Management of autonomous cortisol secreting incidental adrenal adenoma: evolving clinical pathway

Shreyans Darla; Thomas Payne; Neetha Joseph; Mark Rochester; Melanie Maxwell; David Manson-Barh; Janak Saada; Rupa Ahluwalia; Myint Khin Swe

doi:10.1530/endoabs.109.P59

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Endocrine Abstracts (2025) 109 P59 | DOI: 10.1530/endoabs.109.P59

SFEBES2025 Poster Presentations Adrenal and Cardiovascular (61 abstracts)

Management of autonomous cortisol secreting incidental adrenal adenoma: evolving clinical pathway

Shreyans Darla ¹ , Thomas Payne ¹ , Neetha Joseph ¹ , Mark Rochester ¹ , Melanie Maxwell ¹ , David Manson-Barh ¹ , Janak Saada ¹ , Rupa Ahluwalia ¹ & Khin Swe Myint ^1,2

Author affiliations

¹Norfolk and Norwich University Hospital, Norwich, United Kingdom; ²University of East Anglia, Norwich, United Kingdom

Background: Autonomous cortisol secretion (ACS) is the most common (up to 40%) functioning adrenal incidentaloma. Active management of ACS become increasingly important due to emerging evidence of its associated cardiometabolic risk and osteoporosis. Aim: We aim to evaluate our service of ACS from 2016-2024.

Method: We retrospectively collected data from patients with ACS with the search term Autonomous Cortisol Secretion’ and/or ‘failed to suppress overnight dexamethasone suppression test (ODS)’. Demographic data, investigations to assess cortisol excess, cardiovascular comorbidities were analysed descriptively. Our clinical pathway was evaluated.

Result: We identified 80 cases of patients with a failed ODS (cortisol >50nmol/L- mean cortisol 123nmol/l). The demographic showed mean age 69.2yrs (SD± 13.1), female (57%), with established comorbidities (hypertension (76%), diabetes (39%), other CVD risks (51%), and osteoporosis (21%). 76 (95%) underwent Low dose dexamethasone suppression test (LDDST) and 50 (63%) had a paired plasma ACTH. Only 9 (12%) LDDST was normal (cortisol <50nmol/l) excluded ACS diagnosis. In remaining 71 cases (mean cortisol post LDDS 109nmol/l), assessment of cortisol burden was carried out. 38 (54%) cases had serum cortisol day curve (mean cortisol 310nmol/l), 23:00 salivary cortisol (mean 2.77nmol/l) and cortisone. 55 (77%) had DEXA scan (mean T score –1.7). 13 patients (18%) underwent laparoscopic robotic adrenalectomy with cure of ACS and improved CVD risks.

Discussion: ACS is a complex entity which needs thorough work-up to determine treatment course. It is reassuring that ODS is still a good screening tool with an 89% specificity comparing with LDDS. We recommend development of a standardised more detailed investigation pathway allowing for multiparametric assessment of cortisol burden and comorbid status to help inform decision-making, particularly surrounding curative (surgical) management. Further evaluation of our data is needed for outcomes of those who were currently under observation, deem not fit for surgery or those who declined surgery.