MON-467 - Standardised Clinical and Biochemical Assessment to Inform Decision-Making in Mild Autonomous Cortisol Secretion

Background: Mild Autonomous Cortisol Secretion (MACS) is characterised by adrenal incidentalomas with evidence of possible hypercortisolism in the absence of clinical features of Cushing’s syndrome. MACS may be associated with cardiovascular and metabolic morbidity as well as a negative impact on bone health. Optimal pathways for managing patients with MACS have not yet been established, but data supports positive long-term outcomes in select patients undergoing adrenalectomy. This study aims to assess performance of a standardised clinical and biochemical assessment pathway in a real-world cohort of patients with possible MACS.

Methods: A retrospective analysis of 102 patients who had undergone a standardised MACS assessment (54% female; mean age 66±11 years) was conducted. Data collected included demographics, possible cortisol related end-organ co-morbidities (hypertension, type 2 diabetes and/or osteoporosis), Clinical Disease Severity score for Hypercortisolism (CDSH) and biochemical severity score, and standard cortisol related hormonal assessment: Overnight Dexamethasone Suppression Test (ONDST) via immunoassay and liquid chromatography-mass spectrometry (LCMS), late night salivary cortisol/cortisone, ACTH, and DHEAS. A CDSH score >8 and a biochemical score >3 were classed as moderate severity.

Results: Mean CDSH score as 2.7±2.4 with a mean biochemical severity score of 3.0±1.3. No correlation was found between age or CDSH score and biochemical severity (p=0.33). LCMS cortisol correlated significantly with biochemical score (p=0.01), whereas standard immunoassay cortisol did not. Higher biochemical score was correlated with presence of 2 or more end-organ co-morbidities (p=0.04).
Of 5 patients with CDSH scores >8, none were deemed surgical candidates (mean biochemical score 2.8). In contrast, of 30 patients with a moderate/high biochemical score (>3), three were confirmed surgical candidates, despite having a low mean CDSH score of 3. All 3 had potential end-organ effects from hypercortisolism (hypertension, type 2 diabetes and/or osteoporosis). Females had significantly higher CDSH scores compared to males (p=0.004), despite no significant difference in biochemical severity between the sexes.

Conclusion: While CDSH scoring is a valuable tool for screening for overt Cushing’s, in this analysis it does not correlate with biochemical severity or directly inform the need for surgical intervention for patients with MACS. Biochemical scoring, particularly when supported by LCMS cortisol ONDST, as opposed to standard immunoassay, appears to be a more sensitive and reliable indicator for identifying potential candidates for adrenalectomy. Development of an integrated biochemical and end-organ damage scoring tool, specifically targeted for patients with MACS, should be considered to guide decisions regarding surgery.

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