Frequently asked questions and answers (if any) in patients with adrenal incidentaloma

Purpose Adrenal incidentalomas (AIs) are incidentally discovered adrenal masses, during an imaging study undertaken for other reasons than the suspicion of adrenal disease. Their management is not a minor concern for patients and health-care related costs, since their increasing prevalence in the aging population. The exclusion of malignancy is the first question to attempt, then a careful evaluation of adrenal hormones is suggested. Surgery should be considered in case of overt secretion (primary aldosteronism, adrenal Cushing’s Syndrome or pheochromocytoma), however the management of subclinical secretion is still a matter of debate. Methods The aim of the present narrative review is to offer a practical guidance regarding the management of AI, by providing evidence-based answers to frequently asked questions. Conclusion The clinical experience is of utmost importance: a personalized diagnostic-therapeutic approach, based upon multidisciplinary discussion, is suggested.

Usefulness of salivary cortisol as a marker of secondary adrenal insufficiency in paediatric patients

Background: The main cause of adrenal insufficiency (AI) in paediatric patients is prolonged treatment with corticosteroids. Determination of plasma cortisol (PC) during ACTH test is the most used adrenal function indicator in clinical practice. However, determination of salivary cortisol (SC), a simple test especially useful in children in order to avoid invasive procedures, can be used as an alternative technique for the diagnosis of adrenal disease. Methods: A two-year prospective study (January 2014-January 2016) in paediatric patients (2-18 years of age) treated with corticosteroids for more than fifteen days, who were investigated for suspected AI. Low-dose ACTH test was used to determine adrenal function and samples for SC and PC were obtained simultaneously in basal situation and during the test (at 30, 60 and 90 minutes). Results: 230 samples (118 PC-112 SC) of 30 studies belonging to 20 patients (4 males), mean age 10.93 years ± 3.69 SD. Pearson’s correlation coefficient showed a positive correlation between PC and SC (r = 0.618, p < 0.001). All the studies with some determination of PC higher than 18 μg/dL (n = 8) had a SC peak higher than 0.61 μg/dL with a specificity of 66.67% and a sensitivity of 93.94% (ROC analysis). Conclusion: Measurement of SC is a less invasive, easier and quicker test than PC to measure plasma free cortisol levels. In our study, a SC peak in low-dose ACTH test higher than 0.61 μg/dL was able to discriminate patients without AI, and proved to be a useful tool in the initial evaluation of children with suspected AI.

Comparison of the Vcheck and IMMULITE 2000 methods for cortisol measurement in canine serum

The aim of this study was to compare canine cortisol results obtained by the Vcheck method with those obtained by the IMMULITE 2000 immunoassay, which had previously been validated for canine serum. The concentration of cortisol in 44 canine serum samples was determined concurrently by the Vcheck and IMMULITE methods, the latter as the reference method. Cortisol values were compared using Pearson’s correlation analysis and simple regression analysis. Agreement between the two methods was calculated with a Bland-Altman plot. According to regression analysis and the Bland-Altman plot, the two methods gave comparable results. The results of the Vcheck method were comparable to those of the IMMULITE 2000 reference method, so the Vcheck may be used as an alternative assay to evaluate serum cortisol concentration in dogs for the diagnosis of adrenal disease.

Adrenal incidentalomas: Effect of size on cortisol secretion and clinical features

Purpose: The aim of this study was to assess the relationship between adrenal incidentaloma size, cortisol secretion suppressibility by Dexamethasone and relevant clinical and laboratory parameters. Methods: This retrospective study included all patients diagnosed with adrenal incidentaloma and admitted to the single department of the Clinic of endocrinology, Diabetes and Diseases of Metabolism during the period from 2012 till the end of 2019. The inclusion criterion was the presence of an asymptomatic adrenal mass on imaging not performed for suspected adrenal disease. The study group included 197 subjects. Adrenal masses were detected using CT or NMR scan. We analysed the correlation between tumour size and relevant hormonal and clinical parameters. Results: We found a significant positive correlation between incidentaloma size and morning cortisol, cortisol after overnight Dexamethasone, and a significant negative correlation between incidentaloma size and morning ACTH, and hip T score. Also, there was a weak but statistically significant correlation between incidentaloma size and systolic blood pressure. Conclusions: Our study shows that the prevalence of adrenal autonomous cortisol secretion increases with incidentaloma size, and that prevalence of hypertension and osteoporosis also increases with an increase of incidentaloma size.

Update: Selective adrenal venous sampling (AVS) – Indication, technique, and significance

Background Primary aldosteronism (PA) is the most common detectable cause of secondary hypertension. The majority of patients have either an adrenal aldosterone-producing adenoma (APA) or bilateral adrenal hyperplasia (BAH) demanding different therapeutic approaches. Screening tests and imaging cannot reliably distinguish between a unilateral or bilateral PA. Methods This review article gives an overview concerning etiology, diagnostics, and therapeutic options of PA, and reviews the indication, the technique, and relevance of selective adrenal venous sampling (AVS) in the context of the current literature and the authors’ experience. Results AVS can verify or exclude a unilaterally dominated secretion with a high success rate. Patients with PA and a unilateral APA can be treated curatively by adrenalectomy. Conclusions AVS is an established diagnostic examination for differentiation of unilateral from bilateral adrenal disease in patients with PA. Key Points: Citation Format

Cardiomyopathies and Adrenal Diseases

Cardiomyopathies are myocardial disorders in which heart muscle is structurally and/or functionally abnormal. Previously, structural cardiomyocyte disorders due to adrenal diseases, such as hyperaldosteronism, hypercortisolism, and hypercatecholaminism, were misunderstood, and endomyocardial biopsy (EMB) was not performed because was considered dangerous and too invasive. Recent data confirm that, if performed in experienced centers, EMB is a safe technique and gives precious information about physiopathological processes implied in clinical abnormalities in patients with different systemic disturbances. In this review, we illustrate the most important features in patients affected by primary aldosteronism (PA), Cushing’s syndrome (CS), and pheochromocytoma (PHEO). Then, we critically describe microscopic and ultrastructural aspects that have emerged from the newest EMB studies. In PA, the autonomous hypersecretion of aldosterone induces the alteration of ion and water homeostasis, intracellular vacuolization, and swelling; interstitial oedema could be a peculiar feature of myocardial toxicity. In CS, cardiomyocyte hypertrophy and myofibrillolysis could be related to higher expression of atrogin-1. Finally, in PHEO, the hypercontraction of myofilaments with the formation of contraction bands and occasional cellular necrosis has been observed. We expect to clear the role of EMB in patients with cardiomyopathies and adrenal disease, and we believe EMB is a valid tool to implement new management and therapies.