Bone mineral density, prevalence of vertebral fractures, and bone quality in patients with adrenal incidentalomas with and without subclinical hypercortisolism: an Italian multicenter study
Abstract
CONTEXT: In patients with adrenal incidentalomas and subclinical hypercortisolism (SH), the factors influencing bone and the prevalence of vertebral fractures are debated. Spinal deformity index (SDI), which reflects bone quality, has never been evaluated. OBJECTIVE: The objective of the study was to investigate in these patients SDI and factors influencing the prevalence of fractures. DESIGN: This was a retrospective, multicenter study. SETTING: The study was conducted on an in- and outpatient basis. PATIENTS: Patients included 287 adrenal incidentaloma patients (111 eugonadal males, 31 premenopausal, 145 postmenopausal females) and 194 controls (90 eugonadal males, 29 premenopausal, 75 postmenopausal females). MAIN OUTCOME MEASURE: Bone mineral density (BMD) was measured by dual X-ray absorptiometry at lumbar spine and femoral neck. By radiograph each vertebra was assessed as intact (grade 0) or grade 1 (20-25%), 2 (25-40%), or 3 (>40%) deformity; SDI was calculated by summing the grade of deformity for each vertebra. SH was diagnosed in the presence of at least two of the following: urinary free cortisol greater than 70 microg per 24 h (193.1 nmol/liter), cortisol after 1-mg dexamethasone test greater than 3.0 microg/dl (>82.8 nmol/liter), ACTH less than 10 pg/ml (<2.2 pmol/liter). RESULTS: BMD was significantly lower in SH+ than SH- patients and controls (lumbar spine -0.73 +/- 1.43, 0.17 +/- 1.33, 0.12 +/- 1.21, respectively; femoral neck -0.37 +/- 1.06, 0.07 +/- 1.09, 0.17 +/- 1.02). Patients with SH had higher fracture prevalence and SDI than those without SH and controls (70.6, 22.2, 21.8%, respectively, P < 0.0001; 0.31 +/- 0.68, 0.39 +/- 0.93, 1.35 +/- 1.27, respectively, P < 0.0001). Fractures and SDI were associated with SH (odds ratio 7.27, 95% confidence interval 3.94-13.41, P = 0.0001; beta = 0.352, t = 6.241, P = 0.0001, respectively) regardless of age, BMD, menopause, and gender. CONCLUSION: SH is associated with low BMD, high fracture prevalence, and reduced bone quality as measured by SDI.
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The risk of vertebral fracture in ACS is independent of age, sex, gonadal status, or bone mineral density.
“and this risk is independent of age, sex, gonadal status, or bone mineral density (264).”
From Adrenal incidentaloma (2020) · cites this paper as [264]
Both trabecular and cortical bone loss have been described in patients with ACS.
“Both trabecular (65,261-263) and cortical (259,262,264-266) bone loss have been described in patients with ACS.”
From Adrenal incidentaloma (2020) · cites this paper as [264]
Diabetes/metabolic syndrome, renal damage, impaired bone mineral density, and osteoporosis have been reported more prevalent in AI patients with PA.
“Diabetes mellitus/metabolic syndrome (278,279), renal damage (280), impaired bone mineral density (81), and osteoporosis (264,281,282) have also been reported to be more prevalent in AI patients with PA.”
From Adrenal incidentaloma (2020) · cites this paper as [264]
Low serum ACTH levels are frequently found in patients with adrenal incidentalomas.
“Low serum ACTH levels are frequently found in AI patients (19,21,32,36,40,43,44,48,49,56,60,61).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [21]
Few studies have reported elevated urinary free cortisol levels in more than 25% of patients with adrenal incidentalomas.
“Few studies reported a high frequency (i.e. higher than 25%) of elevated UFC levels in patients with AI (21,43,48,49,53,60).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [21]
The 1-mg dexamethasone suppression test is the most used test for diagnosing subclinical hypercortisolism.
“To date, the 1-mg DST is the most used test to diagnose SH, either alone (34 -36, 38, 44 -46) or in combination with other parameters (9, 18, 21, 32, 37, 39, 42, 49, 52-54, 56, 60, 61).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [21]
Several studies and the French Society for Endocrinology have proposed a lower 1-mg dexamethasone suppression test cutoff to increase sensitivity.
“Several studies (19,21,32,34,38,39,44,46,49,53,60,61,67) and recently the French Society for Endocrinology (68), however, have proposed a lower cutoff to increase sensitivity.”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [21]
Other authors used the simultaneous presence of at least two altered HPA axis parameters for diagnosing subclinical hypercortisolism.
“To simplify the diagnostic workout, other authors used the concomitant presence of at least two altered parameters of HPA axis activity for SH diagnosis (9, 18, 19, 21, 32, 37, 39, 40, 42, 47, 49, 52-54, 56, 60, 61).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [21]
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References 38 · Cited by 168
- Authors
- Chiodini, I., Morelli, V., Masserini, B., Salcuni, A. S., Eller-Vainicher, C., Viti, R., Coletti, F., Guglielmi, G., Battista, C., Carnevale, V., Iorio, L., Beck-Peccoz, P., Arosio, M., Ambrosi, B., & Scillitani, A.
- Affiliations
- University of Milan (IT)
- Casa Sollievo della Sofferenza (IT)
- Ospedale San Giuseppe (IT)
- Endocrinology and Diabetology Unit (I.C., V.M., B.M., A.S.S., C.E.-V., P.B.-P., M.A.), Department of Medical and Surgical Sciences, Instituto di Ricovero e Cura a Carattere Scientifico Policlinico, San Donato Institute, San Donato Milanese, University of Milan, 20122 Milan, Italy
- Corresponding author
- Chiodini, Iacopo
- ORCID
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2009-09-01
- Volume
- 94
- Issue
- 9
- Pages
- 3207-3214
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- OpenAlex
- W2118314343
- Semantic Scholar
- 0b696982a7eac67d825e33dac29c09f39b184d20
- Cited by
- 168
- References
- 38
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 7 · 2023: 10 · 2022: 8 · 2021: 8 · 2020: 9 · 2019: 10 · 2018: 13 · 2017: 2 · 2016: 12 · 2015: 16 · 2014: 11 · 2013: 7 · 2012: 20
- FWCI
- 15.38
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Bone health and osteoporosis research
- Health Sciences › Medicine › Surgery › Adrenal and Paraganglionic Tumors
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hormonal Regulation and Hypertension
- Keywords
- adrenal incidentaloma, subclinical hypercortisolism, bone mineral density, vertebral fractures, bone quality, osteoporosis, glucocorticoid-induced osteoporosis, postmenopausal women, urinary free cortisol, dexamethasone suppression test, ACTH, lumbar spine, femoral neck, fracture risk factors, sex differences
- MeSH terms
- Adrenal Cortex Neoplasms, Adult, Aged, Aged, 80 and over, Cushing Syndrome, Female, Humans, Male, Middle Aged, Retrospective Studies, Bone Density, Body Mass Index, Prevalence, Spinal Fractures
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