Publication Highlights

There are 2 fundamental questions that clinicians are faced with when discovering an adrenal mass:

Clinicians should consider biochemical screening for adrenal hormone excess, even if radiographic characteristics suggest that the adrenal mass is benign. In most scenarios, patients do not display the typical signs of overt syndromes of hormone excess, such as Cushing syndrome. However, clinicians may still uncover hormone excess upon biochemical evaluation.

Managing incidentally discovered adrenal masses

a simplified clinical algorithm

All patients with adrenal masses are usually recommended for screening with 1-mg DST.

• Despite a lack of classical features suggestive of Cushing syndrome during physical examination, biochemical testing may detect autonomous hypercortisolism
• Even mild or autonomous hypercortisolism can increase the risk for future cardiometabolic and skeletal concerns
• A 1-mg DST is the recommended initial test for hypercortisolism, where morning cortisol levels ≤1.8 μg/dL are considered “normal”
• The prevalence of autonomous hypercortisolism with incidentally discovered adrenal masses has been reported as approximately 5% among more than 2,000 patients from 13 different studies; however, milder degrees of hypercortisolism may exist in a much higher percentage of individuals with adrenal tumors
• The collective results may indicate a possible benefit for the treatment of hypercortisolism if:
  • Multiple lines of biochemical evidence suggest autonomous, adrenocorticotropic hormone-independent hypercortisolism, and
  • Clinical evidence associated with cortisol excess (fragility fractures, dyslipidemia, and type 2 diabetes) exists