title: High prevalence of subclinical hypercortisolism in patients with bilateral adrenal incidentalomas: a challenge to management.
abstract: OBJECTIVE
  The prevalence of subclinical hypercortisolism (SH) in unilateral incidentalomas (UI) has been extensively studied; however, patients with bilateral incidentalomas (BI) have not been thoroughly investigated. We therefore aimed to describe the characteristics of patients with BI compared to their unilateral counterparts. The surgical outcome in a small number of patients is reported.
  
  
  METHODS
  Observational retrospective study in a single secondary/tertiary centre.
  
  
  METHODS
  One hundred and seventy-two patients with adrenal incidentalomas (41 with BI).
  
  
  METHODS
  Morning cortisol (F), ACTH, dehydroepiandrosterone sulphate (DHEA-S), midnight F, 24-h urine collection for cortisol (UFC), low-dose dexamethasone suppression test (LDDST), fasting glucose, insulin, and oral glucose tolerance test (OGTT). Primarily, SH was defined as F-post-LDDST>70 nmol/l and one more abnormality; several diverse cut-offs were also examined.
  
  
  RESULTS
  No difference was noted in age, body mass index, or prevalence of diabetes and impaired glucose tolerance between patients with UI and those with BI. Patients with BI had higher F-post-LDDST (119·3 ± 112·8 vs 54·3 ± 71·5 nmol/l, P<0·001) and lower DHEA-S (1·6 ± 1·5 vs 2·5 ± 2·3 μmol/l, P=0·003) but similar UFC, ACTH and midnight F levels, compared to UI. SH was significantly more prevalent in BI (41·5%vs 12·2%, P<0·001). Fourteen patients were operated on; four underwent bilateral interventions. In 10 patients, unilateral adrenalectomy on the side of the largest lesion resulted in significant improvement in F-post-LDDST (P=0·008) and a decrease in midnight F (P=0·015) levels.
  
  
  CONCLUSIONS
  Subclinical hypercortisolism is significantly more prevalent in bilateral incidentaloma patients, posing great dilemmas for its optimum management.
authors.affiliation: Department of Endocrinology, Athens Polyclinic Hospital, Athens, Greece.
authors.forename: Dimitra A
authors.initials: DA
authors.lastname: Vassiliadi
authors.forename: Georgia
authors.initials: G
authors.lastname: Ntali
authors.forename: Eirini
authors.initials: E
authors.lastname: Vicha
authors.forename: Stylianos
authors.initials: S
authors.lastname: Tsagarakis
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000097:blood / Q000503:physiopathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003480:Cushing Syndrome / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology*; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D006854:Hydrocortisone