Subclinical Cushing’s syndrome: lots of questions — little answers

The literature review provides a definition of the essence of subclinical Cushing’s syndrome. Subclinical Cushing’s syndrome (subclinical hypercortisolism) is a pathological condition of the body characterized by an autonomous, excessive secretion of glucocorticoids, most often an adrenal cortex adenoma, suppression of the adrenocorticotropic function of the pituitary gland and the functional state of the opposite adrenal gland. Such a condition may be clini-cally asymptomatic or be accompanied by some nonspecific signs of hypercortisolism (arterial hypertension, diabetes mellitus, obesity, osteoporosis). Noteworthy is the large variability in the frequency of its detection, which is possibly due to the use of various criteria for assigning individual cases to this category. As a basic screening test for the detection of subclinical hypercortisolism, most researchers consider the most acceptable and effective night suppressive test with 1.0 mg of dexamethasone. Modern tactical and technical approaches to the treatment of subclinical Cushing’s syndrome are quite diverse and are more often based on pragmatic principles than on reliably substantiated ones. The author raises the question: could subclinical Cushing’s syndrome be the result of hyperfunction of normal or diffusely enlarged (hyperplastic) adrenal glands as a result of some disturbances in the hypothalamic-pituitary-adrenal hierarchy. And, finally, are the disorders “accompanying” subclinical Cushing’s syndrome a consequence of the overproduction of cortisol, although often insignificant, or can they be the cause of the onset of subclinical hypercortisolism? For the treatment of subclinical hypercortisolism, adrenalectomy is currently proposed, with the aim of reducing the intake of excessive amounts of glucocorticoids into the patient’s body, leading to the development of these disorders. Known drug methods of suppressing the function of the adrenal cortex — drugs chloditan, mitotane, ketoconazole.

An Uncommon Presentation of Adrenal Cyst with Subclinical Cushing’s Syndrome: A Diagnosis Dilemma

Adrenal cysts are a rare entity that is usually nonfunctional and asymptomatic. Their association with adrenal neoplasms was rarely described in the literature. We report a unique case of a 40 -year-old woman who was referred for evaluation of a left adrenal incidentaloma with subclinical Cushing’s syndrome. The tumor was suspicious for malignancy regarding computed tomography scan (CT scan) features. Therefore, a laparoscopic left partial adrenalectomy was performed. Pathology examination showed multilocular spaces lined by endothelial cells which are compatible with endothelial adrenal cyst, associated to an adrenocortical adenoma. We further discuss the management of adrenal cyst with review of the literature.

Mixed corticomedullary tumor accompanied by unilateral aldosterone-producing adrenocortical micronodules: A case report

Mixed corticomedullary tumors (MCMTs) are rare and comprise of medullary and cortical cells in a single adrenal tumor. The mechanisms underlying its development have not been fully elucidated. Here, we report a case of MCMT in a 42-year-old woman. Based on the preoperative clinical findings, the patient was diagnosed as having a pheochromocytoma with subclinical Cushing's syndrome. Postoperative pathological diagnosis revealed that the tumor demonstrated morphologically distinct medullary and cortical components, which produced catecholamines and cortisol, respectively. Hybrid tumor cells producing both catecholamines and cortisol were not detected. Adrenocorticotropic hormone (ACTH)-positive tumor cells were identified to be present in the pheochromocytoma. This ectopic production of ACTH can contribute to an autonomous cortisol production in a paracrine manner. In addition, micronodules producing aldosterone were detected in the adrenal tissue adjacent to the tumor. The simultaneous development of these two lesions may not be correlated with each other; however, this case confirms the importance of a detailed histopathological examination of the adrenal lesions harboring complicated hormonal abnormalities by providing pivotal and indispensable information on their pathogenesis and the possible interaction of the hormones produced in the adrenal gland.

Approach to the Patient with Subclinical Cushing’s Syndrome

A growing number of patients with adrenal incidentalomas and subclinical Cushing’s syndrome (SCS) led to an increasing number of different guidelines, and diagnostic and treatment recommendations. Excess cortisol secretion in patients with SCS is associated with several comorbidities, such as hypertension, dyslipidemia, type 2 diabetes mellitus, and obesity, which in the long-term increase mortality of these patients. Subtle cortisol secretion affects bone health, quality of life and causes depression, but due to the unapparent clinical features, patients with SCS are often at risk between over and under treatment. This narrative review aimed to summarize the latest recommendations on the approach to the patient with subclinical Cushing’s syndrome.