Spinal Volumetric Bone Mineral Density and Vertebral Fractures in Female Patients with Adrenal Incidentalomas: The Effects of Subclinical Hypercortisolism and Gonadal Status

Abstract

Although adrenal incidentalomas (AI) are not associated with clinically evident syndromes, some patients display biochemical features of subclinical hypercortisolism (SH). Previous studies indicated a negative effect of SH on bone in AI patients, but the prevalence of vertebral fractures and the roles of SH and gonadal status in volumetric bone mineral density are unknown. In 70 female AI patients and 84 controls, the prevalence of vertebral fractures and spinal bone mineral density (by quantitative computed tomography) were evaluated. Subjects were subdivided according to menopausal status into groups Pre (21 patients and 23 controls) and Post (49 patients and 61 controls); there were 14 and 35 patients without SH (SH(-)) and 7 and 14 patients with SH (SH(+)) in groups Pre and Post, respectively. The prevalence of fractures was higher in SH(+) than in controls and in SH(-) subjects in both groups Pre [SH(+), 42.9%; controls, 0% (P = 0.001); SH(-), 7.1% (P = 0.049)] and post [SH(+), 78.6%; controls, 37.7% (P = 0.006); SH(-) 42.9% (P = 0.024)]. In group Post, the mean z-score quantitative computed tomography values were lower in SH(+) patients (-0.78 +/- 0.29) than in controls (0.06 +/- 0.14; P = 0.011) and SH(-) patients (0.02 +/- 0.19; P = 0.034). Evaluation of spinal bone is indicated in female AI patients with SH.

Subclinical Cushing's Syndrome

“…An increased risk of osteoporosis has been documented by the most recent studies that addressed this issue (37)(38)(39)(40). Moreover, in a recent study an increased prevalence of vertebral fractures in women with subclinical Cushing' syndrome was found, corroborating the notion that even subtle glucocorticoid excess can exert a detrimental effect on bone quality, particularly in condition of estrogen deficiency (41). Longitudinal studies of adequate statistical power are urgently needed to estimate the risk of osteoporotic fractures and their attendant impact on outcome and quality of life.…”

Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?

“…Indeed, if the presence of post-surgical hypocortisolism has to be considered a reliable index of pre-surgical subtle hypercortisolism, it would be expected that the complications of cortisol excess would be more frequent in subjects experiencing post-operative adrenal insufficiency than in those not experiencing it. Indeed, some of the previous cross-sectional studies suggested that also a subtle hypercortisolism may be associated with an increased prevalence of metabolic syndrome and osteoporosis (30)(31)(32)(33)(34)(35)(36)(37)(38)(39), which are common, though not specific, features of overt cortisol excess. However, although the glucocorticoid sensitivity may be different in different tissues (29), it is conceivable that in some patients, this subtle cortisol hypersecretion may be enough to determine end-organ consequences but not to constantly suppress HPA axis function and, therefore, to lead to hypocortisolism after surgery.…”

Eugonadal male patients with adrenal incidentalomas and subclinical hypercortisolism have increased rate of vertebral fractures

“…Nevertheless, data about the most common complication of bone loss, such as vertebral fractures, are scarce. The only study focused on this topic found a higher proportion of vertebral fractures in AI female patients with SH, 12 while no study has been performed so far on vertebral fractures in male patients with and without SH. This point seems of utmost importance as the presence of vertebral fractures is a strong predictor of future fractures.…”

“…2,3 This condition has been suggested to be associated to several complications, including bone loss, which is a typical feature, even not specific, of overt cortisol excess. 4 Indeed, most of the previous studies, [5][6][7][8][9][10][11][12] even not all, 13-15 strongly suggested a possible negative effect of SH on bone. Nevertheless, data about the most common complication of bone loss, such as vertebral fractures, are scarce.…”