**5. Hormone assessment**

There are basically three types of production by adrenocortical tumors:


## **5.1 Cortisol-producing tumors**

Such tumors generally produce minute quantities of cortisol, which, most of times, do not suffice to increase the excretion of free cortisol in urine. They are, nonetheless, able to cause suppression of the hypothalamic-pituitary axis. Ordinarily, there are no Cushing-related manifestations in those patients. For that reason, this condition has been known as subclinical Cushing's syndrome or subclinical hypercortisolism [11]. There might be the classic Cushing's syndrome in long-evolving cases.

A suppression test with 1 mg of dexamethasone should be carried out at night for tracking Cushing's syndrome. The patient orally takes 1 mg of dexamethasone at 11:00 pm the night prior to sample collection of plasmatic cortisol, which is to be carried out at 8:00 am the following morning. Values that determine abnormal response of cortisol in this test varied in several studies from 1.8 to 5.0 mcg/dL, yet most guidelines lead to the following interpretation:

Levels of plasmatic cortisol <1.8 mcg/dL virtually exclude autonomous production of cortisol, with sensitivity >95% and specificity from 70 to 80%.

**47**

*Preoperative Assessment of Functioning Benign Adrenocortical Tumors: A Clinical Surgical…*

Values >5 mcg/dL would indicate a highly probable diagnosis of Cushing's

syndrome, many experts propose confirmation under the following criteria:

[1]. **Figure 2** shows an algorithm of investigation of Cushing's syndrome.

sulfate in serum suggests a chronical suppression of ACTH levels [12].

• Type 2 diabetes mellitus or glucose intolerance (20–75%)

occurrences of mortality due to cardiovascular disease [1].

An abnormal suppression of 1 mg of dexamethasone during the night is consistent with a positive tracking, and it should be confirmed by a 24-hour free urinary cortisol, which should then be followed by an investigation of the serum dosage of cortisol after a high dose (8 mg) of dexamethasone during the night and the serum dosage ACTH [3, 4]. This latter investigation aims at determining the origin of the Cushing's syndrome, as to refute a hypopituitary cause. This condition is typically presented with unsuppressed levels (ACTH dependent). For diagnosis of subclinical Cushing's

Values > 5 mcg/dL in plasmatic cortisol at the 1 mg dexamethasone test without

Levels of plasmatic ACTH < 10 pg/ml with an increased 24-hour free urinary cortisol and values > 3 mcg/dL of plasmatic cortisol at the 1 mg dexamethasone test

Dehydroepiandrosterone sulfate is an adrenal androgen that is produced under stimulus of ACTH. Thus, an undetectable concentration of dehydroepiandrosterone

Percentage of patients suffering from subclinical Cushing's syndrome that would

evolve to the classic Cushing's syndrome is uncertain. It is estimated to be <1%,

Even though patients suffering from subclinical Cushing's syndrome do not present the classic stigmata related to hypercortisolism, they present, as suggested in some studies, in comparison with the population in general, higher occurrences of:

An increase in the carotid intima-media thickness has been recently reported, as well as alteration of coagulation parameters, decrease in the quality of life, and

For those reasons, there is still no consensus about the approach to subclinical

Generally, in cases with many occurrences of comorbidity that might be attributed to hypercortisolism, such as systemic arterial hypertension, diabetes mellitus, dyslipidemia, osteoporosis, and central obesity, especially the ones that are difficult to control, a ponderation of the risk/benefit of surgical treatment by adrenalectomy of the affected adrenal should be carried out, as proposed for the treatment of clas-

It is important to mention that up to 75% of patients might develop acute adrenal insufficiency (sometimes deadly) at the post-surgery phase of adrenalectomy in case they are not treated with glucocorticoid due to atrophy of the contralateral gland. This should be an additional functional endocrine characterization for the propaedeutic planning [1]. In case the adrenalectomy is carried out, there should be

Cushing's syndrome. It may be treated clinically or through surgery [2].

*DOI: http://dx.doi.org/10.5772/intechopen.83514*

At least two from the following results:

syndrome (specificity > 95%) [1].

any other stigma **OR**

though [1].

• Hypertension (40–90%)

• Hyperlipidemia (50%)

• Obesity (35–50%)

sic Cushing's syndrome [2].

• Osteopenia/osteoporosis (40–50%)

Cortisol levels between 1.8 and 5 mcg/dL have been considered to be undetermined.

*Preoperative Assessment of Functioning Benign Adrenocortical Tumors: A Clinical Surgical… DOI: http://dx.doi.org/10.5772/intechopen.83514*

Values >5 mcg/dL would indicate a highly probable diagnosis of Cushing's syndrome (specificity > 95%) [1].

An abnormal suppression of 1 mg of dexamethasone during the night is consistent with a positive tracking, and it should be confirmed by a 24-hour free urinary cortisol, which should then be followed by an investigation of the serum dosage of cortisol after a high dose (8 mg) of dexamethasone during the night and the serum dosage ACTH [3, 4]. This latter investigation aims at determining the origin of the Cushing's syndrome, as to refute a hypopituitary cause. This condition is typically presented with unsuppressed levels (ACTH dependent). For diagnosis of subclinical Cushing's syndrome, many experts propose confirmation under the following criteria:

Values > 5 mcg/dL in plasmatic cortisol at the 1 mg dexamethasone test without any other stigma
