Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?
Abstract
OBJECTIVE: Few data are available regarding the need of steroid substitutive therapy after unilateral adrenalectomy for adrenal incidentaloma (AI). It is unknown whether, before surgery, the hypothalamic-pituitary-adrenal (HPA) axis secretion parameters can predict post-surgical hypocortisolism. AIM: This study aimed to evaluate whether, in AI patients undergoing unilateral adrenalectomy, post-surgical hypocortisolism could be predicted by the parameters of HPA axis function. DESIGN: Prospective, multicenter. METHODS: A total of 60 patients underwent surgical removal of AI (surgical indication: 29 subclinical hypercortisolism (SH); 31 AI dimension). Before surgery, SH was diagnosed in patients presenting at least three criteria out of urinary free cortisol (UFC) levels>60 microg/24 h, cortisol after 1-mg dexamethasone suppression test (1 mg-DST)>3.0 microg/dl, ACTH levels<10 pg/ml, midnight serum cortisol (MSC)>5.4 microg/dl. Two months after surgery, HPA axis function was assessed by low dose ACTH stimulation test or insulin tolerance test when needed: 39 patients were affected (Group B) and 21 were not affected (Group A) with hypocortisolism. The accuracy in predicting hypocortisolism of pre-surgical HPA axis parameters or their combinations was evaluated. RESULTS: The presence of >2 alterations among 1 mg-DST>5.0 microg/dl, ACTH<10 pg/ml, elevated UFC and MSC has the highest odds ratio (OR) for predicting post-surgical hypocortisolism (OR 10.45, 95% confidence interval, CI 2.54-42.95, P=0.001). Post-surgical hypocortisolism was predicted with 100% probability by elevated UFC plus MSC levels, but not ruled out even in the presence of the normality of all HPA axis parameters. CONCLUSION: Post-surgical hypocortisolism cannot be pre-surgically ruled out. A steroid substitutive therapy is indicated after unilateral adrenalectomy for SH or size of the adenoma.
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In the same study, lowering the 1-mg dexamethasone suppression test cutoff reduced specificity from 85.7% to 23.8% and increased sensitivity from 33.3% to 79.5%.
“Also in this study, lowering the cutoff of 1-mg DST was demonstrated to lead to a reduction in specificity (from 85.7 to 23.8%) and an increase in sensitivity (from 33.3 to 79.5%).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [58]
After excluding midnight serum cortisol, all combinations of the remaining HPA axis parameters lacked sufficient reliability for predicting postsurgical hypocortisolism, and normal preoperative HPA axis parameters could not rule out postsurgical adrenal insufficiency with 100% probability.
“Moreover, after excluding MSeC, all combinations of the remaining parameters did not show enough reliability for predicting hypocortisolism after surgery, and conversely, the normality of all parameters of HPA axis activity before surgery could not rule out with 100% probability the appearance of postsurgical adrenal insufficiency.”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [58]
Postsurgical hypocortisolism after removal of an adrenal adenoma has been proposed as a gold standard for diagnosing subclinical hypercortisolism.
“The occurrence of hypocortisolism after the removal of an adrenal adenoma has been proposed as the gold standard for diagnosing SH (58).”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [58]
In a study of 60 patients with adrenal incidentalomas, simultaneous elevated urinary free cortisol and midnight serum cortisol above 5.4 g/dl before surgery had 100% specificity for predicting postsurgical hypocortisolism but only 30.8% sensitivity.
“We found that the simultaneous presence of elevated UFC and MSeC levels [Ͼ5.4 g/dl (149 nmol/liter)] before surgery had a 100% specificity for predicting postsurgical hypocortisolism, but at the expense of a 30.8% sensitivity.”
From Diagnosis and Treatment of Subclinical Hypercortisolism (2011) · cites this paper as [58]
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References 41 · Cited by 75
- Authors
- Eller-Vainicher, C., Morelli, V., Salcuni, A. S., Torlontano, M., Coletti, F., Iorio, L., Cuttitta, A., Ambrosio, A., Vicentini, L., Carnevale, V., Beck-Peccoz, P., Arosio, M., Ambrosi, B., Scillitani, A., & Chiodini, I.
- Affiliations
- University of Milan (IT)
- Casa Sollievo della Sofferenza (IT)
- Ospedale San Giuseppe (IT)
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (IT)
- Corresponding author
- Chiodini, Iacopo
- ORCID
- Venue
- European Journal of Endocrinology
- Publisher
- Oxford University Press (OUP)
- Published
- 2010-01
- Volume
- 162
- Issue
- 1
- Pages
- 91-99
- ISSN
- 0804-4643 (ISSN-L)
- 1479-683X
- OpenAlex
- W2158965084
- Cited by
- 75
- References
- 41
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 3 · 2023: 3 · 2022: 3 · 2021: 4 · 2020: 3 · 2019: 2 · 2018: 6 · 2017: 1 · 2016: 4 · 2015: 7 · 2014: 7 · 2013: 1 · 2012: 10
- FWCI
- 6.29
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Endocrinology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Surgery › Adrenal and Paraganglionic Tumors
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Pituitary Gland Disorders and Treatments
- Keywords
- adrenal incidentaloma, unilateral adrenalectomy, subclinical hypercortisolism, hypothalamic-pituitary-adrenal axis, steroid replacement therapy, urinary free cortisol, dexamethasone suppression test, ACTH, insulin tolerance test
- MeSH terms
- Adrenal Cortex Neoplasms, Adrenalectomy, Adult, Aged, Cushing Syndrome, Female, Follow-Up Studies, Humans, Hydrocortisone, Male, Middle Aged, Postoperative Complications, Predictive Value of Tests, Preoperative Care, Prospective Studies, Sensitivity and Specificity, Endocrine Surgical Procedures, Adrenocortical Adenoma, Incidental Findings, Young Adult
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