Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?
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.


OBJECTIVE
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.


METHODS
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.


CONCLUSIONS
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.
Department of Medical Sciences, University of Milan, Fondazione Policlinico IRCCS, Milan, Italy.
Cristina
C
Eller-Vainicher
Valentina
V
Morelli
Antonio Stefano
AS
Salcuni
Massimo
M
Torlontano
Francesca
F
Coletti
Laura
L
Iorio
Antonello
A
Cuttitta
Angelo
A
Ambrosio
Leonardo
L
Vicentini
Vincenzo
V
Carnevale
Paolo
P
Beck-Peccoz
Maura
M
Arosio
Bruno
B
Ambrosi
Alfredo
A
Scillitani
Iacopo
I
Chiodini
D000306:Adrenal Cortex Neoplasms / Q000097:blood* / Q000601:surgery; D000315:Adrenalectomy / Q000009:adverse effects; D018246:Adrenocortical Adenoma / Q000097:blood* / Q000601:surgery; D000328:Adult; D000368:Aged; D003480:Cushing Syndrome / Q000097:blood* / Q000175:diagnosis / Q000209:etiology; D013507:Endocrine Surgical Procedures / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D033162:Incidental Findings; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000097:blood* / Q000175:diagnosis / Q000209:etiology; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000592:standards*; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D055815:Young Adult
D006854:Hydrocortisone