Subclinical Cushing's syndrome in adrenal incidentaloma

Terzolo, Massimo; Osella, Giangiacomo; Alı̀, Anna; Borretta, Giorgio; Cesario, Flora; Paccotti, Piero; Angeli, Alberto

doi:10.1046/j.1365-2265.1998.00357.x

Cited by 185 publications

(151 citation statements)

References 28 publications

(58 reference statements)

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“…To test the effectiveness of the different proposed cortisol cut-off after the 1-mg DST by using Bayesan analysis we had to define a priori the probability of autonomous cortisol secretion based on observed alterations in the tests used to assess the function of the HPA axis. We acknowledge that such a definition is arbitrary, but the presence of at least two alterations of the HPA axis has been widely used in previous work (14,22,23,24). Our data confirm that only a cut-point at 138 nmol/l achieves an incremental diagnostic effectiveness to detect functional adrenal autonomy.…”

Section: Discussionsupporting

confidence: 62%

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

Reimondo

Allasino

Bovio

et al. 2011

J Endocrinol Invest

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The results of dexamethasone suppression tests (DST) in the screening of subclinical hypercortisolism are not readily comparable. Aim of the present study was to review the effectiveness of the overnight 1-mg DST and 8-mg DST to look for functional autonomy of clinically inapparent adrenal adenomas.Sixty-eight consecutive patients with clinically inapparent adrenal adenomas were enrolled. All patients underwent 1-mg DST. The 8-mg DST was performed in the 11 patients who had post 1-mg DST cortisol >138 nmol/L and in 11 patients who had post 1-mg DST cortisol between 50 -138 nmol/L. The a priori probability to have autonomous cortisol secretion was defined by the presence of at least two alterations of the HPA axis among reduced ACTH concentrations, elevated UFC or elevated midnight serum cortisol. Cortisol levels > 138 nmol/L after the 1-mg DST increases the post-test probability of adrenal functional autonomy to 55%, whereas cortisol levels <50 nmol/L reduce the post-test probability to 8%. Cortisol levels recorded after the 8-mg DST were non-significantly lower than after the 1-mg DST and all the patients with cortisol >138 nmol/L after the 1 mg DST maintained cortisol above this cut-point.The 1-mg DST should be considered as the more effective test to detect autonomous cortisol secretion by a clinically inapparent adrenal adenoma when cortisol levels are >138 nmol/l, while cortisol levels < 50 nmol/L reduces remarkably the post-test probability of this event. The 8-mg DST seems to replicate by large the results of the 1-mg DST.4

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Section: Discussionsupporting

confidence: 62%

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

Reimondo

Allasino

Bovio

et al. 2011

J Endocrinol Invest

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“…The reported prevalence of subclinical Cushing's syndrome among patients with adrenal incidentaloma ranges from 5% to 20% (2,3,(11)(12)(13)(14)(15)(16)(17). The sources of this heterogeneity may be found in the different work-up protocols and variable criteria used to define subclinical cortisol excess as well as in different inclusion criteria and size of the reported series (table 1).…”

Section: Diagnosismentioning

confidence: 99%

“…[Terzolo et al,ref. 3] tectable ACTH levels have been frequently reported (11)(12)(13) even if technical problems associated with measurement of ACTH concentrations close to the detection limits of the assay affect the utility of ACTH determination to demonstrate functional autonomy of an adrenal adenoma (9). Use of CRH test does not seem to add significant information to baseline ACTH levels (11,12,17,18).…”

Section: Diagnosismentioning

confidence: 99%

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Subclinical Cushing's Syndrome

et al. 2004

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Subclinical Cushing's syndrome (CS) is attracting increasing interest since the serendipitous discovery of an adrenal mass has become a rather frequent event owing to the routine use of sophisticated radiologic techniques. Cortical adenoma is the most frequent type of adrenal incidentaloma accounting for approximately 50% of cases in surgical series and even greater shares in medical series. Incidentally discovered adrenal adenomas may secrete cortisol in an autonomous manner that is not fully restrained by pituitary feedback, in 5 to 20% of cases depending on study protocols and diagnostic criteria. The criteria for qualifying subclinical cortisol excess are controversial and presently there is no consensus on a gold standard for the diagnosis of this condition. An increased frequency of hypertension, central obesity, impaired glucose tolerance, diabetes and hyperlipemia has been described in patients with subclinical CS; however, there is still no clear demonstration of the long-term complications of this condition whose management remains largely empirical. Either adrenalectomy or careful observation associated with treatment of the metabolic syndrome have been suggested as treatment options. RESUMO Síndrome de Cushing Subclínica.A síndrome de Cushing subclínica (SCS) tem atraído interesse cada vez maior desde que a descoberta casual de uma massa adrenal se tornou um evento freqüente devido ao emprego rotineiro de técnicas sofisticadas de imagem. O adenoma cortical é o tipo mais freqüente de incidentaloma adrenal, correspondendo a cerca de 50% dos casos em séries cirúrgicas e até mais do que isso em séries médicas. Adenomas adrenais descobertos incidentalmente podem secretar cortisol de maneira autônoma ou não controlada totalmente pelo feedback hipofisário, em 5 a 20% dos casos, dependendo do protocolo de estudo e dos critérios diagnósticos. Os critérios para qualificar um excesso subclínico de cortisol são controversos e atualmente não existe consenso a respeito de "padrão ouro" para o diagnóstico dessa condição. Em pacientes com SCS, tem sido descrita uma freqüência elevada de hipertensão, obesidade central, intolerância à glicose, diabetes e hiperlipemia; entretanto, ainda não existe uma evidente demonstração de complicações a longo prazo dessa condição, cujo manejo permanece amplamente empírico. Tanto a adrenalectomia como a observação cuidadosa, associada com o tratamento da síndrome metabólica, têm sido sugeridos como opções terapêuticas.

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“…The main problem is that the natural course of adrenal incidentalomas has not yet been fully clarified. Prespecified protocols that have prospectively investigated the evolution of these masses are scanty and those reported in the literature have given inconsistent results on the basis of different duration of observation, number of patients studied and methodological approaches adopted (Jockenhovel et al, 1992;Terzolo et al, 1998;Barzon and Boscaro, 2000;Siren et al, 2000). In particular, it is not known if these masses may increase in size and, above all, whether this is a marker of malignant transformation or whether malignancy may also occur without size variation.…”

mentioning

confidence: 99%

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

et al. 2005

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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.

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Subclinical Cushing's syndrome in adrenal incidentaloma

Cited by 185 publications

References 28 publications

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

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

Subclinical Cushing's Syndrome

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

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