Mortality prevalence and causes in patients with adrenal incidentaloma

Introduction: Incidental adrenal masses (adrenal incidentalomas) (AI) are quite common lesions in cross-sectional imaging methods. An incidence of 5% has been reported in computed tomography (CT) series. The most common cause is adrenal adenomas. Major categories are non-functional adenomas (NFA) (80%), pheochromocytomas (7%), subclinical Cushing syndrome (SCS) (5%), primary aldosteronism (2.5%), primary adrenocortical carcinomas (ACC), metastases and other rare masses. It is well known that metabolic and cardiovascular diseases such as hypertension (HT), impaired glucose tolerance (IGT), obesity, dyslipidemia, atherosclerosis and osteoporosis and mortality increase in patients with adrenal incidentaloma, especially in the group with autonomous cortisol production. However, mortality studies in patients with adrenal incidentaloma seem to be limited to this field. Adrenal incidentalomas are more common today and patients are taken to a long follow-up period of at least 5 years.. There are studies showing that the risks such as metabolic syndrome and cardiovascular disease may be increased even in nonfunctional patient groups. In our study, we aimed to determine the prevalence and causes of mortality in patients with adrenal incidentaloma. Materials and Method: Our study is an observational retrospective cohort study. Computed tomographies of all adult patients were reviewed at Dokuz Eylül University Medical Faculty Hospital between 2004 and 2016, and patients with adrenal lesions were identified. A total of 759 patients whose demographic, hormonal and mortality data were available were analyzed. Demographic data of the patients, basal biochemical examinations at the time of diagnosis, final hormonal evaluations, pathological diagnoses, if any, radiological characteristics, comorbidities, and mortality data were recorded. Follow-up periods (months) were calculated based on April 2020. After the diagnosis, new comorbidity conditions (diabetes mellitus, hypertension, cardiovascular disease) or worsening of existing comorbidity conditions were examined during the follow-up. The results were recorded in the SPSS program and analyzed. Statistical significance level was set at p <0.05. Results: In our study, data of 759 patients with adrenal incidentaloma were evaluated. 30.9% of the patients were male and 69.1% female. The median age of the patients was found to be 54 (22-86). 40.5% of the lesions were detected in the left adrenal gland, 37.5% in the right adrenal gland, and 22% in the bilateral adrenal gland. Mortality data of 757 of 759 patients were obtained. It was noted that a total of 91 (12%) patients died in follow-up. It was observed that the group with the fastest decrease in cumulative total survival rate was the group with malignancy, followed by the SCS group. In the subgroup analyzes, cardiovascular mortality was 16.1% and 45.8% in the NFA and SCS groups, respectively. When the cumulative survival rates were examined in the NFA and SCS groups, it was seen that the rate decreased more rapidly in the SCS group. Comparing the NFA and SCS groups; There was a statistically significant difference in mean age (p = 0.005) and lesion size (p <0.0001). The association with HT at the time of diagnosis (59.2%) was higher in the SCS group compared to the NFA group (49%) (p <0.05). Also, the association of cardiovascular disease at the time of diagnosis (15.2%) in the SCS group was higher than the NFA group (6.5%) (p <0.001). Also, at the end of the follow-up period, the association of cardiovascular disease was higher in the SCS group (p <0.0001). In addition, the analysis showed that the higher the cortisol value after DST, the higher the cardiovascular morbidity. Conclusion: According to our study, higher cardiovascular mortality was found in patients with AI with autonomic cortisol secretion compared to patients with non-functional adrenal incidentaloma. The risk of new cardiovascular events was also higher in the group with cortisol secretion. It was observed that the higher the cortisol value after DST, the higher the cardiovascular morbidity at the end of the follow-up. Cardiovascular comorbidity at the time of diagnosis and cortisol value measured after DST were found to be a good predictor of cardiovascular mortality and morbidity. Keywords: Adrenal incidentaloma, mortality, subclinical Cushing Syndrome, cardiovascular mortality