¿Como optimizar el diagnóstico funcional de los incidentalomas suprrarenales? Importancia de un estudio protocolizado / How to optimize the functional diagnosis of suprarenal incidenta- lomas? Importance of a protocolized study

Adrenal incidentalomas are an increasingly common pathology. Although historically they have been considered largely non-functioning, recent evidence suggests that the usually performed study is incomplete and/or not sensitive enough. In the last decade the clinical spectrum of adrenal hypercortisolism has expanded considerably, including milder cases which are also associated with cardiovascular morbidity and even mortality. Furthermore, primary aldosteronism has also expanded beyond the classic phenotype with advanced vascular damage, resistant hypertension and hypokalemia, currently including asymptomatic, normotensive and normokalemic patients. For this reason, a correct protocolized study is essential in all adrenal incidentalomas, including a precise radiological characterization, as well as a systematic hormonal evaluation using more sensitive cut points. The findings of this workup are relevant, because they allow a more individualized approach to the medical and surgical management of these patients.

Los incidentalomas suprarrenales son una patología cada vez más frecuente. Si bien históricamente han sido considerados no funcionantes en su gran mayoría, evidencia reciente sugiere que el estudio habitual es incompleto y/o poco sensible. En la última década el espectro clínico del hipercortisolismo de origen adrenal se ha ampliado de forma considerable, incluyendo casos leves que también se asocian a morbilidad cardiovascular e incluso mortalidad. Por otro lado, el hiperaldosteronismo primario también ha expandido su fenotipo más allá del clásicamente descrito con daño vascular avanzado, hipertensión resistente e hipokalemia, abarcando en la actualidad a pacientes asintomáticos, normotensos y normokalemicos. Por esta razón es imprescindible un correcto estudio protocolizado en todo incidentaloma suprarrenal, incluyendo una precisa caracterización radiológica, así como una evaluación hormonal sistemática utilizando puntos de corte más sensibles. Los hallazgos de este estudio son relevantes, pues permiten guiar de forma más individualizada el manejo médico y quirúrgico de estos pacientes.

Hipertensão arterial, osteoporose, amenorreia e depressão como manifestações da síndrome de cushing acth-independente: evolução após adrenalectomia laparoscópica / Arterial hypertension, osteoporosis, amenorrhea, and depression as presentation of ACTH-independent Cushing's syndrome: follow-up after laparoscopic adrenalectomy

A síndrome de Cushing é caracterizada por excesso de glicocorticóides circulantes. Os tumores suprarrenais secretores de cortisol representam a principal causa desse distúrbio, dentre os quais adenomas, que correspondem a 65% dos casos. A apresentação clínica típica inclui obesidade centrípeta, fadiga, hipertensão arterial de difícil controle, osteoporose, distúrbios menstruais, hirsutismo, equimoses e estrias violáceas. Entretanto, casos de síndrome de Cushing subclínica vem sendo descritos com frequência crescente, o que faz com que essa doença ainda representardesafio diagnóstico na atualidade, pela capacidade de mimetizar outras entidades nosológicas, tais como síndrome metabólica, depressão e alcoolismo. Relata-se o caso de uma mulher de 27 anos, que vinha em tratamento de hipertensão arterial, osteoporose e depressão intensa antes do diagnóstico de síndrome de Cushing ACTH-independente,na qual o tratamento cirúrgico da doença de base resultou abrandamento significativo das comorbidades.

Cushing’s syndrome is characterized by an excess of circulating glucocorticoids. Cortisol-secreting adrenal tumors are the most common cause of endogenous ACTH-independent disease, with adrenal adenomas accounting for 65% of these cases. The typical clinical presentation includes centripetal obesity, fatigue, arterial hypertension, osteoporosis, menstrual disorders, hirsutism, easy bruising, and diffuse violaceous striae. However, subclinical Cushing´s syndrome is being described with growing frequency, still making this disease a diagnostic challenge, due to the ability to mimicother nosologic entities, such as the metabolic syndrome, depression and alcoholism. The authors report the case of a 27-year-old woman, who has been treated for hypertension, osteoporosis and depression before the diagnosis of ACTH-independent Cushing’s syndrome was established, and in whom the surgical treatment of the disease resulted in significant improvement of co-morbidities.