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

Only 23% of patients with mild autonomous cortisol secretion required postoperative steroid replacement after unilateral adrenalectomy.

• 139 total patients with mild autonomous cortisol secretion underwent minimally invasive adrenalectomy between 2000 and 2024.
• 32 of 139 patients (23%) received postoperative steroid replacement.
• This proportion is described as lower than previously reported in the literature.
• This is characterized as the largest study to date on postoperative steroid management in patients with mild autonomous cortisol secretion.

Postoperative steroid replacement decisions were based on a combination of postoperative day 1 cortisol levels, ACTH stimulation test results, and clinical evidence of adrenal insufficiency.

• All 139 patients had postoperative day 1 AM cortisol levels measured.
• 85 patients had ACTH stimulation tests performed on postoperative day 1.
• Steroid replacement was initiated for: POD1 cortisol <5 µg/dL (n=15), POD1 cortisol <10 µg/dL combined with failed ACTH stimulation test (n=15), and/or symptoms of adrenal insufficiency (n=2).
• These three criteria were used as the basis for the practical algorithm described.

Preoperative plasma ACTH <7.0 pg/mL was an independent predictor of postoperative steroid replacement therapy.

• Identified via multivariate logistic regression analysis.
• P = .02.
• Univariate and multivariate logistic regression models were used to identify predictors.

Preoperative cortisol >4.2 µg/dL on low-dose dexamethasone suppression test was an independent predictor of postoperative steroid replacement therapy.

• Identified via multivariate logistic regression analysis.
• P = .008.
• Mild autonomous cortisol secretion was defined as preoperative serum cortisol >1.8 µg/dL after low-dose dexamethasone suppression without signs and symptoms of overt Cushing syndrome.
• The threshold of >4.2 µg/dL represents a higher level of cortisol non-suppression within the MACS range.

Patients who received steroid replacement were successfully weaned off steroids within a median of 78 days with no evidence of adrenal insufficiency during follow-up.

• Steroids were weaned off within a median of 78 days (interquartile range, 35–251 days).
• Patients were followed up for a median of 15 months (interquartile range, 5–38 months).
• No evidence of adrenal insufficiency was observed with this management approach during follow-up.

Mild autonomous cortisol secretion is identified in up to 50% of patients with adrenal nodules after a low-dose dexamethasone suppression test.

• Defined as preoperative serum cortisol level >1.8 µg/dL after low-dose dexamethasone suppression without signs and symptoms of overt Cushing syndrome.
• The authors note there is confusion in the literature about postoperative steroid replacement in these patients, in contrast to patients with overt Cushing syndrome where steroids are routinely started.