Endocrine Abstracts

Adrenal incidentalomas (AI) are recognized more and more frequently, due to the widespread use of CT. Although unexpected, these tumors raise the question of a putative morbidity related either to their proliferation potential or to their endocrine secretion. Regarding proliferation it is now established that a low (<10 UH) and homogeneous density on unenhanced CT scan is specific for a benign adrenocortical adenoma, which do not need to be operated for fear that they may become malignant. Regarding secretion some patients may have previously unrecognized overt Cushing’s syndrome (CS) and should be operated. By contrast there is a debate regarding patients with no overt CS, but an autonomous secretion of cortisol (ASC), defined by plasma cortisol level>50 nmol/l after 1 mg dexamethasone-suppression. We will argue here that many of these patients should also benefit from surgery, based on the following points:- There is good evidence for an association of ASC with diabetes, hypertension, and an increased mortality, both cardiovascular and global.- Several retrospective studies reported that patients with ASC who were operated showed improvement of hypertension and metabolic control.- One recent prospective randomized controlled study demonstrated improvement of hypertension and metabolic control and the promising results of another larger randomized control are expected soon.- A meta-analysis of laparoscopic unilateral adrenalectomy has reported no mortality and very little morbidity: for AI with ASC there may be transient adrenal insufficiency, related to the previous hypothalamic/pituitary suppression by ASC, but this must be understood as another proof that ASC does have significant clinical effect.- The cost of surgery is considerably lower than the alternative of a life-long medical anticortisolic treatment. We believe that these points should lead us to perform adrenalectomy in most patients with AI and confirmed ASC who do not have specific risks for surgery and who accept it.