Long-term morphological and hormonal follow-up in a single unit on 115 patients with adrenal incidentalomas

Abstract

We investigated the natural course of adrenal incidentalomas in 115 patients by means of a long-term endocrine and morphological (CT) follow-up protocol (median 4 year, range 1 -7 year). At entry, we observed 61 subclinical hormonal alterations in 43 patients (mainly concerning the ACTH -cortisol axis), but confirmatory tests always excluded specific endocrine diseases. In all cases radiologic signs of benignity were present. Mean values of the hormones examined at last follow-up did not differ from those recorded at entry. However in individual patients several variations were observed. In particular, 57 endocrine alterations found in 43 patients (37.2%) were no longer confirmed at follow-up, while 35 new alterations in 31 patients (26.9%) appeared de novo. Only four alterations in three patients (2.6%) persisted. Confirmatory tests were always negative for specific endocrine diseases. No variation in mean mass size was found between values at entry (25.470.9 mm) and at follow-up (25.770.9 mm), although in 32 patients (27.8%) mass size actually increased, while in 24 patients (20.8%) it decreased. In no case were the variations in mass dimension associated with the appearance of radiological criteria of malignancy. Kaplan -Meier curves indicated that the cumulative risk for mass enlargement (65%) and for developing endocrine abnormalities (57%) over time was progressive up to 80 months and independent of haemodynamic and humoral basal characteristics. In conclusion, mass enlargement and the presence or occurrence over time of subclinical endocrine alterations are frequent and not correlated, can appear at any time, are not associated with any basal predictor and, finally, are not necessarily indicative of malignant transformation or of progression toward overt disease.

Bilateral adrenal incidentalomas differ from unilateral adrenal incidentalomas in subclinical cortisol hypersecretion but not in potential clinical implications

“…hypertension, type 2 diabetes, and dyslipidemia) did not differ between patients with BAI (26). Cortisol secretion in patients with adrenal incidentalomas presents a wide range of variability from normal secretion to autonomous cortisol hypersecretion, and intermittent subclinical autonomous cortisol hypersecretion has also been shown in some patients during follow-up (10,27,28). In this setting, it can be explained why no clear-cut difference in the frequency of potentially related morbidities to subtle cortisol hypersecretion has been shown between clinically silent adrenal incidentaloma patients with and without SCS (6,11).…”

Pros and cons of dexamethasone suppression test for screening of subclinical Cushing’s syndrome in patients with adrenal incidentalomas

“…As a matter of fact, the phenomenon of resistance to increasing doses of dexamethasone has been already observed in small groups of patients submitted to both tests (7,31,32). Spontaneous fluctuation of cortisol secretion over time, that has been demonstrated also in subclinical Cushing's syndrome (33), may contribute to the finding that cortisol was paradoxically higher after 8-mg than 1-mg DST.…”

Definition of an optimal strategy to evaluate and follow-up adrenal incidentalomas: time for further research

“…In this context, the risk of evolution from subclinical to clinically overt Cushing's syndrome, although depending upon the definition of the disorder, should not be a major concern (7). On the other hand, spontaneous normalization of subclinical hypercortisolism was also observed in some reports not included in the present analysis, raising the possibility that cortisol output by an adrenocortical adenoma may be variable over the course of time (7,24). As a consequence, Cawood et al (5) argued that follow-up of adrenal incidentalomas initially considered to be benign and not-functional is likely to result in significant costs, both financial and emotional, due to frequent false positive results, carries little clinical benefit and even confers a non-negligible risk of fatal cancer.…”