Steroid replacement after adrenalectomy for mild autonomous cortisol secretion: Clinical predictors and a practical algorithm.

Abstract

Mild autonomous cortisol secretion is identified in up to 50% of patients with adrenal nodules after a low-dose dexamethasone-suppression test. Although steroids are routinely started in patients with Cushing syndrome after adrenalectomy, there is confusion about postoperative steroid replacement in patients with mild autonomous cortisol secretion. The aim of this study was to investigate the frequency and clinical predictors of postoperative steroid replacement in patients with mild autonomous cortisol secretion undergoing unilateral adrenalectomy. This was an institutional review board approved retrospective study. Mild autonomous cortisol secretion was defined as preoperative serum cortisol level of >1.8 μg/dL after low-dose dexamethasone suppression without signs and symptoms of overt Cushing syndrome. In patients who underwent unilateral adrenalectomy between 2000 and 2024 for mild autonomous cortisol secretion, a decision for postoperative steroid replacement was made based on a combination of parameters, including postoperative day 1 cortisol levels, adrenocorticotropic hormone stimulation test results and clinical evidence of adrenal insufficiency. Univariate and multivariate logistic regression models were used to identify predictors of steroid replacement. Continuous data are expressed as medians (interquartile ranges). There was a total of 139 patients with mild autonomous cortisol secretion who underwent minimally invasive adrenalectomy. All patients had am cortisol levels, and 85 patients had adrenocorticotropic hormone stimulation tests done on postoperative day 1. Postoperative steroid replacement was done on 32 patients on the basis of postoperative day 1 cortisol level <5 μg/dL (n = 15), postoperative day 1 cortisol level <10 μg/dL and failed adrenocorticotropic hormone stimulation test (n = 15), and or symptoms of adrenal insufficiency (n = 2). Independent predictors of postoperative steroid replacement therapy included preoperative plasma adrenocorticotropic hormone <7.0 pg/mL (P = .02) and cortisol >4.2 μg/dL on low-dose dexamethasone test (P = .008). Patients were followed up for a median of 15 months (interquartile range, 5-38 months) with no evidence of adrenal insufficiency with this management. Steroids were weaned off within a median of 78 days (interquartile range, 35-251 days). To the best of our knowledge, this is the largest study to date on postoperative steroid management of patients with mild autonomous cortisol secretion. A safe algorithm was described to select patients for steroid replacement. In contrast to previous reports in the literature, a minority (23%) of the patients with mild autonomous cortisol secretion needed postoperative steroid replacement in this cohort with the algorithm used.