Adrenal incidentalomas are found in 3-10% of adults undergoing abdominal imaging. Of these, 30-50% are responsible for mild autonomous cortisol secretion (MACS), which is frequently associated with hypertension. The impact of adrenalectomy on hypertension in patients with unilateral incidentalomas and MACS remains uncertain. The aim of the CHIRACIC study was to prospectively assess the impact of surgical excision of the incidentaloma on blood pressure with a randomised trial combining accurate blood pressure measurement and standardisation of antihypertensive treatment.

CHIRACIC was a multicentre, superiority, open-label, parallel, randomised controlled trial performed at 17 university hospitals in France, Italy, and Germany. Adults with hypertension with MACS entered a run-in phase to confirm hypertension with multiple home blood pressure measurements (HBPM) before blood pressure was normalised with standardised stepped-care antihypertensive treatment. Eligible participants were then randomly assigned (1:1) to adrenalectomy or conservative management. Randomisation was blocked (random block size of 4 and 6) and stratified by intensity of antihypertensive treatment. Participants were followed up for 13 months and systematic attempts were made to gradually reduce antihypertensive treatment. The primary endpoint was the proportion of normotensive participants using HBPM who reduced their antihypertensive treatment in the intention-to-treat population at study completion. Key secondary endpoints included 24 h ambulatory blood pressure measurement (ABPM), mean change in antihypertensive treatment, and the proportion of participants with antihypertensive treatment at study completion. This study was registered with ClinicalTrials.gov, NCT02364089, and is completed.

Between April 9, 2015 and Nov 23, 2022, 78 patients were enrolled, and 52 eligible participants were randomly assigned to adrenalectomy (n=26, 23 underwent adrenalectomy and completed the study) or conservative management (n=26, 25 completed the study). The median age of participants was 63·3 years (IQR 57·4-68·2) and 36 (69%) were female. At study completion, a reduction in antihypertensive treatment with normal HBPM was observed in 12 (46%) of 26 participants treated with adrenalectomy and in four (15%) of 26 treated conservatively (adjusted risk difference [RD] 0·34 [95% CI 0·11 to 0·58]; p=0·0038). Similar results of smaller magnitude were observed for systolic blood pressure during 24 h ABPM. There were ten (43%) of 23 participants still needing antihypertensive treatment in the adrenalectomy group and 24 (96%) of 25 in the conservative management group (adjusted RD -0·58 [95% CI -0·78 to -0·38]; p<0·0001). Mean antihypertensive treatment step was 0·8 (SD 1·1) in the adrenalectomy group and 3·0 (1·4) in the conservative management groups (adjusted difference -2·05 [95% CI -2·61 to -1·50]; p<0·0001]. The number of patients with normal systolic HBPM and no hypertensive treatment was 12 (52%) of 23 in the adrenalectomy group and none in the conservative management group. Serious adverse events occurred in eight (35%) of 23 participants in the adrenalectomy group and eight (31%) of 26 participants in the conservative management group. Three serious adverse events for three (13%) participants were related to the surgery (post-surgical wall pain and hypotension).

MACS associated with unilateral adrenal incidentalomas is responsible for secondary hypertension that can be safely improved by minimally-invasive adrenalectomy.

French Ministry of Health and the German Research Foundation.

Somatic alterations are commonly observed in adrenocortical adenomas including cortisol-producing (CPA) [overt Cushing syndrome (CS) or mild autonomous cortisol secretion (MACS)], aldosterone-producing (APA), and non-functioning (NFAT) tumors. We tested whether somatic variants could be detected in circulating cell-free DNA (ccfDNA) from patients with adenomas and potentially contribute to management strategies.

We investigated 44 patients (17 CPA-MACS, 9 CPA-CS, 12 APA, and 6 NFAT). 23 healthy subjects (HS) served as controls. ccfDNA was extracted from blood samples and quantified with fluorimeter. Tumor DNA (T-DNA) was isolated from paraffin embedded tissue in 17/44 cases. Matched ccfDNA/T-DNA were sequenced using a customized panel including 32 genes. Leucocyte DNA was used to filter out germline variants.

Patients with adenomas had higher total ccfDNA concentrations than HS [median 0.12 (IQR 0.05-0.19) vs. 0.05 (0.00-0.08) ng/µl, P < 0.001], with CPA-CS showing the highest ccfDNA levels [0.18 (0.05-0.47) ng/µl]. Within T-DNA, somatic variants were identified in 53% of adenomas: PRKACA in 2/7 CPA-CS, CTNNB1 in 3/5 CPA-MACS and 1/7 CPA-CS, KCNJ5 in 2/5 APA and CACNA1D in 1/5 APA. Somatic mutations were not detected in any of the investigated ccfDNA samples.

Total ccfDNA concentrations are higher in patients with CPA-CS. Despite the presence of somatic variants in half of tumor samples, we did not detect any at ccfDNA level. Therefore, this approach appears ineffective for pre-operative detection of genetic alterations.

Benign adrenocortical tumours are the most common adrenal neoplasms. Evidence over the past few decades has highlighted sex differences in their prevalence, clinical characteristics, and treatment outcomes. Cortisol-producing adenomas causing either Cushing's syndrome, particularly those with PRKACA or GNAS somatic mutations associated with a more severe phenotype, or mild autonomous cortisol secretion (MACS) are more commonly observed in women. The mechanisms underpinning this sexual dimorphism remain to be fully elucidated. Studies in mice have revealed a protective role of androgens in males, leading to a decelerated growth rate of adrenocortical cells. Furthermore, evidence from human adrenal tumour tissue suggests that oestrogen, progesterone, and luteinising hormone/choriogonadotropin signalling in the adrenal cortex may play a role in adrenal tumourigenesis and steroid production. Clinically, this is supported by the increased incidence of cortisol-producing adrenocortical adenomas or nodular hyperplasia during puberty, pregnancy, and menopause. Notably, women with MACS seem to be more vulnerable to the harmful effects of cortisol excess and carry a higher mortality risk than men. Women with aldosterone-producing adenomas have a higher prevalence of somatic KCNJ5 mutations than men, and patients harbouring these mutations are likely to have more favourable clinical outcomes after adrenalectomy. In this review, we summarise the possible mechanisms behind the sexual dimorphism of benign adrenocortical tumours and provide an up-to-date overview of the sex-specific differences in their prevalence, clinical presentation, and outcomes, focusing on cortisol and aldosterone excess. Considering sexual dimorphism is crucial to guide diagnosis and management, and to counsel these patients for optimised care.

This study investigated long-term alterations in cardiometabolic comorbidities among patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) who received surgical or conservative treatments.

A single-center, retrospective study analyzed 132 patients with PBMAH, divided into a surgery group (n = 68) and a control group (n = 64) based on treatment modalities. The main outcomes included changes in blood pressure (BP), blood glucose, lipids, and body weight.

Among the 132 patients, hypertension, abnormal glucose metabolism, dyslipidemia, and overweight/obesity were prevalent in over 50% of cases. The surgery group demonstrated significantly greater improvements in BP, blood glucose, and weight control compared with the control group. Adrenalectomy was associated with enhanced BP control, blood glucose control, and at least one cardiometabolic risk factor control. In a group of 95 patients with mild autonomous cortisol secretion, the surgery group also exhibited higher rates of improvement in BP and blood glucose than the control group. Adrenalectomy was associated with improved BP, blood glucose, and at least one cardiometabolic risk factor.

Our study observed that most patients with PBMAH exhibited at least one cardiometabolic risk factor. Adrenalectomy was associated with improved BP and blood glucose for patients with PBMAH, including those with mild autonomous cortisol secretion.

Adrenal incidentalomas (AIs) and pituitary incidentalomas (PIs) have become frequent findings in the last two decades due to the widespread use of cross-sectional imaging in clinical practice. This review investigates the prevalence of endogenous hypercortisolism in patients with AIs and PIs. We aim to underscore the importance of early detection and management of endogenous hypercortisolism in this subset of patients to mitigate associated cardiometabolic complications and reduce mortality.

We performed a PubMed literature search to provide updates regarding the prevalence of endogenous hypercortisolism in patients with AIs and PIs, the demographic and clinical characteristics of the studied populations, and the diagnostic test accuracy for early identification of endogenous hypercortisolism.

Hypercortisolism, especially mild autonomous cortisol secretion (MACS), was identified in a notable proportion of patients with AIs. MACS was associated with increased cardiometabolic risks, contributing to an elevated overall mortality rate in this cohort. Furthermore, PIs were found to be linked with Cushing's disease in a subset of patients, emphasizing the need for thorough evaluation and monitoring.

Early diagnosis and appropriate management of endogenous hypercortisolism are essential in preventing complications and improving patient outcomes. As the presence of undetected hypercortisolism is associated with clinical complications over time, the accurate identification of high-risk populations to screen remains crucial.

Mild autonomous cortisol secretion (MACS) is the most common hormonal alteration in patients with adrenal incidentalomas (AIs). Given its prevalence and associated adverse outcomes, reviewing its impact and interventions is essential.

In this article, we provide a comprehensive review on the diagnosis of MACS, the cardiometabolic burden associated with MACS and on its surgical and medical treatment. The diagnosis of MACS requires three criteria: hormonal evidence of hypercortisolism, the absence of typical Cushing's syndrome signs, and the presence of an AI. The most recommended test for MACS diagnosis is the 1 mg dexamethasone suppression test. There is plenty of evidence of the detrimental effect of MACS, including an increased risk of diabetes, hypertension, dyslipidemia and all-cause mortality. Surgery should be considered for patients with significant comorbidities and has been shown to significantly improve anthropometric variables, hyperglycemia and blood pressure. Medical therapy to lower cortisol offers an effective alternative, particularly for patients with bilateral AI, when surgery is contraindicated, or the patient declines surgery.

Based on our expert opinion, steroid profiling has the potential to become the gold standard for MACS diagnosis, and further studies should identify which patients benefit most from specific treatment to guiding evidence-based recommendations.

The prevalence of secondary hypertension is reported to be 5-15% of people with hypertension. Causes of secondary hypertension include Cushing's syndrome (CS), a rare but serious clinical condition characterized by chronic endogenous hypercortisolism associated with increased morbidity and mortality, especially for cardiovascular complications. The challenge for the clinician is thus to identify the phenotype of hypertensive patients who should be screened for endogenous hypercortisolism.

This study was performed according to the PRISMA statement. The search was last updated in June 2023, and only English language studies were considered. Titles and abstracts have been screened for articles selection, identifying only those that dealt with prevalence of Cushing's syndrome in hypertensive patients. Finally, eight papers were included in the review. Data regarding year of publication, populations' characteristics, inclusion criteria, screening test and cut-off used, and CS prevalence have been extracted.

The study search identified eight studies, from 1977 to 2020, including a total number of 11,504 patients, ranging from 80 to 4429 patients for each study. The prevalence of CS reported was variable among the studies, ranging from 0 to 7.7%, having Cushing's disease (CD) a prevalence range of 0-1.2%. The highest prevalence has been found in selected populations of hypertensive patients younger than 40 years (6.2%) or harbouring an adrenal lesion (7.7%). The most used screening test was 1 mg overnight dexamethasone suppression test (1 mg DST), with different cut-off.

The most fitting CS profile encompasses younger age (i.e., < 40 years old), rapidly evolving hypertension and the presence of adrenal adenomas, along with subjects with pituitary lesions, who should still be prioritized in the diagnostic pathway. Overall, in the case of hypertensive patients presenting a clinical picture highly suggestive of CS, it is advisable to perform one of the available screening tests (UFC, 1 mg DST, LNSC). LNSC is likely the most discriminatory test and may be preferred, depending on its availability. Conversely, for hypertensive patients with an adrenal incidentaloma, the 1 mg DST is recommended as the screening test to exclude CS.

Autonomous cortisol secretion (ACS) is linked to a higher prevalence of metabolic abnormalities and an increased risk of major adverse cardiovascular events.

To evaluate glucose and bone metabolism in patients with ACS using a continuous glucose monitoring system (CGMS) and dual-energy X-ray absorptiometry (DXA).

Patients diagnosed with ACS, including Cushing syndrome, mild ACS (MACS), and nonfunctional adrenal incidentaloma (NFAI), were recruited for this study. Glucose variability and glycemic status were assessed using CGMS. Regional bone mineral content (BMC), bone mineral density (BMD), and bone area (BA) were evaluated using DXA. CGMS- and DXA-derived parameters were compared across the subgroups of ACS. Correlation analysis was performed to examine relationships between varying degrees of cortisol secretion, measured by cortisol after 1 mg overnight dexamethasone suppression test (DST) or 24-hour urine free cortisol (24h UFC), and CGMS- or DXA-derived parameters.

A total of 64 patients with ACS were included in this study: 19 with Cushing syndrome, 11 with MACS, and 34 with NFAI. Glucose variability, time above range (TAR), and time in range (TIR) along with specific areal BMC, BMD, and BA, differed significantly between groups of Cushing syndrome and NFAI. A significant positive correlation was observed between glucose variability or TAR and cortisol after 1 mg overnight DST or 24h UFC. By contrast, TIR, along with regional BMC, BMD, and BA, were negatively correlated with varying degrees of cortisol secretion.

Glucose and bone metabolism impairments are on a continuum alteration from NFAI to MACS and Cushing syndrome. Prompt attention should be given to these patients with ACS, especially those with mild hormone secretion. Parameters of glucose variability and glycemic status along with bone condition in regions rich in cancellous bone will provide valuable information.

Cushing syndrome represents a multitude of signs and symptoms associated with long-term and excessive exposure to glucocorticoids. Solitary cortisol-producing adenomas (CPAs) account for most cases of ACTH-independent Cushing syndrome (CS). Technological advances in next-generation sequencing have significantly increased our understanding about the genetic landscape of CPAs. However, the conventional approach utilizes fresh/frozen tissue samples, which are not routinely available for most clinical adrenal adenoma specimens. This coupled with the fact that CS is relatively rare reduces the accessibility to CPAs for research. In order to circumvent this issue, our group recently developed a sequencing strategy that allowed the use of formalin-fixed paraffin-embedded (FFPE) CPA samples for mutation analysis. Our streamlined approach includes the visualization and genomic DNA (gDNA) capture of the cortisol-producing regions in the tumor using immunohistochemistry (IHC)-guided techniques followed by targeted and/or whole-exome sequencing analysis. This approach has the advantage of using both prospective and retrospective CPA cohorts since FFPE pathologic specimens are routinely banked. This review discusses this advanced approach using IHC-guided gDNA capture of pathologic tissue followed by NGS as a preferred method for mutational analysis of CPAs.

Mild autonomous cortisol secretion (MACS) is associated with several cardiometabolic and non-metabolic comorbidities, including osteoporosis, fractures and worse quality of life (QoL).

We performed a comprehensive review of the literature including articles that reported the association between MACS and osteoporosis, fractures and impact on QoL.

In relation to bone health, several studies reported that the risk of fractures in patients with MACS is discordant with the degree of bone mineral density loss measured per dual X-ray absorptiometry (DXA), suggesting that a reduction in bone quality rather than density contributes to the increased fracture risk. Nevertheless, in general a greater prevalence of vertebral fractures has been described in MACS compared with nonfunctioning adrenal incidentalomas (NFAIs) patients. Regarding QoL, due to the higher burden of comorbidities and the adverse symptoms linked to MACS diagnosis, MACS patients are overall frailer and have worse QoL than patients with NFAIs or the general population. Higher levels of disability related to mental health, middle insomnia and perceived stress have also been described in patients with MACS when compared to NFAIs patients.

MACS patients have a higher prevalence of fractures and osteoporosis, as well as a worse QoL compared to NFAIs and the general population. Thus, both bone health and QoL evaluation should be part of the assessment of patients with MACS diagnosis.

Adrenal incidentalomas (AIs) are increasingly detected during imaging performed for conditions unrelated to adrenal pathology. Numerous studies have shown that the presence of AI is associated with a higher frequency of hypertension, type 2 diabetes, dyslipidemia, obesity, and osteoporosis. This increased morbidity is mostly related to mild autonomous cortisol secretion, which is the most common hormonal abnormality in these patients. It is well known that glucocorticoid excess affects the hippocampus and prefrontal cortex, brain structures involved in mood regulation and cognitive processes, leading to a wide range of psychiatric symptoms, including depression. While these effects are well documented in patients with Cushing's syndrome, data on mental health changes in patients with AIs remain scarce. Additionally, the few existing studies have several limitations, leaving important clinical questions unanswered. Consequently, the extent to which AIs are associated with impaired mental health and whether patients would benefit from surgical treatment remains unclear. Addressing these challenges is crucial for developing adequate management strategies. This review explores potential psychological and psychiatric implications of AIs. By synthesizing existing literature, we aim to explain the relationship between AIs and mental health disorders, providing a background for future research and clinical practice guidelines.

We aimed to examine how different types of adrenal hormone excess influence body composition.

A retrospective, cross-sectional, single-centre study.

We retrospectively enrolled 2971 consecutive adults with adrenal tumours and age-, sex-, and body mass index-matched controls at a 1:3 ratio. The area and attenuation of skeletal muscle and fat at the L3 vertebrae were measured using computed tomography-based analysis software. Prevalence ratios of cardiometabolic outcomes were calculated using the Poisson regression.

Patients with non-functioning adenoma (n = 1354) and mild autonomous cortisol secretion (MACS; n = 786) showed similar body compositions. Patients with overt Cushing's syndrome (CS) had the highest visceral fat (VF) area to skeletal muscle area ratio (1.14), while pheochromocytoma (PHEO) patients had the lowest (0.52). Muscle attenuation was lowest in CS and highest in PHEO (32.6 vs 41.5 Hounsfield units, P < .001). Mild autonomous cortisol secretion patients had higher risks of hypertension and dyslipidaemia than non-functioning adenoma patients. Non-functioning adenoma and MACS patients had higher VF area and lower muscle/fat attenuation compared with controls, while primary aldosteronism patients had body compositions similar to controls, except for higher fat attenuation.

Adrenal tumours are associated with altered body composition. Even patients with non-functioning adenoma and MACS had increased VF area and lower muscle and fat attenuation compared with controls, indicating potential cardiometabolic risks.

Cushing syndrome (CS) is a constellation of signs and symptoms caused by excessive exposure to exogenous or endogenous glucocorticoid hormones. Endogenous CS is caused by increased cortisol production by one or both adrenal glands (adrenal CS) or by elevated adrenocorticotropic hormone (ACTH) secretion from a pituitary tumour (Cushing disease (CD)) or non-pituitary tumour (ectopic ACTH secretion), which stimulates excessive cortisol production. CS is associated with severe multisystem morbidity, including impaired cardiovascular and metabolic function, infections and neuropsychiatric disorders, which notably reduce quality of life. Mortality is increased owing to pulmonary emboli, infection, myocardial infarction and cerebrovascular accidents. The clinical presentation is variable and because some CS signs and symptoms are common in the general population, the diagnosis might not be considered until many features have accumulated. Guidelines recommend screening patients with suspected CS with 24-h urine cortisol, bedtime salivary cortisol and/or 1 mg dexamethasone suppression test. Subsequently, determining the aetiology of CS is important as it affects management. The first-line therapy for all aetiologies of endogenous CS is surgical resection of the causal tissue, including corticotroph adenoma or ectopic tumour for ACTH-dependent CS or unilateral or bilateral adrenalectomy for adrenal CS. Second-line therapies include steroidogenesis inhibitors for any cause of CS, pituitary radiation (with or without steroidogenesis inhibitors) for CD, and bilateral adrenalectomy for ACTH-dependent causes of CS.

Mild autonomous cortisol secretion (MACS) is diagnosed based on postdexamethasone cortisol >1.8 µg/dL. Scarce evidence exists on steroid circadian secretion and steroid metabolome in MACS.

To characterize 24-hour (h) urine steroid metabolome in patients with MACS and determine circadian differences in urine steroid profiling and cortisol concentrations in patients with MACS vs referent subjects.

Cross-sectional study, 2018-2023, at a referral center. Patients with MACS and age-, sex-, body mass index-, and menopausal status-matched referent subjects were included. Urine was collected over a 24 hour period as separate daytime and nighttime collections. High-resolution mass spectrometry assay was used to measure 25 steroids. A subgroup of patients and referent subjects was admitted for serum measurements of free and total cortisol every 2 hours. Outcomes were steroids, steroid sums, and ratios.

Patients with MACS (n = 72) had lower µg/24 hour median androgens (2084 vs 3283, P < .001), higher glucocorticoids (15 754 vs 12936, P < .001), and higher glucocorticoid/androgen ratio (8.7 vs 3.9, P < .001) than referent subjects. Patients also had lower steroid day/night ratios than referent subjects, reflecting a higher relative nocturnal steroid production in MACS. In a subgroup of 12 patients with MACS and 10 referent subjects, the 24-hour areas under the curve for total and free serum cortisol were similar. However, evening mean total (5.3 vs 4.0 µg/dL, P = .056) and free (0.2 vs 0.1 µg/dL, P = .035) cortisol was higher in patients vs referent subjects.

Patients with MACS demonstrate an abnormal urine steroid metabolome, with a high glucocorticoid to androgen ratio, and a higher nocturnal steroid production.

Patients with adrenal hormone excess demonstrate increased cardiovascular (CV) risk and mortality.

We aimed to determine the effect of adrenal disorders on the inflammation marker glycoprotein acetylation (GlycA), total branched-chain amino acids (BCAAs), ketone bodies, and the gut microbiome-derived metabolites trimethylamine N-oxide (TMAO) and betaine.

We conducted a single-center cross-sectional study of patients with nonfunctioning adenomas (NFAs), mild autonomous cortisol secretion (MACS), primary aldosteronism (PA), Cushing syndrome (CS), pheochromocytoma/paragangliomas (PPGLs), other benign or malignant adrenal masses, and adrenocortical carcinoma (ACC) between January 2015 and July 2022 (n = 802). Referent individuals included participants in the PREVEND (Prevention of Renal and Vascular End-Stage Disease) study (n = 5241). GlycA, BCAAs, ketone bodies, TMAO, and betaine were measured using nuclear magnetic resonance spectroscopy. Multivariable logistic analyses were adjusted for age, sex, body mass index, smoking, hypertension, diabetes mellitus, and statin therapy.

In age- and sex-adjusted comparison to referent individuals, increased GlycA was noted in all patient categories, increased BCAAs in NFA, MACS, CS, PA, and ACC, increased TMAO in patients with other malignant adrenal masses, increased betaine in NFA and MACS, and increased ketone bodies in NFA, CS, and ACC. Essentially similar findings were observed in fully adjusted analysis and after exclusion of participants with diabetes and CV disease.

Patients with functioning and nonfunctioning adrenal masses demonstrated increased GlycA and BCAAs, biomarkers associated with adverse cardiometabolic disorders and mortality. Patients with NFA demonstrated an adverse metabolic profile similar to patients with MACS and CS.

Cortisol concentration is often estimated by competitive chemiluminescent immunoassays, which are prone to interference due to cross-reactivity. The extent of interference is inconsistent across different adrenal disorders and among different analyzers. Although liquid chromatography-mass spectrometry (LC-MS/MS) possesses better analytical specificity, it is not widely available. We aimed to compare cortisol values measured across four different analyzers across different adrenal disorders.

Cortisol concentrations were measured in the serum of patients with congenital adrenal hyperplasia (CAH) (n = 12), primary adrenal insufficiency (PAI) (n = 11), endogenous Cushing's syndrome (CS) (n = 6), adrenal incidentaloma (AI) (n = 8), and healthy subjects (HS) (n = 10) in the following analyzers: Advia Centaur XP (Siemens) (SACXP), Immulite1000 (Siemens) (SI1000), Cobas e411 (Roche) (RCe411), and Architect (Abbott)(AA).

In CAH patients, a poor agreement was observed between SAC XP [median (IQR) 14.6 (4.7) μg/dL] and RC e411 [median (IQR) 4.6 (3.9) μg/dL] [ICC: -0.016, (-0.55, 0.55)]. The correlation was also poor between SAC XP and SI 1000 [ICC: 0.00, (0.558, 0.551)] as well as between SAC XP and AA [ICC: 0.089, (-0.488, 0.612)]. The agreement was good between RCe411, SI 1000 [median (IQR) 9.6 (3) μg/dL], and AA [median (IQR) 5.1 (3.4) μg/dL] platforms in the same group. Measured cortisol values correlated well across all analyzers in PAI, CS, AI, and HS.

Cortisol concentration demonstrated variable agreement among different analyzers in different adrenal disorders. In CAH, cortisol values measured by SAC XP poorly correlate with RC e411, SI 1000, and AA platforms. Reassessment in another analyzer therefore would be prudent to avoid devastating consequences of unrecognized hypocortisolism in this subset of patients. A good concordance was observed among platforms in other conditions.

Serum inflammation-based scores can predict clinical outcome in several cancer types, including adrenocortical carcinoma (ACC). It is unclear whether the extent of inflammation-based scores alterations in ACC reflects malignancy, steroid excess, or both.

We investigated a large retrospective cohort of adrenocortical adenomas (ACA, n = 429) and ACC (n = 61) with available baseline full blood count and hormonal evaluation. We examined the relationship between different inflammation-based scores [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic immune-inflammation index (SII), and prognostic nutrition index (PNI)] and both malignancy and steroid secretion patterns.

All inflammation-based scores differed between ACC and ACA: patients with ACC had higher NLR, PLR, SII and lower LMR and PNI levels compared to ACA (all p values < 0.001). NLR showed a positive correlation with cortisol levels after overnight 1 mg-dexamethasone suppression test (1 mg-DST), both in ACC and ACA (p < 0.01). The ROC curve analysis determined NLR > 2.6 as the best cut-off to discriminate ACC from ACA [AUC = 0.846, p < 0.01]. At multivariable analysis, NLR > 2.6 was independently associated with ACC, 1 mg-DST cortisol levels and age, but not with tumour size. Considering the ACC, NLR and SII were higher and PNI was lower in patients with cortisol excess compared to those without cortisol excess (p = 0.002, p = 0.007, and p = 0.044 respectively). Finally, LMR and NLR differed between inactive-ACC (n = 10) and inactive-ACA (n = 215) (p = 0.040 and p = 0.031, respectively).

Inflammation-based scores are related to steroid secretion both in ACC and ACA. ACCs present a higher grade of inflammation regardless of their hormonal secretion, likely as a feature of malignancy itself.

Patients with nonfunctioning adenomas (NFAs), adenomas with mild autonomous cortisol secretion (MACS) and Cushing syndrome (CS) demonstrate an increased cardiovascular risk.

This work aimed to determine the extent of lipoprotein abnormalities in NFA, MACS, and CS.

We conducted a single-center, cross-sectional study of patients with NFA (n = 167), MACS (n = 213), CS (n = 142), and referent individuals (n = 202) between January 2015 and July 2022. Triglyceride-rich lipoprotein particles (TRLP), low-density lipoprotein particles (LDLP), high-density lipoprotein particles (HDLP), their subclasses and sizes were measured using nuclear magnetic resonance spectroscopy. Multivariable logistic analyses were adjusted for age, sex, body mass index, smoking, hypertension, diabetes and lipid-lowering drug therapy.

In age- and sex-adjusted analysis, all patients categories demonstrated increased very large TRLP, large TRLP, and greater TRLP size (odds ratio [OR], 1.22-2.08) and total LDLP (OR, 1.22-1.75) and decreased LDL and HDL size compared to referent individuals. In fully adjusted analysis, LDLP concentrations remained elevated in all patient categories (OR, 1.31-1.84). Total cholesterol, LDL cholesterol, triglycerides, and apolipoprotein B (ApoB) were also higher in all patient categories in age- and sex-adjusted analysis, with ApoB remaining elevated in all patient categories in fully adjusted analysis. Similar LDLP and ApoB elevations were observed in all patient categories after excluding individuals on lipid-lowering therapy.

Patients with overt, mild, and even absent cortisol excess demonstrate lipoprotein profile abnormalities, in particular, high LDLP and ApoB concentrations, which conceivably contribute to high cardiometabolic risk.

Recent studies investigated the prevalence of arterial hypertension (AH), diabetes mellitus (DM) and/or prediabetes, dyslipidemia (DL), metabolic syndrome (MS) and cardiovascular events (CVE) in patients with non-functioning adrenal incidentalomas (NFAI). We aimed to investigate the available literature to determine the prevalence of AH, DM, DM and/or prediabetes (Composite DM, C-DM), DL, MS and CVE in patients with NFAI as compared to patients without adrenal incidentalomas (AI).

Systematic review and meta-analysis.

A meta-analysis was performed using studies that evaluated the prevalence of AH, DM, C-DM, DL, MS and CVE in patients with NFAI versus matched subjects without AI. A random-effects model (DerSimonian and Laird) was used to calculate the pooled odds ratio (OR) and 95% Confidence Interval (95%CI) for each outcome.

Among the 36 available studies, 19 studies provided the necessary data (4716 subjects, mean age 57.6 ± 4.6). The association between AH, DM, C-DM, DL, MS and CVE was reported in 18 (4546 subjects), 7 (1743 subjects), 5 (4315 subjects), 11 (3820 subjects), 8 (1170 subjects) and 5 (2972 subjects), respectively. The presence of NFAI was associated with AH (OR 1.87, 95%CI 1.39-2.51), C-DM (OR 2.04, 95%CI 1.70-2.45) and MS (OR 2.89, 95%CI 1.93-4.32), but not with DM, DL and CVE.

Patients with NFAI have higher prevalence of AH, C-DM and MS than control subjects without NFAI.

The impact of mild autonomous cortisol secretion (MACS) on cognition is incompletely characterized. We aimed to assess cognition in patients with MACS, identify factors associated with lower cognition, and determine the impact of adrenalectomy on cognition.

We conducted a cross-sectional study (4/2019 to 10/2022) and a longitudinal cohort study (10/2021 to 9/2023) of adults with MACS and referent subjects. Cognition was assessed with National Institute of Health Toolbox Cognition Battery and reported as standardized T scores (adjusted for age, sex, race/ethnicity, and education) for fluid, crystallized, and total composite cognition. Participants were assessed with urine steroid profiling (liquid chromatography-tandem mass spectrometry), frailty index, Beck's Depression Inventory (BDI), and Short Form-36 (SF-36).

A total of 84 patients (median age 57 years, 67% women) and 201 referent subjects (median age 63 years, 58% women) were included. Patients with MACS demonstrated lower mean (SD) total composite (50.9 [9.3] vs 55.4 [8.9], P < .001) and fluid composite T score (49.3 [10.6] vs 55.2 [10.2], P < .001), but not crystallized composite T score (52.3 [8.4] vs 54.0 [8.4], P = .130) when compared with referent subjects. Multivariable analysis adjusted for age, sex, BDI, SF-36, frailty index, total glucocorticoids, and androgens demonstrated that MACS status was associated with lower cognition. When cognition was reassessed in 37 patients post-adrenalectomy and 31 referent subjects, adjusted group differences of cognition change were similar except for a higher comparative increase in attention and executive functioning in patients with MACS.

Patients with MACS demonstrate lower cognition than referent subjects. Adrenalectomy for MACS had a minor positive impact on cognition.

Studies describing the coagulation profile in adrenal adenomas still need to be added.

We explored how sex and mild autonomous cortisol secretion (MACS) affect coagulation parameters in patients with adrenal adenomas.

Cross-sectional study.

From January 2019 until April 2023, participants in the Impact of Adrenal IncidenTalomas and Possible Autonomous Cortisol Secretion on Cardiovascular and Metabolic Alterations trial (NCT04127552) diagnosed with adrenal adenoma were categorised according to the 1 mg overnight dexamethasone-suppression test (1 mg-DST). Coagulation parameters were evaluated, and two-way ANOVA was used to elucidate the cortisol-by-sex interaction.

Of 153 patients screened, 90 were enrolled (62.2% female, mean age 62 ± 10 years): 41 with non-functioning adrenal tumour (1 mg-DST ≤ 1.8 µg/dL), and 49 with a MACS (1 mg-DST > 1.8 µg/dL). Platelet counts were higher in the MACS group (P = .01). Regression analysis identified female sex (B = 36.603, P = .011), 1mg-DST (B = 0.238, P = .042), and younger age (B = -1.452, P = .038) as independent predictors for elevated platelet count. In patients with MACS, women exhibited higher levels of procoagulant factors fibrinogen (P = .004) and factor VIII (P < .001), and coagulation inhibitors protein C (P = .003) and antithrombin III (P = .005) than males. No differences were observed in the non-functioning adrenal tumour group, providing a cortisol-by-sex interaction regarding fibrinogen (P = .047), factor VIII (P = .046), and protein C (P = .028).

Our findings revealed a worse coagulation profile in women with MACS, underscoring the need for a sex-specific approach in clinical practice to manage thrombotic risks effectively. Dedicated prospective studies are needed to validate and integrate these findings into clinical strategies for thromboprophylaxis.

Glucocorticoid (GC) hormones are secreted in a circadian and ultradian rhythm and play a critical role in maintaining physiological homeostasis, with both excess and insufficient GC associated with adverse effects on health. Current assessment of GC status is primarily clinical, often in conjunction with serum cortisol values, which may be stimulated or suppressed depending on the GC disturbance being assessed. In the setting of extreme perturbations in cortisol levels ie, markedly low or high levels, symptoms and signs of GC dysfunction may be overt. However, when disturbances in cortisol GC status values are less extreme, such as when assessing optimization of a GC replacement regimen, signs and symptoms can be more subtle or nonspecific. Current tools for assessing GC status are best suited to identifying profound disturbances but may lack sensitivity for confirming optimal GC status. Moreover, single cortisol values do not necessarily reflect an individual's GC status, as they are subject to inter- and intraindividual variation and do not take into account the pulsatile nature of cortisol secretion, variation in binding proteins, or local tissue concentrations as dictated by 11beta-hydroxysteroid dehydrogenase activity, as well as GC receptor sensitivity. In the present review, we evaluate possible alternative methods for the assessment of GC status that do not solely rely on the measurement of circulating cortisol levels. We discuss the potential of changes in metabolomic profiles, micro RNA, gene expression, and epigenetic and other novel biomarkers such as growth differentiating factor 15 and osteocalcin, which could in the future aid in the objective classification of GC status.

Adrenal masses are found in up to 5%-7% of adults. The 2016 European guidelines on the management of adrenal incidentalomas have standardised the workup of these patients, but evidence of their impact on clinical practice is lacking.

Retrospective review of clinical presentation, radiological characteristics, and final diagnosis of a large cohort of patients with adrenal masses referred to a tertiary care centre 1998-2022. Sub-analysis compares outcomes before and after implementing the 2016 guidelines.

A total of 1397 patients (55.7% women; median age 60 years [interquartile range {IQR}, 49-70]) were included. Incidental discovery was the most frequent mode of presentation (63.7%) and 30.6% of patients had masses ≥ 4 cm (median 2.9 cm [IQR, 1.9-4.7]). Unenhanced computed tomography Hounsfield units (HU) were available for 763 patients; of these, 32.9% had heterogeneous masses or >20 HU. The most common diagnoses were adrenocortical adenoma (56.0%), phaeochromocytoma (12.7%), adrenocortical carcinoma (10.6%), and metastases (5.7%). At multivariable analysis, significant predictors of malignancy included >20 HU or heterogeneous density (odds ratio [OR] 28.40), androgen excess (OR 27.67), detection during cancer surveillance (OR 11.34), size ≥ 4 cm (OR 6.11), and male sex (OR 3.06). After implementing the 2016 guidelines, the number of adrenalectomies decreased (6.1% pre-2016 vs 4.5% post-2016) and the number of patients discharged increased (4.4% pre-2016 vs 25.3% post-2016) for benign non-functioning adrenal masses.

Implementing the 2016 guidelines positively impacted clinical practice, reducing unnecessary surgeries and increasing the discharge rate for benign adrenal masses, thereby preserving healthcare resources and patient burden.

Mild autonomous cortisol secretion (MACS) accounts for a significant proportion of adrenal incidentaloma. Current endocrinological screening tests for MACS are complex, particularly in areas with limited medical resources. This study aimed to develop a diagnostic tool based on leukocyte-related parameters to differentiate between MACS and non-functioning adrenal adenoma (NFA).

Inthis retrospective case-control study, propensity score-matching was used to select 567 patients from a cohort of 1108 patients (201 MACS, 907 NFA). External validation cohort included 52MACS and 48 NFA from two hospitals, which did not overlap with the modeling cohort patients. Leukocyte-related parameters were evaluated, and the diagnostic efficacy of each parameter was assessed by calculating Youden's J index (J) and the area under the curve (AUC). The study population was divided into training and testing samples using a 10-fold cross-validation method. Machine learning (ML) and classification and regression tree (CART) model were established.

After propensity score matching, 567 patients were enrolled, including 197 MACS and 370 NFA. With the exception of basophil percentage, all other parameters differed significantly between the two groups. Lymphocyte count, lymphocyte percentage, eosinophils count, eosinophils percentage, and basophil percentage were lower in the MACS group compared to the NFA group. Eosinophils percentage demonstrated the highest AUC (0.650), with a sensitivity of 51.3% and specificity of 73.2%. The ML model, based on multiple parameters,exhibited better performance in diagnosing MACS (sensitivity 76%, specificity 77.4%, and AUC 0.818). A clinically usable CART model achieved an AUC of 0.872, with a sensitivity of 95% and a specificity of 75.7%.  In the validation cohort, the prediction accuracy of the ML model and the CART model were 0.784 and 0.798, respectively.

TheCART diagnostic model, constructed based on leukocyte-related parameters, could assist clinicians in distinguishing between MACS and NFA.

Adrenal incidentalomas (AI) are predominantly nonfunctional and benign, and their detection and differential diagnosis are aided by computed tomography (CT). A nonfunctioning adrenal incidentaloma (NFAI) usually requires regular follow-up; however, adrenalectomy may be necessary in certain patients. This study aimed to evaluate prognostic predictors to guide the treatment approach for AIs.

This retrospective, single-center study involved patients diagnosed with NFAI from January 2000 to December 2020. Patients were divided into surgery and observation groups. A subgroup analysis compared malignant and benign adenoma within the surgery group.

A total of 307 patients were included, with 127 in the surgery group and 180 in the observation group. The surgery group displayed distinct morphological and malignant potential features in CT scans more frequently than the observational group did. The malignant subgroup exhibited more irregular borders on CT, and a higher number of patients with absolute washout under 60 % and relative washout under 40 % compared with the benign adenoma subgroup. Interestingly, within the surgery group, the mean tumor size was <4 cm for the both malignant and benign adenoma subgroups.

Characterizing NFAI is important for appropriate treatment, as not all AIs have a favorable prognosis. CT findings associated with malignant potential, such as Hounsfield unit and washout values, were useful in determining the need for surgical treatment. However, the conventional criterion of a 4-cm size threshold for surgery was not a reliable malignancy predictor. Surgical resection should be considered for specific patient groups to ensure proper treatment over mere observation.

This white paper provides practical guidance for clinicians encountering bilateral adrenal masses.

A case-based approach to the evaluation and management of bilateral adrenal masses. Specific clinical scenarios presented here include cases of bilateral adrenal adenomas, hemorrhage, pheochromocytomas, metastatic disease, myelolipomas, as well as primary bilateral macronodular adrenal hyperplasia.

Bilateral adrenal masses represent approximately 10% to 20% of incidentally discovered adrenal masses. The general approach to the evaluation and management of bilateral adrenal masses follows the same protocol as the evaluation of unilateral adrenal masses, determined based on the patient's clinical history and examination as well as the imaging characteristics of each lesion, whether the lesions could represent a malignancy, demonstrate hormone excess, or possibly represent a familial syndrome. Furthermore, there are features unique to bilateral adrenal masses that must be considered, including the differential diagnosis, the evaluation, and the management depending on the etiology. Therefore, considerations for the optimal imaging modality, treatment (medical vs surgical therapy), and surveillance are included. These recommendations were developed through careful examination of existing published studies as well as expert clinical opinion consensus.

The evaluation and management of bilateral adrenal masses require a comprehensive systematic approach which includes the assessment and interpretation of the patient's clinical history, physical examination, dynamic hormone evaluation, and imaging modalities to determine the key radiographic features of each adrenal nodule. In addition, familial syndromes should be considered. Any final treatment options and approaches should always be considered individually.

Adrenal incidentalomas (AIs) are relatively uncommon neoplasms in 2% of apparently healthy individuals requiring evaluation for functionality and malignancy.

We aimed to study the clinical, biochemical, and radiological profiles of patients presenting with AI and histopathological outcomes of those undergoing adrenalectomy. Materials and Methods: This retrospective study enrolled 62 AI patients attending a tertiary care center in South India between January 2016 and October 2023. Demographic details, radiological features, functionality, and histopathological data were analyzed.

Out of 62 patients, total masses evaluated were 65 indicating bilaterality in 3 patients. The female: male ratio was 1.69, with a median age of 55 years (interquartile range: 44-64 years). 45.1% of individuals were >60 years. The most common indication for imaging was pain abdomen in 43 (69.4%). The median size was 3.2 cm. Fifty-five (88.7%) were assessed for functionality and 27 (49.1%) were functional. Among the 62 individuals, 14 (20.2%) had hypercortisolism, 11 (15.9%) had pheochromocytoma, 5 (7.24%) had primary hyperaldosteronism (PA), and 4 (5.7%) had hyperandrogenism including plurihormonal in 7. A mass size of 3.2 cm was of great value in distinguishing functional tumors with a sensitivity of 72% and specificity of 66% with an area under the curve of 0.682. A total of 34 (54.8%) patients underwent adrenalectomy. On histopathological examination, Adenoma (44.1%) was the most common followed pheochromocytoma (26.5%), adrenal cysts (8.8%), and Myelolipoma (5.9%). Two (5.9%) incidentalomas were adrenocortical carcinoma (ACC). Eight (53.3%) adenomas were functional with 6 having hypercortisolism (including 1 with hyperandrogenism) and 2 with PA.

In our experience, the incidence of pheochromocytoma was second most common after adenoma. Since most functional tumors (60%) and all ACCs were ≥4 cm, a thorough biochemical evaluation for hormonal excess and evaluation for malignancy followed by surgery should be considered for lesions, especially ≥4 cm. Thus, we report the baseline demographic and clinical characteristics of patients with AI from a single center in South India.

The risk of vertebral fractures (VFx) in patients with nonfunctioning adrenal incidentalomas (NFAI) is unknown.

This work aimed to assess in NFAI patients the prevalence and incidence of VFx and a hormonal marker to identify patients at risk.

A retrospective, cross-sectional, and longitudinal study of outpatients was conducted. A total of 306 NFAI patients (cross-sectional arm) and 213 controls were evaluated for VFx prevalence; 85 NFAI patients (longitudinal arm, follow-up 30.3 ± 17.5 months) were evaluated for VFx incidence. Main outcome measures included serum cortisol after 1 mg-dexamethasone test (F-1mgDST), lumbar spinal (LS), and femoral neck (FN) bone mineral density (BMD) and VFx presence, by radiograph of the spine.

Cross-sectional arm: prevalent VFx associated with F-1mgDST with a cutoff of 1.2 µg/dL (33 nmol/L, area under the curve 0.620 ± 0.39; P = .002). Compared with controls and NFAI patients with F-1mgDST less than 1.2 µg/dL (group A), NFAI patients with F-1mgDST greater than or equal to 1.2 µg/dL (group B) showed a higher VFx prevalence (10.8%, 12.6%, and 29.5%, respectively; P < .001 all comparisons), which was associated with F-1mgDST greater than or equal to 1.2 µg/dL (odds ratio 3.02; 95% CI, 1.63-5.58; P < .001) accounting to confounders. Longitudinal arm: the VFx incidence was higher in group B than in group A (19.3% vs 3.6%; P = .05). In group B, all incident VFx occurred in patients without low BMD. The F-1mgDST cutoff for predicting an incident VFx was 1.2 µg/dL, although statistical significance was not reached after adjustment for confounders (P = .061).

In NFAI patients, F-1mgDST levels greater than or equal to 1.2 µg/L (33 nmol/L) are associated with prevalent VFx and may identify patients at risk of incident VFx.

The number of adrenal incidentaloma (AI) cases has increased in the last few years due to the widespread use of imaging diagnostics. Management requires evaluation of the malignant nature and hormonal activity. The aim of the present study is to assess possible clinical abnormalities in 132 AI patients both at baseline and during follow-up (mean 48.6 ± 12.5 months). In all patients, demographic, anthropometric data, biochemical, metabolic and hormonal data, and 24-h ambulatory blood pressure monitoring were assessed. Mild autonomous cortisol secretions (MACS) were diagnosed in patients without signs and symptoms of overt Cushing's syndrome and post dexamethasone (DXM) plasma cortisol concentration > 50 nmol/L (>1.8 μg/dL). Patients with overnight DXM-1 mg test positive showed higher values of diastolic blood pressure, glycemia and uric acid levels compared to patients with negative DXM test at baseline. During follow-up, the potential development of MACS in patients with nonfunctional AI showed a prevalence of 29%, though the cardiovascular and metabolic alterations were less pronounced compared to those diagnosed with MACS at baseline. Therefore, follow-ups with AI patients are useful for observing changes in clinical features.

Patients with nonfunctioning adrenal adenomas (NFA) and mild autonomous cortisol secretion (MACS) demonstrate an increased risk of chronic kidney disease (CKD); however, factors associated with CKD are unknown.

We aimed to identify the factors associated with CKD and assess the effect of adrenalectomy on kidney function in patients with NFA or MACS.

A single-center cohort study of patients with NFA and MACS, 1999 to 2020, was conducted. MACS was diagnosed based on post dexamethasone suppression test (DST) cortisol greater than or equal to 1.8 mcg/dL. Age, sex, dysglycemia, hypertension, therapy with statin, angiotensin-converting enzyme inhibitor, or angiotensin II receptor blocker were included in the multivariable analysis. Outcomes included estimated glomerular filtration rate (eGFR) at the time of diagnosis with MACS or NFA and postadrenalectomy delta eGFR.

Of 972 patients, 429 (44%) had MACS and 543 (56%) had NFA. At the time of diagnosis, patients with MACS had lower eGFR (median 79.6 vs 83.8 mL/min/1.73 m2; P < .001) than patients with NFA. In a multivariable analysis, factors associated with lower eGFR were older age, hypertension, and higher DST. In 204 patients (MACS: 155, 76% and NFA: 49, 24%) treated with adrenalectomy, postadrenalectomy eGFR improved in both groups starting at 18 months up to 3.5 years of follow-up. Factors associated with increased eGFR were younger age, lower preadrenalectomy eGFR, and longer follow-up period.

DST cortisol is an independent risk factor for lower eGFR in patients with adrenal adenomas. Patients with both MACS and NFA demonstrate an increase in eGFR post adrenalectomy, especially younger patients with lower eGFR pre adrenalectomy.

Secondary hypogonadism (SH) is common in men with Cushing's syndrome (CS), but its impact on comorbidities is largely unknown and longitudinal data are scarce. If SH also affects men with mild autonomous cortisol secretion (MACS) is unknown.

We included 30 treatment-naïve adult men with CS and 17 men with MACS diagnosed since 2012. Hypogonadism was diagnosed based on total testosterone (TT) concentrations < 10.4 nmol/L and age-specific cut-offs. Outcomes were compared to age- and BMI-matched controls. In 20 men in remission of CS, a longitudinal analysis was conducted at 6, 12, and 24 months.

Men with CS had significantly lower concentrations of TT, bioavailable T, and free T compared to controls (P < .0001) with lowest concentrations in ectopic CS. Likewise, TT was lower in men with MACS compared to controls. At baseline, 93% of men with CS and 59% of men with MACS had SH. Testosterone correlated negatively with late night salivary cortisol and serum cortisol pre- and post-1 mg dexamethasone suppression test. Following successful surgery, TT increased significantly (P = .001), normalising within 6 months. Despite normalisation, several RBC parameters remained lower in men with CS even 2 years after successful surgery.

Secondary hypogonadism is common in men with CS and MACS but usually reversible after successful surgery. The persisting changes observed in RBC parameters need to be further investigated in larger cohorts and longer follow-up durations.

To investigate the clinical, laboratory findings and signal intensity index (SII) on magnetic resonance imaging (MRI) of patients with bilateral and unilateral macronodular mild autonomous cortisol secretion (MACS).

Clinical and laboratory findings of 81 patients with MACS were examined from retrospective records. SII of adenomas and internodular areas were evaluated by MRI. The unilateral group included patients with an adrenal macronodule (≥1 cm) in a single adrenal gland, while the bilateral group included patients with at least one macronodule in both adrenal glands.

In total, 46 patients were in the unilateral (57%), while 35 (43%) patients were in the bilateral groups. The dehydroepiandrosterone sulphate (DHEA-S) level was lower in the unilateral than in the bilateral group (p < .001). The presence of type 2 diabetes mellitus (T2DM), glycosylated haemoglobin (HbA1c) and low-density lipoprotein (LDL) concentrations were higher in the bilateral group (p < .05). However, no significant difference was detected in terms of adrenocorticotropic hormone (ACTH) and overnight 1 mg dexamethasone suppression test (DST) between the two groups (p > .05). There was no difference in SII between adenomas within the same patient, as well as between the unilateral and bilateral groups (p > .05). Logistic regression analysis based on the differentiation between unilateral and bilateral macronodular MACS demonstrated that DHEA-S, HbA1c and LDL concentrations were associated factors.

DHEA-S levels may not be as suppressed in patients with bilateral macronodular MACS as compared to those with unilateral adenoma. T2DM and hypercholesterolaemia have a higher frequency in bilateral patients. However, ACTH, overnight 1 mg DST and SII may not provide additional information for differentiation of bilaterality and unilaterality.

The human adrenal gland is a complex endocrine tissue. Studies on adrenal renewal have been limited to animal models or human foetuses. Enhancing our understanding of adult human adrenal homeostasis is crucial for gaining insights into the pathogenesis of adrenal diseases, such as adrenocortical tumours. Here, we present a comprehensive cellular genomics analysis of the adult human normal adrenal gland, combining single-nuclei RNA sequencing and spatial transcriptome data to reconstruct adrenal gland homeostasis. As expected, we identified primary cells of the various zones of the adrenal cortex and medulla, but we also uncovered additional cell types. They constitute the adrenal microenvironment, including immune cells, mostly composed of a large population of M2 macrophages, and new cell populations, including different subpopulations of vascular-endothelial cells and cortical-neuroendocrine cells. Utilizing spatial transcriptome and pseudotime trajectory analysis, we support evidence of the centripetal dynamics of adrenocortical cell maintenance and the essential role played by Wnt/β-catenin, sonic hedgehog, and fibroblast growth factor pathways in the adult adrenocortical homeostasis. Furthermore, we compared single-nuclei transcriptional profiles obtained from six healthy adrenal glands and twelve adrenocortical adenomas. This analysis unveiled a notable heterogeneity in cell populations within the adenoma samples. In addition, we identified six distinct adenoma-specific clusters, each with varying distributions based on steroid profiles and tumour mutational status. Overall, our results provide novel insights into adrenal homeostasis and molecular mechanisms potentially underlying early adrenocortical tumorigenesis and/or autonomous steroid secretion. Our cell atlas represents a powerful resource to investigate other adrenal-related pathologies.