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The 10 Hounsfield units unenhanced computed tomography attenuation threshold does not apply to cortisol secreting adrenocortical adenomas

Claire Chambre, Emily McMurray, Camille Baudry, Marine Lataud, Laurence Guignat, Sébastien Gaujoux, Najiba Lahlou, Jean Guibourdenche, Frédérique Tissier, Mathilde Sibony, Bertrand Dousset, Xavier Bertagna, Jérôme Bertherat, Paul Legmann, and Lionel Groussin

Context

Computed tomography (CT) unenhanced attenuation value of <10 Hounsfield units (HU) has an excellent specificity (98%) to diagnose lipid-rich adrenocortical adenomas (ACAs) with a weaker sensitivity (71%).

Objective

To determine from a routine clinical perspective if unenhanced attenuation value is influenced by cortisol secretion in ACAs.

Design

This was a retrospective study of cases collected between 2009 and 2012.

Setting

This study was conducted in a tertiary-care university hospital.

Patients

Seventy-two patients operated on for an ACA (Weiss score ≤2) were analysed. Thirty-four patients had an ACA oversecreting cortisol (Cush-ACA). Thirty-eight patients had an ACA without cortisol oversecretion (Non Hyper-ACA).

Main outcome measure

CT unenhanced attenuation value was correlated with the functional status. The Weiss score items were analysed.

Results

Among the 34 patients with a Cush-ACA a minority (n=7) had an unenhanced attenuation value under 10 HU. Among the high precontrast density (>10 HU) Cush-ACAs, washout analysis after contrast administration was consistent with the benign nature of the tumor in ∼60% of the cases. Less than 25% clear cells (lipid-rich cells), a Weiss score item, was present in 50% of the Cush-ACAs in favour of a lipid-poor content.

Conclusions

Unenhanced attenuation value has a poor sensitivity to diagnose an ACA in case of cortisol oversecretion due to poor lipid content. Nevertheless, the accuracy of washout analysis was preserved in the group of Cush-ACAs.

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Corticotroph tumor progression speed after adrenalectomy

Laura Bessiène, Sandrine Moutel, Marine Lataud, Anne Jouinot, Fidéline Bonnet-Serrano, Jean Guibourdenche, Chiara Villa, Bertrand Baussart, Stephan Gaillard, Maxime Barat, Anthony Dohan, Xavier Bertagna, Bertrand Dousset, Jérôme Bertherat, and Guillaume Assié

Objectives

After bilateral adrenalectomy in Cushing’s disease, corticotroph tumor progression occurs in one-third to half of patients. However, progression speed is variable, ranging from slow to rapid. The aim was to explore corticotroph progression speed, its consequences and its risk factors.

Design

A retrospective single-center observational study.

Methods

In total,103 patients with Cushing’s disease who underwent bilateral adrenalectomy between 1990 and 2020 were included. Clinical, biological, histological and MRI features were collected. Median duration of follow-up after bilateral adrenalectomy was 9.31 years.

Results

In total,44 patients progressed (43%). Corticotroph tumor progression speed ranged from 1 to 40.7 mm per year. Progression speed was not different before and after bilateral adrenalectomy (P  = 0.29). In univariate analyses, predictive factors for rapid corticotroph tumor progression included the severity of Cushing’s disease before adrenalectomy as the cause of adrenalectomy, high ACTH in the year following adrenalectomy and high Ki67 immunopositivity in the tumor. During follow-up, early morning ACTH absolute variation was associated with corticotroph tumor progression speed (P-value = 0.001). ACTH measurement after dynamic testing did not improve this association.

Conclusion

After adrenalectomy, corticotroph progression speed is highly variable and manageable with MRI and ACTH surveillance. Progression speed does not seem related to bilateral adrenalectomy but rather to intrinsic properties of highly proliferative and secreting tumors.