Publications by authors named "Irina Bancos"

139 Publications

Approach to the patient with adrenal incidentaloma.

J Clin Endocrinol Metab 2021 Jul 14. Epub 2021 Jul 14.

Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.

Adrenal tumors are commonly discovered incidentally, on cross-sectional abdominal imaging performed for reasons other than adrenal mass. Incidence of adrenal tumors increased 10-fold in the last two decades, with most diagnosed in older adults. In any patient with a newly discovered adrenal mass determining whether the adrenal mass is malignant and whether it is hormonally active is equally important to guide the best management. Malignancy is diagnosed in 5-8% of patients with adrenal tumors, with a higher risk in young patients, if history of extra-adrenal malignancy, in those with large adrenal tumors with indeterminate imaging characteristics, and in bilateral adrenal tumors. While overt hormone excess is uncommon in adrenal incidentalomas, mild autonomous cortisol secretion can be diagnosed in up to 30-50% of patients. As autonomous cortisol secretion is associated with increased cardiovascular morbidity and metabolic abnormalities, all patients with adrenal incidentalomas require work up with dexamethasone suppression test. Management of adrenal tumors varies based on etiology, associated comorbidities, and patient's preference. This article reviews the current evidence on the diagnosis and evaluation of patients with adrenal mass and focuses on management of the most common etiologies of adrenal incidentalomas.
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http://dx.doi.org/10.1210/clinem/dgab512DOI Listing
July 2021

Concomitant Pheochromocytoma and Primary Aldosteronism: A Case Series and Literature Review.

J Endocr Soc 2021 Aug 16;5(8):bvab107. Epub 2021 Jun 16.

Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.

Context: The detection and management of concomitant pheochromocytoma (PHEO) and primary aldosteronism (PA) is not well understood.

Objective: To investigate varying presentations and outcomes of cases with coexisting PHEO and PA to provide an approach to its diagnosis and management.

Methods: We conducted a retrospective case series of adult patients with concomitant PHEO and PA at Mayo Clinic from 2000-2020 and an additional review of cases before 2000 and from the medical literature. Clinical, biochemical, radiologic, and histologic parameters were measured.

Results: Fifteen patients (53% men, median age 53 years) were diagnosed with concomitant PHEO and PA. The majority presented with hypertension (13, 87%) and hypokalemia (13, 87%), and 6 (40%) presented with symptoms suggestive of catecholamine excess. All patients who underwent preoperative workup for catecholamine excess (14, 93%) were found to have biochemical levels above the upper limits of normal. Adrenal vein sampling (AVS) was performed in 9 patients (60%), where 5 (56%) were diagnosed with bilateral PA, and 4 (44%) with unilateral PA. Patients underwent either unilateral (12, 80%) or bilateral (3, 20%) adrenalectomy. Biochemical improvement or resolution of catecholamine excess was confirmed in all cases with documented measurements. Recurrence of PHEO was not observed. Six patients (40%) displayed persistent PA postoperatively.

Conclusion: Concomitant PHEO and PA is a rare but likely underreported condition. Hypertension with or without hypokalemia should prompt evaluation for PA, while any indeterminate adrenal mass should be assessed for PHEO. Coexisting disease warrants consideration of AVS to determine the laterality of PA to ensure appropriate management.
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http://dx.doi.org/10.1210/jendso/bvab107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8271195PMC
August 2021

Evaluation of FKBP5 as a cortisol activity biomarker in patients with ACTH-dependent Cushing syndrome.

J Clin Transl Endocrinol 2021 Mar 6;24:100256. Epub 2021 Jun 6.

Corcept Therapeutics, 149 Commonwealth Drive, Menlo Park, CA 94025, USA.

Purpose: To evaluate the performance of FKBP5 as a cortisol activity biomarker in patients with ACTH-dependent Cushing syndrome (CS).

Methods: This was a prospective, multicenter, nonrandomized, noninterventional study of a cortisol activity biomarker in adult patients (≥18 years) with documented ACTH-dependent, endogenous CS. The impact of surgery on FKBP5 mRNA expression levels in these patients and the difference in expression levels between these patients and healthy controls were evaluated. Cortisol and biomarker samples were collected before and immediately after surgery. A custom NanoString assay was used to quantify FKBP5 mRNA expression levels. The same method was used to analyze healthy volunteer samples collected from a different study.

Results: Surgery was considered successful in 14/24 patients (58.3%) and changes from baseline in serum cortisol were -92.6% ( = 0.0005) and -43.8% (not significant) in patients with successful and unsuccessful surgeries, respectively. A strong positive correlation between FKBP5 and cortisol levels was observed (before surgery: r = 0.72,  = 0.0002; after surgery: r = 0.85,  < 0.0001). After successful surgery, FKBP5 expression levels were similar to those of healthy subjects. In patients without surgical success, FKBP5 levels remained unchanged from baseline and distinct from healthy subjects ( = 0.0025).

Conclusions: Our findings confirm that FKBP5 levels are higher in the presence of excess cortisol exposure in patients with CS and decrease to normal baseline levels after successful surgery. These findings suggest that FKBP5 can serve as a measure of biological cortisol activity and set the stage for the development of an FKBP5 mRNA expression assay as a biomarker of cortisol activity.
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http://dx.doi.org/10.1016/j.jcte.2021.100256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8260880PMC
March 2021

Glucocorticoid induced adrenal insufficiency.

BMJ 2021 07 12;374:n1380. Epub 2021 Jul 12.

Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA

Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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http://dx.doi.org/10.1136/bmj.n1380DOI Listing
July 2021

Diagnostic Accuracy of Dehydroepiandrosterone Sulfate and Corticotropin in Autonomous Cortisol Secretion.

Biomedicines 2021 Jun 28;9(7). Epub 2021 Jun 28.

Division of Endocrinology, Mayo Clinic, Rochester, MN 55902, USA.

Autonomous cortisol secretion (ACS) affects up to 50% of patients with adrenal adenomas. Despite the limited evidence, clinical guidelines recommend measurement of serum concentrations of dehydroepiandrosterone-sulfate (DHEA-S) and corticotropin (ACTH) to aid in the diagnosis of ACS. Our objective was to determine the accuracy of serum concentrations of DHEA-S and ACTH in diagnosing ACS. We conducted a retrospective single center study of adults with adrenal adenoma evaluated between 2000-2020. Main outcome measure was diagnostic accuracy of DHEA-S and ACTH. ACS was defined as post-dexamethasone cortisol >1.8 mcg/dL. Of 468 patients, ACS was diagnosed in 256 (55%) patients with a median post-DST cortisol of 3.45 mcg/dL (range, 1.9-32.7). Patients with ACS demonstrated lower serum concentrations of DHEA-S (35 vs. 87.3 mcg/dL, < 0.0001) and ACTH (8.3 vs. 16 pg/mL, < 0.0001) compared to patients with non-functioning adrenal tumors (NFAT). Serum DHEA-S concentration <40 mcg/dL diagnosed ACS with 84% specificity and 81% PPV, while serum ACTH concentration <10 pg/mL diagnosed ACS with 75% specificity and 78% PPV. The combination of serum concentrations of DHEA-S <40 mcg/dL and ACTH <10 pg/mL diagnosed ACS with the highest accuracy with 92% specificity and 87% PPV. Serum concentrations of DHEA-S and ACTH provide additional value in diagnosing ACS.
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http://dx.doi.org/10.3390/biomedicines9070741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301396PMC
June 2021

Cardiometabolic Outcomes and Mortality in Patients with Adrenal Adenomas: A Population-Based Cohort Study.

J Clin Endocrinol Metab 2021 Jun 29. Epub 2021 Jun 29.

Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.

Context: While adrenal adenomas have been linked with cardiovascular morbidity in convenience samples of patients from specialized referral centers, large-scale population-based data is lacking.

Objective: To determine the prevalence and incidence of cardiometabolic disease and assess mortality in a population-based cohort of patients with adrenal adenomas.

Design: Population-based cohort study.

Setting: Olmsted County, Minnesota.

Patients: Patients diagnosed with adrenal adenomas without overt hormone excess and age- and sex-matched referent subjects without adrenal adenomas.

Main Outcome Measure: Prevalence, incidence of cardiometabolic outcomes, mortality.

Results: Adrenal adenomas were diagnosed in 1,004 patients (58% women, median age 63 years). At baseline, patients with adrenal adenomas were more likely to have hypertension (aOR 1.96, 95% CI 1.58-2.44), dysglycemia (aOR 1.63, 95% CI 1.33-2.00), peripheral vascular disease (aOR 1.59, 95% CI 1.32-2.06), heart failure (aOR 1.64, 95% CI 1.15-2.33), and myocardial infarction (aOR 1.50, 95% CI 1.02-2.22) compared to referent subjects. During median follow-up of 6.8 years, patients with adrenal adenomas were more likely than referent subjects to develop de novo chronic kidney disease(aHR 1.46, 95% CI 1.14-1.86), cardiac arrhythmia(aHR 1.31, 95% CI 1.08-1.58), peripheral vascular disease (aHR 1.28, 95% CI 1.05-1.55), cardiovascular events (aHR 1.33, 95% CI 1.01-1.73), and venous thromboembolic events (aHR 2.15, 95% CI 1.48-3.13). Adjusted mortality was similar between the two groups.

Conclusion: Adrenal adenomas are associated with an increased prevalence and incidence of adverse cardiometabolic outcomes in a population-based cohort.
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http://dx.doi.org/10.1210/clinem/dgab468DOI Listing
June 2021

Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes.

Surgery 2021 Jun 25. Epub 2021 Jun 25.

Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. Electronic address:

Background: Clinical manifestations and treatment outcomes in children and adolescents with multiple endocrine neoplasia type 1 are not well characterized.

Methods: We conducted a retrospective cohort study of 80 patients with multiple endocrine neoplasia type 1 who commenced tumor surveillance at ≤18 years of age.

Results: Fifty-six patients (70%) developed an endocrine tumor by age ≤18 years (median age = 14 years, range = 6-18 years). Primary hyperparathyroidism occurred in >80% of patients, with >70% undergoing parathyroidectomy, in which less-than-subtotal (<3-gland) resection resulted in decreased disease-free outcomes versus subtotal (3-3.5-gland) or total (4-gland) parathyroidectomy (median 27 months versus not reached; P = .005). Pancreaticoduodenal neuroendocrine tumors developed in ∼35% of patients, of whom >70% had nonfunctioning tumors, >35% had insulinomas, and <5% had gastrinomas, with ∼15% having metastases and >55% undergoing surgery. Pituitary tumors developed in >30% of patients, and ∼35% were macroprolactinomas. Tumor occurrence in male patients and female patients was not significantly different. Genetic analyses revealed 38 germline MEN1 mutations, of which 3 were novel.

Conclusion: Seventy percent of children aged ≤18 years with multiple endocrine neoplasia type 1 develop endocrine tumors, which include parathyroid tumors for which less-than-subtotal parathyroidectomy should be avoided; pancreaticoduodenal neuroendocrine tumors that may metastasize; and pituitary macroprolactinomas.
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http://dx.doi.org/10.1016/j.surg.2021.04.041DOI Listing
June 2021

Percutaneous Image-Guided Thermal Ablation of Adrenal Metastasis from Melanoma: a Single-Institution Experience.

J Vasc Interv Radiol 2021 Jun 16. Epub 2021 Jun 16.

Department of Radiology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota.

The outcomes of technically successful image-guided percutaneous thermal ablation of melanoma adrenal metastases involving 11 tumors in 9 consecutive patients over 12 years (2009-2020) were evaluated. All patients had multiple treated metastatic sites, and 44.4% (4/9) had greater than 5 metastatic sites. The mean maximal tumor diameter was 3.6 ± 1.6 cm. The local recurrence-free survival at 1 year was 85.7%. With a median survival of 19.4 months, 66.6% (6/9) of patients died from tumor progression. The 1- and 3-year overall survival rate was 60.0% and 30.0%, respectively. All patients were pretreated with alpha-adrenergic blockade, and 36% (4/11) developed a hypertensive crisis. The median hospital length of stay was 1 day (range, 1-2 days), without any major complications. Thermal ablation of adrenal metastasis from a melanoma provides acceptable local control and a good safety profile.
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http://dx.doi.org/10.1016/j.jvir.2021.06.002DOI Listing
June 2021

Pituitary Tumor Surgery: Comparison of Endoscopic and Microscopic Techniques at a Single Center.

Mayo Clin Proc 2021 Jun 10. Epub 2021 Jun 10.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

Objective: To understand the transition from microscopic surgery (MS) to endoscopic surgery (ES) on the pituitary across the United States, we assessed a single institution practicing both procedures to discern advantages and disadvantages for each.

Patients And Methods: Retrospective institutional chart review of 534 patients in a large practice over a 6-year period (January 1, 2014, to December 31, 2019) comparing a single MS neurosurgeon with a single ES neurosurgeon operating on the same days.

Results: In this series, 14% (n=75) of patients had a prior operation, there were no carotid artery injuries, the overall risk for a postoperative infection was 0.4% (n=2), and risk for a postoperative cerebrospinal fluid leak requiring treatment was 2.0% (n=11). Mean ± SD hospital stay was 1.3±0.04 days; readmission for any reason within 30 days occurred in 3.4% (n=18) of patients. The mean volumetric resection for MS was 86.9%±1.7% and for ES was 91.7%±1.3% (P=.03). There was a higher rate of notable events (P=.015) with MS, but MS had 16% lower cost and operative times were 48 minutes shorter than for ES (83±7 vs 131±6 minutes). The ES required substantially fewer postoperative secondary treatments such as radiation therapy (P=.003).

Conclusion: Pituitary surgery is a very safe and effective procedure regardless of technique. The MS has shorter operative times and overall lower cost. The ES results in increased volumetric resection and fewer secondary treatments. Both techniques can be valuable to a large practice, and understanding these niches is important when selecting optimal approaches to pituitary surgery for a given patient.
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http://dx.doi.org/10.1016/j.mayocp.2021.03.028DOI Listing
June 2021

The Impact of the COVID-19 Pandemic on Self-Reported Outcomes in Patients With Adrenal Insufficiency.

J Clin Endocrinol Metab 2021 06;106(7):e2469-e2479

Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.

Context: The COVID-19 pandemic has impacted healthcare environment.

Objective: To determine the impact of the pandemic on self-reported outcomes in patients with adrenal insufficiency (AI).

Design And Setting: Prospective longitudinal survey study at 2 tertiary centers.

Participants: Patients with AI.

Intervention: Patient-centered questionnaire.

Main Outcome Measures: Depression Anxiety Stress Scales-21, Short Form-36, and AI self-management.

Results: Of 342 patients, 157 (46%) had primary AI, 109 (32%) had secondary AI, and 76 (22%) had glucocorticoid-induced AI. When compared to prepandemic, daily glucocorticoid dose and number of adrenal crises did not change. However, patients reported a higher financial impact from AI (34% vs 23%, P = 0.006) and difficulty accessing medical care (31% vs 7%, P < 0.0001) during the pandemic. A third of patients reported difficulty managing AI during the pandemic. After adjusting for duration and subtypes of AI, younger patients [odds ratio (OR) 2.3, CI 95% 1.3-4.1], women (OR 3.7, CI 95% 1.9-7.1), poor healthcare access(OR 4.2, CI 95% 2.3-7.7), lack of good insurance support (OR 2.8, CI 95% 1.3-5.9), and those with a higher financial impact (OR 2.3, CI 95% 1.3-4.3) reported greater difficulties managing AI. Patients were more likely to report a higher anxiety score (≥8) if they found managing AI challenging during the pandemic (OR 3.0, CI 95% 1.3-6.9), and had lower Physical Component Summary (OR 4.9, CI 95% 2.2-11.0) and Mental Component Summary (OR 4.1, CI 95% 1.8-9.5) scores prior to the pandemic.

Conclusions: A third of patients with AI reported difficulties with management of AI during the pandemic, particularly in younger patients, women, and those with poor healthcare access.
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http://dx.doi.org/10.1210/clinem/dgab334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194854PMC
June 2021

Secondary Adrenal Insufficiency and Growth Hormone Deficiency in Patients with Fibromyalgia.

J Pain Res 2021 19;14:1323-1329. Epub 2021 May 19.

Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA.

Purpose: Patients with fibromyalgia (FM) may demonstrate low cortisol concentrations during diagnostic evaluation. However, it remains unclear whether low cortisol reflects underlying pituitary dysfunction. We aimed to determine if a subset of patients with FM have concomitant secondary adrenal insufficiency (SAI) and growth hormone deficiency (GH).

Patients And Methods: This is a retrospective study of all patients with FM diagnosed with SAI based on abnormal insulin tolerance test (ITT) between June 2002 and August 2019. Patients were excluded if they had other reasons for SAI. Measurements include cortisol and GH during ITT in all patients, and peak cortisol during cosyntropin stimulation test in a subset of patients.

Results: We identified 22 patients (median age of 38 years (range 19-65), 18 (82%) women) diagnosed with secondary AI based on abnormal ITT (peak median cortisol level of 11 mcg/dL (range 5.4-17)). Concomitant GH deficiency was diagnosed in 19 (86%) patients. Cosyntropin stimulation test was performed in 14 (64%) patients and was normal in 11 (79%) (peak cortisol ≥18 mcg/dL). MRI pituitary imaging was performed in 20 patients and showed no significant pituitary pathology. All patients were started on physiologic glucocorticoid replacement, and 5 patients were started on GH replacement. Of the 13 patients with follow-up, 8 (62%) reported symptom improvement after starting treatment.

Conclusion: Patients with FM can have concurrent SAI and GH deficiency. Cosyntropin stimulation test should not be used to exclude SAI in patients with FM. Appropriate glucocorticoid and/or GH replacement may improve symptoms in some patients.
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http://dx.doi.org/10.2147/JPR.S302291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141402PMC
May 2021

Pheochromocytoma and Paraganglioma in Pregnancy: a New Era.

Curr Cardiol Rep 2021 05 7;23(6):60. Epub 2021 May 7.

Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.

Purpose Of Review: Pheochromocytoma and paraganglioma (PPGL) in pregnancy is a rare entity and management of these patients is fraught with uncertainty. Our objective is to review current literature and discuss diagnosis and management of these patients.

Recent Findings: Outcomes of PPGL in pregnancy have improved in recent years. The greatest risk for adverse maternal and fetal outcomes is the diagnosis of PPGL after delivery. Alpha- and beta-adrenergic blockade is well tolerated and is associated with less adverse outcomes. Antepartum surgery is not associated with improved maternal or fetal outcomes. Biochemical testing and cross-sectional imaging should be performed prior to conception for patients with a known germline variant associated with PPGL.

Conclusions: Medical therapy should be initiated when PPGL is diagnosed in pregnancy. Antepartum surgery should be reserved for special circumstances. Case detection testing in high-risk patients can identify PPGL before pregnancy.
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http://dx.doi.org/10.1007/s11886-021-01485-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251512PMC
May 2021

Comment on "A Modern Assessment of Cancer Risk in Adrenal Incidentalomas: Analysis of 2219 Patients" by Kahramangil B et al.

Ann Surg 2021 Feb 26. Epub 2021 Feb 26.

Institute of Metabolism and Systems Research and Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK Division of Endocrinology, Diabetes, Metabolism and Nutrition3, Mayo Clinic, Rochester, MN, USA Institute of Metabolism and Systems Research and Institute of Metabolism and Systems Research and Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK Institute of Metabolism and Systems Research and NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.

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http://dx.doi.org/10.1097/SLA.0000000000004804DOI Listing
February 2021

Editorial.

Curr Opin Endocrinol Diabetes Obes 2021 Jun;28(3):263-264

Endocrinology Fellowship Program, Division of Endocrinology, Metabolism and Nutrition Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1097/MED.0000000000000632DOI Listing
June 2021

American Association of Clinical Endocrinology Disease State Clinical Review on the Evaluation and Management of Adrenocortical Carcinoma in an Adult: a Practical Approach.

Endocr Pract 2020 Nov 14;26(11):1366-1383. Epub 2020 Dec 14.

Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan. Electronic address:

Objective: The aim of this Disease State Clinical Review is to provide a practical approach to patients with newly diagnosed adrenocortical carcinoma, as well as to follow-up and management of patients with persistent or recurrent disease.

Methods: This is a case-based clinical review. The provided recommendations are based on evidence available from randomized prospective clinical studies, cohort studies, cross-sectional and case-based studies, and expert opinions.

Results: Adrenocortical carcinoma is a rare malignancy, often with poor outcomes. For any patient with an adrenal mass suspicious for adrenocortical carcinoma, the approach should include prompt evaluation with detailed history and physical exam, imaging, and biochemical adrenal hormone assessment. In addition to adrenal-focused imaging, patients should be evaluated with chest-abdomen-pelvis cross-sectional imaging to define the initial therapy plan. Patients with potentially resectable disease limited to the adrenal gland should undergo en bloc open surgery by an expert surgeon. For patients presenting with advanced or recurrent disease, a multidisciplinary approach considering curative repeat surgery, local control with surgery, radiation therapy or radiofrequency ablation, or systemic therapy with mitotane and/or cytotoxic chemotherapy is recommended.

Conclusion: As most health care providers will rarely encounter a patient with adrenocortical carcinoma, we recommend that patients with suspected adrenocortical carcinoma be evaluated by an expert multidisciplinary team which includes clinicians with expertise in adrenal tumors, including endocrinologists, oncologists, surgeons, radiation oncologists, pathologists, geneticists, and radiologists. We recommend that patients in remote locations be followed by the local health care provider in collaboration with a multidisciplinary team at an expert adrenal tumor program.

Abbreviations: ACC = adrenocortical carcinoma; ACTH = adrenocorticotropic hormone; BRACC = borderline resectable adrenocortical carcinoma; CT = computed tomography; DHEAS = dehydroepiandrosterone sulfate; EDP = etoposide, doxorubicin, cisplatin; FDG = F-fluorodeoxyglucose; FNA = fine-needle aspiration; HU = Hounsfield units; IVC = inferior vena cava; LFS = Li-Fraumeni syndrome; MEN1 = multiple endocrine neoplasia type 1; MRI = magnetic resonance imaging; OAC = oncocytic adrenocortical carcinoma; PC = palliative care; PET = positron emission tomography.
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http://dx.doi.org/10.4158/DSCR-2020-0567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058447PMC
November 2020

Presentation and outcomes of adrenal ganglioneuromas: A cohort study and a systematic review of literature.

Clin Endocrinol (Oxf) 2021 Jul 22;95(1):47-57. Epub 2021 Mar 22.

Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.

Objective: To describe the presentation and outcomes of patients with adrenal ganglioneuromas (AGNs).

Design: Single-centre retrospective cohort study (1 January 1995 to 31 December 2019) and systematic review of literature (1 January 1980 to 19 November 2019).

Patients: Diagnosed with histologically confirmed AGN.

Measurements: Baseline clinical, imaging and biochemical characteristics, recurrence rates and mortality. Subgroup analysis was performed on tumours with histologic elements of ganglioneuroma and pheochromocytoma (ie composite tumours).

Results: The cohort study included 45 patients with AGN, 20 (44%) of which had composite tumours. Compared to pure AGN, patients with composite tumour were older (median age, 62.5 vs. 35 years, p < .001), had smaller tumours (median size, 3.9 vs. 5.7 cm, p = .016) and were discovered incidentally less frequently (65% vs. 84%, p = .009). No recurrences or ganglioneuroma-specific mortality occurred during follow-up (range, 0-266 months). The systematic review included 14 additional studies and 421 patients. The mean age of diagnosis was 39 years, and 47% were women. AGNs were discovered incidentally in 72% of patients, were predominantly unilateral (99%) and had a mean diameter of 5.8 cm and an unenhanced computed tomography (CT) attenuation of -118 to 49 Hounsfield units (HU). On imaging, 69% of AGNs were homogenous, 41% demonstrated calcifications, and 40% were lobulated.

Conclusions: AGNs are rare benign tumours that present with variable imaging features including large size, unenhanced CT attenuation >20 HU, calcifications and lobulated shape. Imaging characteristics can assist in establishing a diagnosis and avoiding an unnecessary adrenalectomy. The association of pheochromocytomas with AGNs is frequent. Diagnosis should include biochemical testing.
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http://dx.doi.org/10.1111/cen.14460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178203PMC
July 2021

Adrenal insufficiency.

Nat Rev Dis Primers 2021 03 11;7(1):19. Epub 2021 Mar 11.

Endocrinology in Charlottenburg, Berlin, Germany.

Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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http://dx.doi.org/10.1038/s41572-021-00252-7DOI Listing
March 2021

The Role for Metyrosine in the Treatment of Patients With Pheochromocytoma and Paraganglioma.

J Clin Endocrinol Metab 2021 May;106(6):e2393-e2401

Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Context: Treatment of pheochromocytoma and paraganglioma (PPGL) requires preintervention titration of alpha- and beta-adrenergic blockade, but patients may still be at risk for complications from catecholamine excess. Metyrosine decreases catecholamine production, making it an attractive therapeutic adjunct for select patients.

Evidence Acquisition: A systematic literature review was performed (Ovid Medline and Scopus databases) on December 17, 2019, including studies with humans and original data. Studies with 10 or more patients on metyrosine for PPGL were included. Studies were screened for overlapping populations, and the most comprehensive study was included. The references of included studies were reviewed for additional data. Patient data from our institution between 2000 and 2015 were also reviewed.

Evidence Synthesis: Metyrosine is well tolerated when used for a short course and can improve intraoperative outcomes in PPGL. Metyrosine should be considered when a difficult PPGL resection is expected (eg, pericardiac paraganglioma, abdominal paraganglioma with great vessel involvement), a large release of catecholamines is anticipated (eg, ablative therapy, chemotherapy), or when standard alpha- and beta-adrenergic blockade are not tolerated or cannot adequately control hypertension. Side effects are generally mild and self-limited, with sedation in a majority of patients. Extrapyramidal side effects are rare but can limit use of metyrosine. Because of its expense and limited availability, metyrosine use should be carefully planned and timed in relation to surgery.

Conclusions: Metyrosine is a safe addition to traditional alpha- and beta-adrenergic blockade and should be considered in those patients with PPGL at high risk for acute release of catecholamines.
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http://dx.doi.org/10.1210/clinem/dgab130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118583PMC
May 2021

A Comprehensive Study of Spindle Cell Oncocytoma of the Pituitary Gland: Series of 6 Cases and Meta-Analysis of 85 Cases.

World Neurosurg 2021 May 18;149:e197-e216. Epub 2021 Feb 18.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Objective: To discuss optimal treatment strategy for spindle cell oncocytoma (SCO) of the pituitary gland.

Methods: Institutional cases were retrospectively reviewed. A systematic literature search and subsequent quantitative synthesis were performed for further analysis. The detailed features were summarized and the tumor control rate (TCR) was calculated.

Results: Eighty-five patients (6 institutional and 79 literature) were included. The annual incidence was approximately 0.01-0.03/100,000. The mean age was 56 years. Vision loss was present in 60%. Seventy-three percent showed hormonal abnormalities. On magnetic resonance imaging, tumor was avidly enhancing, and the normal gland was commonly displaced anterosuperiorly. Evidence of hypervascularity was seen in 77%. Gross total resection (GTR) was achieved in only 24% because of its hypervascular, fibrous, and adhesive nature. The mean postoperative follow-up was 3.3 years for institutional cases and 2.3 years for the integrated cohort. The TCR was significantly better after GTR (5-year TCR, 75%; P = 0.012) and marginally better after non-GTR + upfront radiotherapy (5-year TCR, 76%; P = 0.103) than after non-GTR alone (5-year TCR, 24%). The TCRs for those with low Ki-67 index (≤5%) were marginally better than those with higher Ki-67 index (5-year rate, 57% vs. 23%; P = 0.110).

Conclusions: Frequent endocrine-related symptoms, hypervascular signs, and anterosuperior displacement of the gland support preoperative diagnosis of SCO. GTR seems to have better long-term tumor control, whereas the fibrous, hypervascular, and adhesive nature of SCO makes it difficult to achieve GTR. In patients with non-GTR, radiotherapy may help decrease tumor progression.
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http://dx.doi.org/10.1016/j.wneu.2021.02.051DOI Listing
May 2021

Risk of bone fractures after the diagnosis of adrenal adenomas: a population-based cohort study.

Eur J Endocrinol 2021 Apr;184(4):597-606

Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.

Objective: Several small studies reported increased prevalence and incidence of asymptomatic vertebral fractures in patients with non-functioning adrenal adenomas and adenomas with mild autonomous cortisol secretion. However, the risk of symptomatic fractures at vertebrae, and at other sites remains unknown. Our objective was to determine the prevalence and incidence of symptomatic site-specific fractures in patients with adrenal adenomas.

Design: Population-based cohort study, Olmsted County, Minnesota, USA, 1995-2017.

Methods: Participants were the patients with adrenal adenoma and age/sex-matched referent subjects. Patients with overt hormone excess were excluded. Main outcomes measures were prevalence and incidence of bone fractures.

Results: Of 1004 patients with adrenal adenomas, 582 (58%) were women, and median age at diagnosis was 63 years (20-96). At the time of diagnosis, patients had a higher prevalence of previous fractures than referent subjects (any fracture: 47.9% vs 41.3%, P = 0.003, vertebral fracture: 6.4% vs 3.6%, P = 0.004, combined osteoporotic sites: 16.6% vs 13.3%, P = 0.04). Median duration of follow-up was 6.8 years (range: 0-21.9 years). After adjusting for age, sex, BMI, tobacco use, prior history of fracture, and common causes of secondary osteoporosis, patients with adenoma had hazard ratio of 1.27 (95% CI: 1.07-1.52) for developing a new fracture during follow up when compared to referent subjects.

Conclusions: Patients with adrenal adenomas have higher prevalence of fractures at the time of diagnosis and increased risk to develop new fractures when compared to referent subjects.
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http://dx.doi.org/10.1530/EJE-20-1396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7974392PMC
April 2021

Steroid profiling in the diagnosis of mild and overt Cushing's syndrome.

Best Pract Res Clin Endocrinol Metab 2021 01 6;35(1):101488. Epub 2021 Feb 6.

Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA. Electronic address:

In this review, we provide a comprehensive overview of the utility of steroid profiling for diagnosis of management of overt Cushing syndrome and mild autonomous cortisol secretion. A diagnosis of Cushing syndrome is made through a multistep process that includes confirmation of endogenous hypercortisolism, followed by determination of its cause. Steroid metabolomic testing applied to serum or urine steroids and their metabolites can provide additional and novel insights into alterations of steroid biosynthesis and metabolism and its causes. In particular, increased availability and advances in mass spectrometry-based steroid analysis, coupled with machine learning-based algorithms, have facilitated the development of tailored diagnostic and subtyping approaches for autonomous cortisol secretion and might be useful for detecting low grade autonomous glucocorticoid secretion and in predicting and monitoring of disease severity and associated comorbidities.
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http://dx.doi.org/10.1016/j.beem.2021.101488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164982PMC
January 2021

Clinical Presentation and Outcomes of Opioid-Induced Adrenal Insufficiency.

Endocr Pract 2020 Nov;26(11):1291-1297

Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, Minnesota. Electronic address:

Objective: Opioid-induced adrenal insufficiency (OIAI) may develop in patients treated with chronic opioids due to suppression of the hypothalamic-pituitary-adrenal axis. Our objective was to describe the clinical manifestations, biochemical presentation, and clinical course of OIAI.

Methods: A retrospective study of adults diagnosed with OIAI between 2006 and 2018 at an academic center. Opioid daily dose was converted into morphine milligram equivalents (MMEs).

Results: Forty patients (women, n = 29 [73%]) taking chronic opioids at a daily median MME dose of 105 (60 to 200) mg and median duration of 60 (3 to 360) months were diagnosed with OIAI. Patients reported fatigue (n = 29, 73%), musculoskeletal pain (n = 21, 53%), and weight loss (n = 17, 53%) for a median of 12 (range, 1 to 132) months prior to diagnosis, and only 7.5% (n = 3) of patients were identified with OIAI through case detection. Biochemical diagnosis of OIAI was based on (1) low morning cortisol, baseline adrenocorticotropic hormone and/or dehydroepiandrosterone sulfate in 59% (n = 26) of patients or (2) abnormal cosyntropin stimulation test in 41% (n = 14) of patients. With glucocorticoid replacement, 16/23 (70%) patients with available follow-up experienced improvement in symptoms. Opioids were tapered or discontinued in 15 patients, of whom 10 were followed for adrenal function and of which 7 (70%) recovered from OIAI.

Conclusion: Minimum daily MME in patients diagnosed with OIAI was 60 mg. OIAI causes significant morbidity, and recognition requires a high level of clinical suspicion. Appropriate glucocorticoid treatment led to improvement of symptoms in 70%. Resolution of OIAI occurred following opioid cessation or reduction.
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http://dx.doi.org/10.4158/EP-2020-0297DOI Listing
November 2020

Corticotroph tumor progression after bilateral adrenalectomy (Nelson's syndrome): systematic review and expert consensus recommendations.

Eur J Endocrinol 2021 Mar;184(3):P1-P16

Section on Genetics & Endocrinology Eunice Kennedy Shriver National Insitute of Child Health & Human Development (NICHD) National Institute of Health (NIH), NIH Clinical Research Center, Bethesda, Maryland, USA.

Background: Corticotroph tumor progression (CTP) leading to Nelson's syndrome (NS) is a severe and difficult-to-treat complication subsequent to bilateral adrenalectomy (BADX) for Cushing's disease. Its characteristics are not well described, and consensus recommendations for diagnosis and treatment are missing.

Methods: A systematic literature search was performed focusing on clinical studies and case series (≥5 patients). Definition, cumulative incidence, treatment and long-term outcomes of CTP/NS after BADX were analyzed using descriptive statistics. The results were presented and discussed at an interdisciplinary consensus workshop attended by international pituitary experts in Munich on October 28, 2018.

Results: Data covered definition and cumulative incidence (34 studies, 1275 patients), surgical outcome (12 studies, 187 patients), outcome of radiation therapy (21 studies, 273 patients), and medical therapy (15 studies, 72 patients).

Conclusions: We endorse the definition of CTP-BADX/NS as radiological progression or new detection of a pituitary tumor on thin-section MRI. We recommend surveillance by MRI after 3 months and every 12 months for the first 3 years after BADX. Subsequently, we suggest clinical evaluation every 12 months and MRI at increasing intervals every 2-4 years (depending on ACTH and clinical parameters). We recommend pituitary surgery as first-line therapy in patients with CTP-BADX/NS. Surgery should be performed before extrasellar expansion of the tumor to obtain complete and long-term remission. Conventional radiotherapy or stereotactic radiosurgery should be utilized as second-line treatment for remnant tumor tissue showing extrasellar extension.
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http://dx.doi.org/10.1530/EJE-20-1088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060870PMC
March 2021

Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature.

Lancet Diabetes Endocrinol 2021 01 26;9(1):13-21. Epub 2020 Nov 26.

Section for Preventive Medicine, Faculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany.

Background: Phaeochromocytoma or paraganglioma (collectively known as PPGL) in pregnant women can lead to severe complications and death due to associated catecholamine excess. We aimed to identify factors associated with maternal and fetal outcomes in women with PPGL during pregnancy.

Methods: We did a multicentre, retrospective study of patients with PPGL and pregnancy between Jan 1, 1980, and Dec 31, 2019, in the International Pheochromocytoma and Pregnancy Registry and a systematic review of studies published between Jan 1, 2005, and Dec 27, 2019 reporting on at least five cases. The inclusion criteria were pregnancy after 1980 and PPGL before or during pregnancy or within 12 months post partum. Eligible patients from the retrospective study and systematic review were included in the analysis. Outcomes of interest were maternal or fetal death and maternal severe cardiovascular complications of catecholamine excess. Potential variables associated with these outcomes were evaluated by logistic regression.

Findings: The systematic review identified seven studies (reporting on 63 pregnancies in 55 patients) that met the eligibility criteria and were of adequate quality. A further 197 pregnancies in 186 patients were identified in the International Pheochromocytoma and Pregnancy Registry. After excluding 11 pregnancies due to potential overlap, the final cohort included 249 pregnancies in 232 patients with PPGL. The diagnosis of PPGL was made before pregnancy in 37 (15%) pregnancies, during pregnancy in 134 (54%), and after delivery in 78 (31%). Of 144 patients evaluated for genetic predisposition for phaeochromocytoma, 95 (66%) were positive. Unrecognised PPGL during pregnancy (odds ratio 27·0; 95% CI 3·5-3473·1), abdominal or pelvic tumour location (11·3; 1·5-1440·5), and catecholamine excess at least ten-times the upper limit of the normal range (4·7; 1·8-13·8) were associated with adverse outcomes. For patients diagnosed during pregnancy, α-adrenergic blockade therapy was associated with fewer adverse outcomes (3·6; 1·1-13·2 for no α-adrenergic blockade vs α-adrenergic blockade), whereas surgery during pregnancy was not associated with better outcomes (0·9; 0·3-3·9 for no surgery vs surgery).

Interpretation: Unrecognised and untreated PPGL was associated with a substantially higher risk of either maternal or fetal complications. Appropriate case detection and counselling for premenopausal women at risk for PPGL could prevent adverse pregnancy-related outcomes.

Funding: US National Institutes of Health.
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http://dx.doi.org/10.1016/S2213-8587(20)30363-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758862PMC
January 2021

ENSAT registry-based randomized clinical trials for adrenocortical carcinoma.

Eur J Endocrinol 2021 Feb;184(2):R51-R59

Department of Endocrinology & Diabetes Mellitus, c/o Department of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Galway, Ireland.

Adrenocortical carcinoma (ACC) is an orphan disease lacking effective systemic treatment options. The low incidence of the disease and high cost of clinical trials are major obstacles in the search for improved treatment strategies. As a novel approach, registry-based clinical trials have been introduced in clinical research, so allowing for significant cost reduction, but without compromising scientific benefit. Herein, we describe how the European Network for the Study of Adrenal Tumours (ENSAT) could transform its current registry into one fit for a clinical trial infrastructure. The rationale to perform randomized registry-based trials in ACC is outlined including an analysis of relevant limitations and challenges. We summarize a survey on this concept among ENSAT members who expressed a strong interest in the concept and rated its scientific potential as high. Legal aspects, including ethical approval of registry-based randomization were identified as potential obstacles. Finally, we describe three potential randomized registry-based clinical trials in an adjuvant setting and for advanced disease with a high potential to be executed within the framework of an advanced ENSAT registry. Thus we, therefore, provide the basis for future registry-based trials for ACC patients. This could ultimately provide proof-of-principle of how to perform more effective randomized trials for an orphan disease.
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http://dx.doi.org/10.1530/EJE-20-0800DOI Listing
February 2021

Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort.

J Neurol Surg B Skull Base 2020 Oct 24;81(5):594-602. Epub 2019 Jul 24.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States.

 Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era.  Retrospective case series.  Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified.  Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.
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http://dx.doi.org/10.1055/s-0039-1692484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591353PMC
October 2020

Epidemiology of adrenal tumours in Olmsted County, Minnesota, USA: a population-based cohort study.

Lancet Diabetes Endocrinol 2020 11;8(11):894-902

Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Adrenal tumours are commonly encountered in clinical practice, but epidemiological data mainly originate from referral centres. We aimed to determine incidence, prevalence, and rates of malignancy and hormone excess in patients with adrenal tumours in a standardised geographically well defined population.

Methods: In this retrospective population-based cohort study we assessed the standardised incidence rate of adrenal tumours in all patients with tumours who lived in Olmsted County, MN, USA, from Jan 1, 1995, to Dec 31, 2017. The Rochester Epidemiology Project infrastructure, which links medical records across all health-care providers for the entire population of Olmsted County since 1966, was used to allow researchers to identify individuals with specific diagnoses, surgical interventions, and other procedures, and to locate their medical records, which were then used in the analysis. Incidence rates and prevalence were standardised for age and sex according to the 2010 US Population.

Findings: An adrenal tumour was diagnosed in 1287 patients (median age 62 years; 713 (55·4%) were women; and 13 (1·0%) were children). Standardised incidence rates increased from 4·4 (95% CI 0·3-8·6) per 100 000 person-years in 1995 to 47·8 (36·9-58·7) in 2017, mainly because of the incidental discovery of adenomas less than 40 mm in diameter in patients older than 40 years. Prevalence of adrenal tumours in 2017 was 532 per 100 000 inhabitants, ranging from 13 per 100 000 in children (aged <18 years) to 1900 per 100 000 in patients older than 65 years. 111 (8·6%) of 1287 patients were diagnosed with malignancy (96 [7·5%] of whom has metastases), 14 (1·1%) with phaeochromocytoma, and 53 (4·1%) with overt steroid hormone excess. Malignancy was more common in children (62%) versus those older than 18 years (8%; p<0·0001), tumours discovered during cancer-staging or follow-up (43% vs 3% for incidentalomas; p<0·0001), tumours more than 40 mm in diameter (34% vs 6% for tumours <20 mm; p<0·0001), tumours with unenhanced CT attenuation of 30 Hounsfield units or more (20% vs 1% for <20 Hounsfield units; p<·0001), and bilateral masses (16% vs 7% for unilateral, p=0·0004).

Interpretation: Adrenal tumour standardised incidence rates increased 10 times from 1995 to 2017. Population-based data revealed lower rates of malignancy, phaeochromocytoma, and overt steroid hormone excess than previously reported.

Funding: National Institutes of Health.
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http://dx.doi.org/10.1016/S2213-8587(20)30314-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7601441PMC
November 2020

Urine metabolomic phenotyping for detection of adrenocortical carcinoma: still a long way to go - Authors' reply.

Lancet Diabetes Endocrinol 2020 11;8(11):877-878

Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK; Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK. Electronic address:

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http://dx.doi.org/10.1016/S2213-8587(20)30345-4DOI Listing
November 2020