In the Journals

Certain adrenal tumors may increase cardiometabolic risk

Although nonfunctioning adrenal tumors and adenomas that cause mild autonomous cortisol excess were not associated with significant tumor changes in size or hormonal function, these benign tumors may increase risk for cardiometabolic comorbidities, according to study results published in the Annals of Internal Medicine.

“The incidental detection of adrenal masses by imaging is increasingly common in clinical practice owing to the ever-increasing use of cross-sectional imaging,” Yasir S. Elhassan, MBBS, of the University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Center for Endocrinology, Diabetes and Metabolism, United Kingdom, and colleagues wrote. “Adrenal incidentalomas are found in about 5% of the population, and incidence increases with age.”

Guidelines regarding how to manage adrenal incidentalomas that do not require immediate surgery differ: some recommend reported imaging and hormonal assessment for up to 5 years, and others that discourage repeat imaging and hormonal assessment but call for annual overt Cushing syndrome screening in those with mild autonomous cortisol excess (MACE).

To provide more evidence to guide follow-up and management for patients with nonfunctioning adrenal tumors (NFAT) and MACE, researchers conducted a systematic review and meta-analysis of the natural history of both types of adrenal incidentalomas.

Researchers conducted online searches of multiple databases to identify studies of patients with NFAT and MACE from January 1990 to February 2019. Studies that included 20 or more conservatively managed patients that reported outcomes at the baseline and had a least 12 months of follow-up were included in analyses.

They identified 32 studies that included follow-up and outcomes of interest for 4,121 patients with NFAT or MACE, with a mean follow-up of 50.2 months. The mean patient age was 60.2 years, and mean tumor growth was 2 mm over 52.8 months.

No patients included in the analysis developed adrenal cancer, and significant tumor growth (10 mm or more) occurred in only 2.5% of patients.

Less than 0.1% of patients with NFAT or MACE developed clinically overt hormone excess. Approximately 4.3% of patients with NFAT developed MACE, and preexisting MACE resolved in less than 0.1% of patients.

Among patients with NFAT and MACE, hypertension (60%), obesity (42%), dyslipidemia (33.7%) and type 2 diabetes (18.1%) were highly prevalent, but the conditions were more likely to develop and worsen in those with MACE compared with patients with NFAT. The prevalence of new cardiovascular events was also higher in patients with MACE (15.5%) than in those with NFAT (6.4%).

The overall mortality rate, 11.2%, was similar in patients with NFAT and MACE.

Researchers noted that the lack of tumor growth in patients with NFAT and MACE suggested that radiological follow-up is unnecessary once a tumor is determined to be benign. They also noted that the findings suggest that MACE does not require repeated hormone testing due to the likelihood of developing Cushing syndrome or resolving MACE during follow-up.

“Elhassan and colleagues have provided important insights on the natural history of adrenal incidentalomas that help in solving controversy and informing practice,” Massimo Terzolo, MD, and Guiseppe Reimondo, MD, PhD, of San Luigi Gonzaga Hospital and the University of Turin, Italy, wrote in an editorial accompanying the study. “Further studies are needed to associate results of endocrine work-up with clinical phenotyping and to dene patient-centered outcomes for optimal treatment of such a common endocrine disorder.” – by Erin Michael

Disclosures: Elhassan and Reimondo report no relevant financial disclosures. Terzolo reports grants from HRA PHARMA and NOVARTIS and personal fees from HRA PHARMA outside the submitted work. Please see study for all other authors’ relevant financial disclosures.

Although nonfunctioning adrenal tumors and adenomas that cause mild autonomous cortisol excess were not associated with significant tumor changes in size or hormonal function, these benign tumors may increase risk for cardiometabolic comorbidities, according to study results published in the Annals of Internal Medicine.

“The incidental detection of adrenal masses by imaging is increasingly common in clinical practice owing to the ever-increasing use of cross-sectional imaging,” Yasir S. Elhassan, MBBS, of the University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Center for Endocrinology, Diabetes and Metabolism, United Kingdom, and colleagues wrote. “Adrenal incidentalomas are found in about 5% of the population, and incidence increases with age.”

Guidelines regarding how to manage adrenal incidentalomas that do not require immediate surgery differ: some recommend reported imaging and hormonal assessment for up to 5 years, and others that discourage repeat imaging and hormonal assessment but call for annual overt Cushing syndrome screening in those with mild autonomous cortisol excess (MACE).

To provide more evidence to guide follow-up and management for patients with nonfunctioning adrenal tumors (NFAT) and MACE, researchers conducted a systematic review and meta-analysis of the natural history of both types of adrenal incidentalomas.

Researchers conducted online searches of multiple databases to identify studies of patients with NFAT and MACE from January 1990 to February 2019. Studies that included 20 or more conservatively managed patients that reported outcomes at the baseline and had a least 12 months of follow-up were included in analyses.

They identified 32 studies that included follow-up and outcomes of interest for 4,121 patients with NFAT or MACE, with a mean follow-up of 50.2 months. The mean patient age was 60.2 years, and mean tumor growth was 2 mm over 52.8 months.

No patients included in the analysis developed adrenal cancer, and significant tumor growth (10 mm or more) occurred in only 2.5% of patients.

Less than 0.1% of patients with NFAT or MACE developed clinically overt hormone excess. Approximately 4.3% of patients with NFAT developed MACE, and preexisting MACE resolved in less than 0.1% of patients.

Among patients with NFAT and MACE, hypertension (60%), obesity (42%), dyslipidemia (33.7%) and type 2 diabetes (18.1%) were highly prevalent, but the conditions were more likely to develop and worsen in those with MACE compared with patients with NFAT. The prevalence of new cardiovascular events was also higher in patients with MACE (15.5%) than in those with NFAT (6.4%).

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The overall mortality rate, 11.2%, was similar in patients with NFAT and MACE.

Researchers noted that the lack of tumor growth in patients with NFAT and MACE suggested that radiological follow-up is unnecessary once a tumor is determined to be benign. They also noted that the findings suggest that MACE does not require repeated hormone testing due to the likelihood of developing Cushing syndrome or resolving MACE during follow-up.

“Elhassan and colleagues have provided important insights on the natural history of adrenal incidentalomas that help in solving controversy and informing practice,” Massimo Terzolo, MD, and Guiseppe Reimondo, MD, PhD, of San Luigi Gonzaga Hospital and the University of Turin, Italy, wrote in an editorial accompanying the study. “Further studies are needed to associate results of endocrine work-up with clinical phenotyping and to dene patient-centered outcomes for optimal treatment of such a common endocrine disorder.” – by Erin Michael

Disclosures: Elhassan and Reimondo report no relevant financial disclosures. Terzolo reports grants from HRA PHARMA and NOVARTIS and personal fees from HRA PHARMA outside the submitted work. Please see study for all other authors’ relevant financial disclosures.