Journal Article

Mild autonomous cortisol secretion: pathophysiology, comorbidities and management approaches

Prete, Alessandro, Bancos, Irina

2024

Overview

The majority of incidentally discovered adrenal tumours are benign adrenocortical adenomas and the prevalence of adrenocortical adenomas is around 1–7% on cross-sectional abdominal imaging. These can be non-functioning adrenal tumours or they can be associated with autonomous cortisol secretion on a spectrum that ranges from rare clinically overt adrenal Cushing syndrome to the much more prevalent mild autonomous cortisol secretion (MACS) without signs of Cushing syndrome. MACS is diagnosed (based on an abnormal overnight dexamethasone suppression test) in 20–50% of patients with adrenal adenomas. MACS is associated with cardiovascular morbidity, frailty, fragility fractures, decreased quality of life and increased mortality. Management of MACS should be individualized based on patient characteristics and includes adrenalectomy or conservative follow-up with treatment of associated comorbidities. Identifying patients with MACS who are most likely to benefit from adrenalectomy is challenging, as adrenalectomy results in improvement of cardiovascular morbidity in some, but not all, patients with MACS. Of note, diagnosis and management of patients with bilateral MACS is especially challenging. Current gaps in MACS clinical practice include a lack of specific biomarkers diagnostic of MACS-related health outcomes and a paucity of clinical trials demonstrating the efficacy of adrenalectomy on comorbidities associated with MACS. In addition, little evidence exists to demonstrate the efficacy and safety of long-term medical therapy in patients with MACS. Mild autonomous cortisol secretion from benign adrenocortical adenomas (usually diagnosed incidentally) is associated with cardiometabolic risk and other comorbidities, but without the signs of overt Cushing syndrome. This Review outlines the mechanisms, complications and comorbidities, diagnosis and management of mild autonomous cortisol secretion. Key points Mild autonomous cortisol secretion (MACS) is diagnosed based on the 1 mg overnight dexamethasone test and is found in 20–50% of patients with adrenal adenomas lacking signs and symptoms of Cushing syndrome. Patients with adrenal adenomas show distinct changes in the steroid and global metabolome, which correlate with the degree of cortisol excess across MACS and Cushing syndrome. MACS is associated with an increased likelihood of having cardiovascular risk factors and an increased risk of mortality. Management of MACS must be individualized based on patient characteristics; the options range from adrenalectomy to long-term follow-up and conservative management of comorbidities. Post-operative adrenal insufficiency is seen in around 50% of patients with MACS who undergo unilateral adrenalectomy.

• Publisher: Nature Publishing Group UK,Nature Publishing Group
• Subject: 692/698/1460/6 / 692/699/2743/2037 / Adenoma / Adrenal Cortex Neoplasms - complications / Adrenal Cortex Neoplasms - diagnosis / Adrenal Cortex Neoplasms - epidemiology / Adrenal Cortex Neoplasms - metabolism / Adrenal Cortex Neoplasms - physiopathology / Adrenal Cortex Neoplasms - therapy / Adrenal Gland Neoplasms - diagnosis / Adrenal Gland Neoplasms - epidemiology / Adrenal Gland Neoplasms - metabolism / Adrenal Gland Neoplasms - physiopathology / Adrenal Gland Neoplasms - therapy / Adrenalectomy / Adrenocortical Adenoma - complications / Adrenocortical Adenoma - diagnosis / Adrenocortical Adenoma - epidemiology / Adrenocortical Adenoma - metabolism / Adrenocortical Adenoma - therapy / Adrenocorticotropic hormone / Cardiovascular diseases / Clinical trials / Comorbidity / Cortisol / Cushing syndrome / Cushing Syndrome - diagnosis / Cushing Syndrome - epidemiology / Cushing Syndrome - metabolism / Cushing Syndrome - physiopathology / Cushing Syndrome - therapy / Dexamethasone / Diagnosis / Endocrinology / Fractures / Hormones / Humans / Hydrocortisone - blood / Hydrocortisone - metabolism / Medicine / Medicine & Public Health / Morbidity / Nervous system diseases / Neuroendocrine tumors / Patients / Pituitary / Quality of life / Review Article / Secretion / Tumors