Surgery May Improve Symptoms in Subclinical Cushing's Syndrome

DALLAS, Dec. 12 -- For subclinical Cushing's patients, an adrenalectomy may ease fatigue and bruising even if biochemical profiles fall short of syndrome criteria, according to researchers here.
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Explain to interested patients that this report is based on a small number of patients treated at a single center. The findings cannot be used to make generalized treatment recommendations.
A wide range of symptoms including sudden weight gain and thinning skin in patients with subclinical Cushing's improved or resolved following surgery, Fiemu E. Nwariaku, M.D., of the University of Texas Southwestern Medical Center, and colleagues reported in the December issue of Surgery.
The eight patients who reported preoperative bruising said it resolved a median of five months after surgery, as did muscle weakness in six of eight patients who presented with that symptom.
The authors reviewed records of 24 patients who underwent adrenalectomy for adrenal corticosteroid hypersecretion. They identified nine patients who had subclinical Cushing's syndrome (defined as patients with an adrenal incidentaloma and median serum cortisol of 2.0 µg/dL after 1 mg overnight dexamethasone suppression testing rather than the traditional cutoff of 5.0 µg/dL).
The median age of patients was 52.3 and all were Caucasian. Eight of the nine subclinical Cushing's syndrome patients were women.
Patients also had a range of clinical findings on preoperative evaluation including unexplained weight gain, proximal muscle weakness, abnormal fat pads, skin thinning, fatigue, facial plethora, and skin bruising.
The median preoperative BMI was 33 kg/m2. Eight patients had hypertension and three had type 2 diabetes.
The median adrenal mass diameter as measured by CT was 3.1 cm.
Seven patients lost weight postoperatively with an average decrease in BMI of 2 kg/m2. One patient became normotensive and three patients were able to reduce antihypertensive medication.
"One patient no longer required a cane for walking, could walk farther, and felt her fatigue was much improved," they wrote. "Eighty percent of patients who reported fatigue preoperatively noted postoperative improvement."
Thin skin improved in all five patients in whom it was seen prior to surgery and three patients had improvement in facial plethora.
Eight patients underwent laparoscopic transperitoneal adrenalectomy. The remaining patient underwent a planned open procedure due to a history of previous abdominal operations.
Six patients (all with postoperative cortisol levels of less than 10.0 µg/dL) were started on oral supplementation. Two additional patients who received glucocorticoids in the operating room were continued postoperatively without assessing serum cortisol values. Supplementation was continued for a median of six weeks.
The study was limited by its small size and the absence of a control group, the authors noted. Moreover, they said their criteria for subclinical Cushing's syndrome were defined post hoc and there were no standard evaluations.
Those limitations "coupled with a selection bias inherent in those patients who underwent adrenalectomy, precludes a definitive statement of which patients benefit from adrenalectomy," they wrote.
The authors concluded that, "given the prevalence of this condition, its morbidity, and the controversies surrounding its diagnosis and management," it is time for a multicenter trial to establish a more precise definition as well as an effective treatment algorithm.
No funding source was disclosed and the authors disclosed no financial conflicts.
Primary source: SurgerySource reference:Mitchell IC, "'Subclinical Cushing's syndrome' is not subclinical: improvement after adrenalectomy in 9 patients" Surgery 2007; 142: 900-5.