Endocrine Abstracts

Introduction: Patients with subclinical Cushing’s syndrome (SCS) are thought to have excess cortisol from an adrenal adenoma, secreting ACTH-independent cortisol that is not fully suppressed by the pituitary feedback system. High cortisol levels may be linked to metabolic complications. There are no specific guidelines on the surgical management of SCS.

Objective: To evaluate if patients with SCS are monitored and managed for metabolic complications due to cortisol excess.

Method: A retrospective service evaluation study on patients diagnosed with SCS from 2016 to 2019 at the University Hospital of Wales, United Kingdom. We identified 114 patients with a non-suppressed response to the overnight dexamethasone test (ODST), qualified as a 0900 h cortisol > 50 nmol/l. 48/114 were excluded either due to a further negative dexamethasone suppression test or no adrenal adenoma present on imaging. Data of 66 patients were collected on the monitoring and management for metabolic complications in July 2021.

Results: 66 patients showed a mean age of 66±12.74 S.D., a male to female ratio of 2:1. 89% (59) had a single adenoma, 11% (7) had bilateral adenomas, and the mean lesion size was 2.82 cm ±1.34 S.D.. 70% (46) of patients had at least one known metabolic complication present. The four metabolic complications present were hypertension (65%), diabetes mellitus (21%), dyslipidaemia (15%), and osteoporosis/osteopenia (27%). 21% (14) of patients had a history of cardiovascular disease (CVD). The majority had one to three metabolic risk factors (RF) screened; four patients had all four RF tests done; positive results for HbA1c (7/22), lipid profile (11/33), blood pressure (24/43), and DEXA scan (18/21). 28 (42%) patients had been discharged, 12 (18%) were deceased. Surgery was discussed in 26 patients (39%); 10/26 were offered and ultimately 8 underwent the surgery. The criteria to be offered surgery were only clear in 4/8 (50.0%) patients, as they had a lesion > 4 cm. 6/8 surgical patients had at least one metabolic complication, and 5/8 had a minimum of one positive RF result. All the adrenal adenomas removed were shown to be benign in the histopathology studies.

Conclusion: SCS is linked with other metabolic complications; improvement in monitoring of these complications will help the patient receive the required treatment earlier to reduce their CVD risk. More defined surgical criteria could aid clinicians in decision-making. Non-surgical patients may benefit from continued monitoring of metabolic risk factors/complications even after discharge.