219 (2003)

    Article  PubMed  CAS  Google Scholar 

  17. I. Chiodini, V. Morelli, A.S. Salcuni, C. Eller-Vainicher, M. Torlontano, F. Coletti, L. Iorio, A. Cuttitta, A. Ambrosio, L. Vicentini, F. Pellegrini, M. Copetti, P. Beck-Peccoz, M. Arosio, B. Ambrosi, V. Trischitta, A. Scillitani, Beneficial metabolic effects of prompt surgical treatment in patients with an adrenal incidentaloma causing biochemical hypercortisolism. J. Clin. Endocrinol. Metab. 95(6), 2736–2745 (2010). doi:10.1210/jc.2009-2387

    Article  PubMed  CAS  Google Scholar 

  18. A. Toniato, I. Merante-Boschin, G. Opocher, M.R. Pelizzo, F. Schiavi, E. Ballotta, Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study. Ann. Surg. 249(3), 388–391 (2009). doi:10.1097/SLA.0b013e31819a47d2

    Article  PubMed  Google Scholar 

  19. M. Korobkin, T.J. Giordano, F.J. Brodeur, I.R. Francis, E.S. Siegelman, L.E. Quint, N.R. Dunnick, J.P. Heiken, H.H. Wang, Adrenal adenomas: relationship between histologic lipid and CT and MR findings. Radiology 200(3), 743–747 (1996)

    PubMed  CAS  Google Scholar 

  20. D.H. Szolar, M. Korobkin, P. Reittner, A. Berghold, T. Bauernhofer, H. Trummer, H. Schoellnast, K.W. Preidler, H. Samonigg, Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT. Radiology 234(2), 479–485 (2005). doi:10.1148/radiol.2342031876

    Article  PubMed  Google Scholar 

  21. M.A. Blake, C.G. Cronin, G.W. Boland, Adrenal imaging. AJR Am. J. Roentgenol. 194(6), 1450–1460 (2010). doi:10.2214/AJR.10.4547

    Article  PubMed  Google Scholar 

  22. L. Barzon, C. Scaroni, N. Sonino, F. Fallo, M. Gregianin, C. Macri, M. Boscaro, Incidentally discovered adrenal tumors: endocrine and scintigraphic correlates. J. Clin. Endocrinol. Metab. 83(1), 55–62 (1998)

    Article  PubMed  CAS  Google Scholar 

  23. D.A. Vassiliadi, G. Ntali, E. Vicha, S. Tsagarakis, High prevalence of subclinical hypercortisolism in patients with bilateral adrenal incidentalomas: a challenge to management. Clin. Endocrinol. (2010). doi:10.1111/j.1365-2265.2010.03963.x

    Google Scholar 

  24. S. Tsagarakis, P. Kokkoris, C. Roboti, C. Malagari, J. Kaskarelis, V. Vlassopoulou, C. Alevizaki, N. Thalassinos, The low-dose dexamethasone suppression test in patients with adrenal incidentalomas: comparisons with clinically euadrenal subjects and patients with Cushing’s syndrome. Clin. Endocrinol. (Oxf.) 48(5), 627–633 (1998)

    Article  CAS  Google Scholar 

  25. M. Terzolo, A. Stigliano, I. Chiodini, P. Loli, L. Furlani, G. Arnaldi, G. Reimondo, A. Pia, V. Toscano, M. Zini, G. Borretta, E. Papini, P. Garofalo, B. Allolio, B. Dupas, F. Mantero, A. Tabarin, AME position statement on adrenal incidentaloma. Eur. J Endocrinol./Eur. Fed. Endocr. Soc. 164(6), 851–870 (2011). doi:10.1530/EJE-10-1147

    Article  CAS  Google Scholar 

  26. M. Terzolo, A. Pia, G. Reimondo, Subclinical Cushing’s syndrome: definition and management. Clin. Endocrinol. 76(1), 12–18 (2012). doi:10.1111/j.1365-2265.2011.04253.x

    Article  CAS  Google Scholar 

  27. V. Morelli, B. Masserini, A.S. Salcuni, C. Eller-Vainicher, C. Savoca, R. Viti, F. Coletti, G. Guglielmi, C. Battista, L. Iorio, P. Beck-Peccoz, B. Ambrosi, M. Arosio, A. Scillitani, I. Chiodini, Subclinical hypercortisolism: correlation between biochemical diagnostic criteria and clinical aspects. Clin. Endocrinol. (Oxf.) 73(2), 161–166 (2010). doi:10.1111/j.1365-2265.2010.03794.x

    CAS  Google Scholar 

  28. S. Tsagarakis, C. Roboti, P. Kokkoris, V. Vasiliou, C. Alevizaki, N. Thalassinos, Elevated post-dexamethasone suppression cortisol concentrations correlate with hormonal alterations of the hypothalamo-pituitary adrenal axis in patients with adrenal incidentalomas. Clin. Endocrinol. (Oxf.) 49(2), 165–171 (1998)

    Article  CAS  Google Scholar 

  29. S. Bujawansa, D. Bowen-Jones, Low investigation rate for adrenal incidentalomas. Endocrine 40(1), 134–136 (2011). doi:10.1007/s12020-011-9487-9

    Article  PubMed  CAS  Google Scholar 

  30. L. Barzon, F. Fallo, N. Sonino, M. Boscaro, Overnight dexamethasone suppression of cortisol is associated with radiocholesterol uptake patterns in adrenal incidentalomas. Eur. J. Endocrinol. 145(2), 223–224 (2001)

    Article  PubMed  CAS  Google Scholar 

  31. A. Comlekci, S. Yener, S. Ertilav, M. Secil, B. Akinci, T. Demir, L. Kebapcilar, F. Bayraktar, S. Yesil, S. Eraslan, Adrenal incidentaloma, clinical, metabolic, follow-up aspects: single centre experience. Endocrine 37(1), 40–46 (2010). doi:10.1007/s12020-009-9260-5

    Article  PubMed  CAS  Google Scholar 

  32. D.A. Vassiliadi, G. Ntali, T. Stratigou, M. Adali, S. Tsagarakis, Aberrant cortisol responses to physiological stimuli in patients presenting with bilateral adrenal incidentalomas. Endocrine 40(3), 437–444 (2011). doi:10.1007/s12020-011-9490-1

    Article  PubMed  CAS  Google Scholar 

  33. J. Majnik, A. Patocs, K. Balogh, M. Toth, P. Gergics, A. Szappanos, A. Mondok, G. Borgulya, P. Panczel, Z. Prohaszka, K. Racz, Overrepresentation of the N363S variant of the glucocorticoid receptor gene in patients with bilateral adrenal incidentalomas. J. Clin. Endocrinol. Metab. 91(7), 2796–2799 (2006). doi:10.1210/jc.2006-0066

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

Zoégas foundation has supported this study with an unrestricted grant. Dr Margareta Bramnert, Skåne University Hospital, Malmö and all other physicians and research nurses for collection of data.

Conflict of interest

No conflict of interests to declare.

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Authors and Affiliations

  1. Department of Internal Medicine, Hospital of Helsingborg, 251 87, Helsingborg, Sweden

    Henrik Olsen

  2. Department of Endocrine Surgery, Skåne University Hospital, Lund, Sweden

    Erik Nordenström & Anders Bergenfelz

  3. Department of Radiology, Hospital of Trelleborg, Trelleborg, Sweden

    Ulf Nyman

  4. Department of Oncology, Skåne University Hospital, Lund, Sweden

    Stig Valdemarsson

  5. Department of Surgery, Hospital of Halmstad, Halmstad, Sweden

    Erik Palmqvist

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  1. Henrik Olsen
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  2. Erik Nordenström
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Correspondence to Henrik Olsen.

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On behalf of the Southern Sweden network group for diseases in thyroid, parathyroid, adrenal glands and abdominal endocrine tumours.

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Olsen, H., Nordenström, E., Bergenfelz, A. et al. Subclinical hypercortisolism and CT appearance in adrenal incidentalomas: a multicenter study from Southern Sweden. Endocrine 42, 164–173 (2012). https://doi.org/10.1007/s12020-012-9622-2

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  • DOI: https://doi.org/10.1007/s12020-012-9622-2

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