Adrenal Size Research Articles

Primary Bilateral Macronodular Adrenal Hyperplasia: A Case Series from a Tertiary Hospital

Introduction: Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare etiology of Cushing’s syndrome characterized by the presence of multiple adrenal macronodules and variable levels of cortisol excess. Its pathogenesis is complex, involving mechanisms such as aberrant hormone receptors, adrenal paracrine ACTH production, and genetic germline pathogenic variants. However, management is not well established. Methods: This was a retrospective, observational study. We evaluated patients with PBMAH at our tertiary center. We aimed to describe the clinical, hormonal, and radiological characteristics; treatment approaches; and outcomes. Results: Twenty patients were included in this study. Patients had a mean age at diagnosis of PBMAH of 56.1 ± 11.1 years, and 10 patients (50.0%) were females. Most cases were initially investigated for adrenal incidentalomas. Median 8:00 a.m. serum cortisol after 1 mg dexamethasone overnight suppression test was 223.5 (73.1–698.6) nmol/L (8.11 [2.65–25.3] µg/dL), late-night salivary cortisol was 1.48 (0.765–3.21) times the upper limit of normal (ULN), and 24 h-UFC was 1.61 (0.42–3.64) times the ULN. One patient presented with the co-secretion of cortisol and aldosterone. Mean total adrenal size was 98.5 ± 25.6 mm, and the largest nodule size was 32.1 ± 9.09 mm. In six (31.6%) patients, the largest nodule had an attenuation higher than 10 HU. Germline pathogenic variants in ARMC5 were found in four (50.0%) of the eight tested patients who underwent genetic testing. Treatment strategies varied, with unilateral adrenalectomy often successfully controlling hypercortisolism in five (83.3%) of 6 patients with modest excess cortisol secretion. For mild autonomous cortisol secretion, active surveillance of comorbidities and appropriate treatment were not associated with progression of cortisol secretion after a median follow-up of 34.0 (10.5–83.0) months. Conclusion: This study underscores the need for personalized management strategies and identifies areas for future research to optimize the care of patients with PBMAH.

7029 Changes In Adrenal Gland Size Seen By Linear Assessment On Routine Abdominal CT During Critical Illness

Abstract Disclosure: D.R. Vangipuram: None. N. Bhagat: None. R. Borkar: None. N.T. Mazengia: None. S. Williams, MD: None. S.K. Majumdar: None. Introduction: During acute stress, the hypothalamus-pituitary-adrenal (HPA) axis is activated, ultimately releasing adrenocorticotropic hormone (ACTH) from the pituitary gland, which stimulates cortisol synthesis and release from the adrenal gland. During this process, ACTH also increases adrenal blood flow which may result in noticeable changes in adrenal gland size on imaging. A previous study compared adrenal gland volume in patients with and without sepsis and concluded that adrenal gland volume was found to be nearly double in sepsis compared with patients without sepsis(1). Another study that evaluated adrenal gland size on MDCT, to provide normal values for volumetry and linear dimensions, found a concordance between volumetric and linear assessment (by cumulative width), though volumetry was more reproducible(2). Method: This is a retrospective study that included 50 adult patients (age 18 and over) who underwent a non-contrast or contrast CT scan of the abdomen within 5 years prior to admission to the Intensive Care Unit (ICU) with any critical illness, and then had another CT of the abdomen during the admission to the ICU. We measured the maximum width of the body (corpus) and that of the medial and lateral limbs of both the adrenal glands, perpendicular to the long axis, as seen on CT. The total (cumulative) width was calculated by adding the width of the corpus and both the limbs of each adrenal gland. The measurements were made by two different radiologists, who were blinded both to the before/after ICU admission CTs, and to each other’s measurements. Results: There was concordance in the measurements made by both the radiologists. We used the averages of both their measurements for analysis. The mean cumulative width of each adrenal gland, i.e., corpus+medial limb+lateral limb (in mm), was: Right adrenal before ICU admission 13.52 (± 3.20); during ICU admission 13.24 (± 3.13); p 0.444. Left adrenal before ICU admission 16.03 (± 3.18); during ICU admission 15.12 (± 3.47); p 0.021. Conclusion: There was a statistically significant decrease in the size of the left adrenal gland during critical illness, but no significant change in the right. Our findings do not suggest an increase in adrenal gland size during ICU admission.

7404 Evaluation Of Cortisol Reserve And Adrenal Imaging In Patients With Graves’ Disease Before And Six Months After Treatment

Abstract Disclosure: P. Sharma: None. S. Mir: None. S. Mohd Patto: None. A.H. Bhat: None. B. Dar: None. M. Bhat: None. Introduction: There is scarcity of data regarding the effect of thyrotoxicosis on cortisol metabolism and adrenal gland size. An increase in cortisol metabolism can deplete the functional reserve of adrenal cortex and lead to adrenocortical insufficiency even when there is no pre-existing Addison's disease. In developing countries patients with Graves’ disease present in advanced states of thyrotoxicosis. Besides they are also exposed to a variety of environmental stresses such as recurrent febrile illnesses, salt, and water loss due to manual labour in hot and humid climates etc., which can precipitate an adrenal crisis in the presence of compromised adrenal reserve. So present study was undertaken to assess cortisol reserve and adrenal gland size in patients with treatment naive Graves' disease. Objectives- The present study, was undertaken to assess cortisol reserve and adrenal imaging in patients with treatment naive Graves' disease. Specific information in this regard would help alert physicians dealing with clinical thyrotoxicosis in developing countries of tropics to the possibility of co-existing adrenal decompensation and adopt appropriate life saving measures promptly. Material & Methods: We examined 38 treatment-naive Graves' Disease patients at GMC, SSH, Srinagar, Kashmir, INDIA. Basal cortisol and cortisol response to ACTH were measured before and after six months of treatment, alongside adrenal CT imaging. Results: In hyperthyroid state, Graves' patients exhibited significantly lower basal cortisol compared to euthyroid and healthy controls (306 vs. 410 vs. 421 nmol/l, p < 0.05). 23.6% patients had subnormal cortisol response to ACTH(250ug). Those with T3 ≥ 400 ng/dl had lower cortisol response (560±133 nmol/l) and delta cortisol response than T3 < 400 ng/dl (724 ± 294 nmol/l, 213+/-73 vs. 428+/-265 nmol/l). After achieving euthyroid state, cortisol levels improved significantly (410±213 nmol/l vs. 306 ± 103 nmol/l, p < 0.05). Adrenal CT scans in 34 patients was done out of which 19 showed statistically significant increases in gland thickness, width, and AP diameter compared to controls (p < 0.01, p < 0.05. Repeat CT in 26 patients demonstrated resolution of hyperplasia (p < 0.05). Conclusion: Treatment-naive Graves' disease patients have compromised adrenocortical reserve and adrenal gland enlargement. Adrenal changes are reversible after achieving euthyroid state. These findings support steroid supplementation in impending thyrotoxic crisis and highlight a unique feature of reversible adrenal gland enlargement in this context. Keywords: Graves’ Disease, Adrenal hyperplasia, Cortisol reserve. Presentation: 6/3/2024

12430 Urine Steroid Profiling In Patients With Unilateral And Bilateral Mild Autonomous Cortisol Secretion

Abstract Disclosure: B. Salama: None. J. Saini: None. V. Fell: None. E.J. Atkinson: None. S.J. Achenbach: None. Background: Mildly autonomous cortisol secretion (MACS) can be unilateral in 80% of cases, or bilateral in 20% of cases, due to either bilateral adrenal adenomas or bilateral macronodular adrenal hyperplasia. Scarce evidence demonstrates the differences in plasma steroid profiling of patients with bilateral versus unilateral MACS, however, these findings have not been confirmed using a more comprehensive 24h urine steroid profiling. Objectives: To characterize 24h urine steroid metabolome in patients with unilateral and bilateral MACS. Methods: We conducted a single-center cross-sectional study between 2019-2022. Eligible participants included consecutive patients with MACS who provided a 24h urine sample. Urine was analyzed for 25 steroids with a high-resolution mass spectrometry assay. MACS was defined as cortisol >1.8 mcg/dL following the overnight administration of 1 mg dexamethasone (DST-cortisol). Partial cohort analysis is presented. Results: Of 72 patients with MACS included in the interim analysis, 36 (50%) had bilateral MACS. The two groups (unilateral vs bilateral) were similar in age (median 58 vs 58 years), sex (women 67% vs 61%), BMI (median 33 vs 32 kg/m2), and menopausal status (36% vs 39%), P>0.05 for all. Prevalence of comorbidities was also similar in both groups: hypertension (89% vs 89%), hyperlipidemia (69% vs 78%), and hyperglycemia (69% vs 61%), P >0.05 for all. While the DST-cortisol (median 3.0 vs 3.2 mcg/dL, P= 0.51) and dehydroepiandrosterone sulfate (DHEAS) (median 37.5 vs 55.0, P = 0.21) were similar between the 2 groups, patients with bilateral MACS had a lower ACTH (median 12.4 vs 8.2 pg/mL, P = 0.012) when compared to patients with unilateral MACS. Median adrenal mass size was similar in patients with both unilateral MACS (2.7 cm, IQR 1.7-3.9) and bilateral MACS (3.0 cm, IQR 2.2-3.6) P = 0.54. Of the 25 steroids measured, only tetrahydrocorticosterone was higher in patients with unilateral MACS (median 245 mcg/24h, IQR 165-416 vs median 184 mcg/24h, IQR 121 -278) P = 0.039. No differences in androgens (median 2229 vs 2036 mcg/24h), cortisol metabolites (median 6566 vs 5191 mcg/24h), cortisone metabolites (median 10300 vs 9429 mcg/24h), or glucocorticoid/androgen ratio (median 7.9 vs 8.9) was demonstrated between the unilateral vs bilateral MACS groups (P>0.05 for all). Conclusion: In this interim analysis of patients with unilateral vs bilateral MACS, we have found that patients had a similar post-DST cortisol and similar tumor bulk. Despite a lower ACTH in patients with bilateral MACS, no differences in androgens were found between the two groups. In addition to expanding steroid profiling analysis to the whole cohort, subgroup analyses will need to distinguish between patients with bilateral adenomas and macronodular adrenal hyperplasia, consider aldosterone co-secretion, and employ a more accurate measurement of adrenal tumor bulk. Presentation: 6/3/2024

6636 Primary Hyperaldosteronism Leading to Aldosterone Deficiency

Abstract Disclosure: N.G. Haverstick: None. J.R. Anthony: None. Primary Hyperaldosteronism is a disease process that is often missed, and under checked due to poor screening tools. The disease presents with a common problem, uncontrolled hypertension. It also presents with hypokalemia, fatigue and headaches. It can easily be masked with blood pressure medications, CKD, and pain medications. After treatment there are some rare reports of patients developing hypoaldosteronism. Some risk factors are age >50, duration of hypertension >10 years, pre-existing renal impairment and adrenal adenoma size >2 cm. The patient will present with the opposite: hyperkalemia and hypotension. This is due to the atrophy of the previously healthy gland. Usually this resolves within a year. However in our patient she has continued to require long standing mineralocorticoid replacement therapy. This case highlights the importance of early recognition of hyperaldosteronism. A 63 year-old-female with a medical history of hypertension and diabetes mellitus is being followed for 30+ years of uncontrolled hypertension. Patient has been on multiple agents and blood pressure remained elevated after trying triamterene/hctz, metoprolol, irbesartan, amlodipine. After changing her PCP, there was further investigation into the cause. Leading differentials were Primary Hyperaldosteronism vs Renal Artery Stenosis vs Primary Hypertension. She also had multiple labs with her Potassium below 3 mEq/l. Additional labs were obtained and her Aldosterone level 209 ng/dl and Renin <0.167 ng/mL/hr. The patient was referred to Endocrinology who performed a fludrocortisone suppression test, which did not suppress the levels. A CT scan of the abdomen was performed that showed a 1.3 cm right adrenal mass typical with adrenal adenoma. The patient had an adrenalectomy surgery in February 2022. The patient recovered well, however now developed hypotension off medication, and had consistent hyperkalemia with K > 5.5 mEq/l. The patient had now developed aldosterone deficiency. This was due to the long standing hyperaldosteronism that had caused her left adrenal gland to atrophy after 30 years. The patient was started on Fludrocortisone 0.1 mg daily and a low potassium diet. She has remained off any blood pressure medications since her right adrenalectomy. She has continued to require the mineralocorticoid replacement to date. The diagnostic work-up for primary aldosteronism involves screening, confirmatory testing, and localization studies to distinguish unilateral pathology which may be amenable to adrenalectomy from bilateral adrenal hyperplasia. Through literature review, one theory is that chronic suppression of renin may cause atrophy of the zona glomerulosa cells and hypoaldosteronism. Throughout the case report we emphasize on the importance of early diagnostic screening of secondary hypertension as well as the complications from adrenalectomy. Presentation: 6/2/2024

12383 Salivary Cortisone Measurement In Mild Autonomous Cortisol Secretion: Retrospective Single-center Cohort Study

Abstract Disclosure: C.A. Villavicencio Torres: None. Y. Chai: None. S.K. Grebe: None. T.D. Maus: None. I. Bancos: None. Background: Mild autonomous cortisol secretion (MACS) is diagnosed based on abnormal post-dexamethasone cortisol >1.8 mcg/dL. Late-night salivary cortisol (SalF) measurements in MACS are usually within normal ranges, and as such are not recommended by the adrenal incidentaloma guidelines. Late-night salivary cortisone (SalE) measurement may have a higher accuracy than SalF in diagnosing MACS. Objectives: To determine associations between SalF and SalE and post-dexamethasone cortisol concentrations in patients with MACS. Methods: We conducted a single-center retrospective cohort study of data between 2020-2023 that included patients with MACS who had concomitant SalF and SalE measurements at the time of diagnosis. Electronic medical records were reviewed for clinical, imaging, biochemical characteristics, and outcome data. Results: In 45 patients with MACS (31, 69% women) evaluated at a median age of 62 years (IQR 54-70), median post-dexamethasone cortisol was 3 mcg/dL (IQR 2.5-5.7), median corticotropin (ACTH) was 11 pg/mL (IQR 5.2-30), and median dehydroepiandrosterone sulfate (DHEAS) was 47.5 mcg/dL (IQR 27.8-98.8). In 36 patients, 24h-urine cortisol was also available, with a median cortisol of 14 mcg/dL (IQR 11.3-18), normal ranges <45 mcg/24h. Median adrenal adenoma size was 2.2 cm (IQR 1.6-3.0), and median unenhanced HU was 10 (IQR -5 to 22).Median SalF was 52 ng/dL (IQR 23.9-97.5), and median SalE was 332 ng/dL (IQR 222.5-607.0), with a median SalE/SalF ratio of 6.6 (IQR 5.7-9.0). SalF was normal (<50 ng/dL) in 22 (49%) patients with MACS, without differences in the post-dexamethasone cortisol concentrations between those with normal and abnormal SalF (median of 3 mcg/dL vs 3 mcg/dL, P=0.94). SalF correlated with SalE (R2=0.83, P<0.0001). However, only SalE was associated with post-dexamethasone cortisol (R2=0.09, P=0.04). Conclusion: SalE is associated with post-dexamethasone cortisol in patients with MACS and, after an appropriate validation, may provide additional value in support of diagnosis of MACS. Presentation: 6/3/2024

Study of Ultrasonographic Changes of the Adrenal Gland in Growth Restricted Fetus

Background: Fetuses with Fetal Growth Restriction (FGR) are at increased risk of chronic intra-uterine hypoxia, due to increased secretion of corticosterone from the fetal adrenal glands. This plays a major role in the cardiovascular and circulatory adaptation of FGR fetuses. These modifications are untimely identified by sonographic imaging. Objective: To study the association between ultrasound features of the adrenal gland and growth restriction in the fetus. Methods: A total of 104 pregnant women (52 FGR pregnancies and 52 controls) were evaluated between 28 and 36 weeks of gestation. All the study participants underwent transabdominal ultrasonography to measure bilateral fetal adrenal gland volume and fetal zone volume, corrected for gestational age. They were followed up until delivery. The two groups were compared to analyze the perinatal outcome in relation to ultrasonographic changes in the adrenal gland. Results: The adrenal gland measurements were significantly larger in fetuses with FGR as compared to the control group. FGR group had a larger corrected adrenal gland volume(cAGV) and fetal zone and adrenal gland (FZ/AG)ratio A statistically significant correlation was found between the two groups regarding gestational age at delivery, birth weight, APGAR score, and NICU admissions. Perinatal morbidity was found to be higher among women diagnosed with FGR, i.e., 14 (53.84%). Conclusion: Fetal adrenal gland size measurement is important to identify FGR fetuses that are vulnerable to hypoxia. It helps the obstetrician prepare for effective in-utero management to reduce perinatal morbidity and mortality.

Acute rimonabant treatment prevents anhedonia and memory loss in rats submitted to mild restraint stress

Stress-related disorders are becoming increasingly common and are often associated with cognitive impairments. Within this context, the endocannabinoid (ECB) system, particularly the type 1 cannabinoid (CB1) receptor, seems to play a decisive role in restoring body homeostasis. There is consistent evidence in the literature that disrupted CB1-mediated neurotransmission can ultimately contribute to stress-related diseases. Therefore, the present study aimed to evaluate the participation of CB1 receptors in the integrity of stress-induced peripheral and behavioral responses. For this purpose, male adult Wistar rats underwent physical restraint (1 h/day, for 7 days), followed by a single administration of rimonabant (CB1 receptor antagonist, 3 mg/Kg, intraperitonial) at the end of stress protocol. Animals were then subjected to evaluation of neuroendocrine responses, behavioral tests and quantification of Iba-1 (microglial) immunoreactivity in the parvocellular subdivisions of the paraventricular nucleus of the hypothalamus (PVN). No effects of restraint stress or rimonabant administration were detected on body mass variation. However, stress significantly increased adrenal relative mass and corticosterone secretion, and reduced thymus relative size. The stress effects on adrenal size and corticosterone plasma levels were absent in rimonabant-treated rats, but the thymus size was further reduced in the restraint-rimonabant group. Restraint stress also induced anhedonia, a depression-like behavior, and reduced object recognition index, indicating memory recovery impairment. Treatment with the CB1 antagonist significantly reversed stress-induced anhedonia and memory deficit. In the PVN, restraint stress reduced the number of Iba-1 positive cells in the medial parvocellular region of vehicle- but not rimonabant-treated animals. Taken together, these results indicate that the acute inhibition of the CB1-mediated endogenous pathway restores stress-induced depression-like behaviors and memory loss, suggesting a role for endocannabinoids in the neuro-immune-endocrine interplay at both peripheral and hypothalamic levels.

Adrenal Volume Quantitative Visualization Tool by Multiple Parameters and an nnU-Net Deep Learning Automatic Segmentation Model.

Abnormalities in adrenal gland size may be associated with various diseases. Monitoring the volume of adrenal gland can provide a quantitative imaging indicator for such conditions as adrenal hyperplasia, adrenal adenoma, and adrenal cortical adenocarcinoma. However, current adrenal gland segmentation models have notable limitations in sample selection and imaging parameters, particularly the need for more training on low-dose imaging parameters, which limits the generalization ability of the models, restricting their widespread application in routine clinical practice. We developed a fully automated adrenal gland volume quantification and visualization tool based on the no new U-Net (nnU-Net) for the automatic segmentation of deep learning models to address these issues. We established this tool by using a large dataset with multiple parameters, machine types, radiation doses, slice thicknesses, scanning modes, phases, and adrenal gland morphologies to achieve high accuracy and broad adaptability. The tool can meet clinical needs such as screening, monitoring, and preoperative visualization assistance for adrenal gland diseases. Experimental results demonstrate that our model achieves an overall dice coefficient of 0.88 on all images and 0.87 on low-dose CT scans. Compared to other deep learning models and nnU-Net model tools, our model exhibits higher accuracy and broader adaptability in adrenal gland segmentation.

The Role of 68 Ga PSMA Imaging in Evaluating Adrenal Lesions in Prostate Cancer Patients.

Objectives Gallium-68 prostate-specific membrane antigen ( 68 Ga-PSMA) imaging is valuable for staging because an accurate diagnosis, metastatic or nonmetastatic for prostate cancer patients, is required for deciding to treatment approaches and prognostic assessment. The aim of this study was primarily to distinguish between benign and metastatic adrenal gland lesions detected during 68 Ga-PSMA positron emission tomography (PET)/CT imaging, to evaluate the presence of factors predicting its development, and then to determine the life expectancy of patients with metastatic adrenal lesions. Materials and Methods We performed a database search for PET/CT records generated from June 2016 to February 2021 for "adrenal gland" in report for patients who underwent 68 Ga-PSMA examination with prostate cancer patients. Results Twenty-three patients (10 benign and 13 metastatic) were included in this study. The total prostate-specific antigen, adrenal gland size, adrenal gland density, and maximum standardized uptake (SUVmax) values are significantly different between groups ( p < 0.05). On receiver operating characteristic curve analysis, the SUVmax cutoff value > 6.8 provided both sensitivity and specificity of 100%. However, with 29 mm as the adrenal gland size cutoff and 21.2 as Hounsfield unit, the sensitivity and specificity were 56.2 and 92.3%, and 93.8 and 92.3%, respectively. The survival of the benign and metastatic groups was compared and a statistically significant difference was found ( p = 0.006). The presence of pelvic lymph nodes was statistically negatively affected the surveillance between the groups. Conclusion The presence of atypical metastases such as adrenal gland is not insignificant in prostate cancer patients. Because of this degree of impact on patient management, accurate staging by imaging with 68 Ga-PSMA should be an integral part of prostate cancer management.

Clinical, radiological, and surgical outcomes of 431 patients with adrenal incidentalomas: retrospective study of a 10-year single-center experience.

The incidence of adrenal tumors is increasing due to the widespread utilization of radiographic imaging techniques. Factors such as tumor size, radiological characteristics, and functionality of adrenal adenomas play crucial roles in diagnosis and subsequent management. In this retrospective study, we investigated the clinical, radiological, and surgical features of patients with adrenal incidentalomas (AIs) and evaluated their follow-up results. We analyzed data from 431 patients diagnosed with AIs (130 males, 301 females) who underwent adrenal hormone evaluation at our center. We compared nonfunctioning and functioning AIs in terms of radiological features. We also compared baseline and follow-up characteristics in nonfunctioning AIs. The mean age of the patients was 55.4 ± 11.5 years, with a mean tumor size of 25.9 ± 14.3 mm. Mean follow-up duration was 3.17 ± 2.07 years. Adenoma localization revealed 165 (38.3%) right-sided, 185 (42.9%) left-sided, and 81 (18.8%) bilateral cases. Most patients (76.6%) had nonfunctioning AIs. During follow-up, nonfunctioning AIs exhibited increased fasting blood glucose, fasting insulin and HOMA-IR values (p = 0.002, <0.001 and 0.004, respectively). Among the functioning AIs cases (23.4%), autonomous cortisol secretion, Cushing's syndrome, pheochromocytoma, and primary aldosteronism were observed in 10.4%, 5.1%, 3.9%, and 3.9% of cases, respectively. Receiver operating characteristic curve analysis determined an adrenal adenoma size of 26.5 mm as the optimal cut-off for distinguishing between functioning and nonfunctioning AIs, with a sensitivity and specificity of 61.4% and 70.0%, respectively. Although the majority of AIs are nonfunctioning, the prevalence of functioning adrenal adenomas is not rare. Our findings suggest that adenoma size emerges as a valuable predictor for early detection of functioning adenomas. In addition, smaller masses appear to carry a lower risk of malignancy.

Differentiation between adrenocortical carcinoma and lipid-poor adrenal adenoma using a multiparametric MRI-based diagnostic algorithm

PurposeThe purpose of this study was to evaluate the capabilities of multiparametric magnetic resonance imaging (MRI) in differentiating between lipid-poor adrenal adenoma (LPAA) and adrenocortical carcinoma (ACC). Materials and methodsPatients of two centers who underwent surgical resection of LPAA or ACC after multiparametric MRI were retrospectively included. A training cohort was used to build a diagnostic algorithm obtained through recursive partitioning based on multiparametric MRI variables, including apparent diffusion coefficient and chemical shift signal ratio (i.e., tumor signal intensity index). The diagnostic performances of the multiparametric MRI-based algorithm were evaluated using a validation cohort, alone first and then in association with adrenal tumor size using a cut-off of 4 cm. Performances of the diagnostic algorithm for the diagnosis of ACC vs. LPAA were calculated using pathology as the reference standard. ResultsFifty-four patients (27 with LPAA and 27 with ACC; 37 women; mean age, 48.5 ± 13.3 [standard deviation (SD)] years) were used as the training cohort and 61 patients (24 with LPAA and 37 with ACC; 47 women; mean age, 49 ± 11.7 [SD] years) were used as the validation cohort. In the validation cohort, the diagnostic algorithm yielded best accuracy for the diagnosis of ACC vs. LPAA (75%; 46/61; 95% CI: 55–88) when used without lesion size. Best sensitivity was obtained with the association of the diagnostic algorithm with tumor size (96%; 23/24; 95% CI: 80–99). Best specificity was obtained with the diagnostic algorithm used alone (76%; 28/37; 95% CI: 60–87). ConclusionA multiparametric MRI-based diagnostic algorithm that includes apparent diffusion coefficient and tumor signal intensity index helps discriminate between ACC and LPAA with high degrees of specificity and accuracy. The association of the multiparametric MRI-based diagnostic algorithm with adrenal lesion size helps maximize the sensitivity of multiparametric MRI for the diagnosis of ACC.

Comparison of chemotherapy outcomes between normal and high serum cortisol concentration in dogs with lymphoma.

Increased serum cortisol (COR) concentrations may induce glucocorticoid resistance by down-regulation of glucocorticoid receptor (GCR), resulting in decreased chemotherapy efficacy in dogs with lymphoma. Investigate the relationship between serum COR concentrations and chemotherapy outcomes in dogs with lymphoma. Thirty client-owned dogs with lymphoma, with serum COR concentration measured using serum samples collected at diagnosis. Retrospective study. Dogs were divided into 2 groups based on serum COR concentrations: a normal group (n = 16) with COR concentrations <6 μg/dL and a high group (14) with COR concentrations ≥6 μg/dL. We compared signalment, clinical signs, stage, type of lymphoma, adrenal gland size, alkaline phosphatase (ALP) activity, response to chemotherapy, progression-free survival (PFS), overall survival (OS), and rate of P-glycoprotein (P-gp)- and GCR-positive cells between the 2 groups. No significant differences were found in the demographic characteristics between the 2 groups. However, the high COR group exhibited a significantly lower response to chemotherapy, PFS, and OS compared with the normal COR group. Serum ALP activity was significantly higher in the high COR group than in the normal COR group. Adrenal gland size was also significantly larger in the high COR group. Although no significant differences were found in the rate of P-gp-positive cells between the 2 groups, the rate of GCR-positive cells was significantly lower in the high COR group. Our data suggests that measurement of serum COR concentrations may serve as a potential prognostic factor and evaluation index.

Adrenal morphology and cortical function in patients with extrapulmonary tuberculosis: response to antituberculosis treatment.

Enlargement of the adrenal glands and variable adrenocortical function have been reported in patients with pulmonary tuberculosis and, in a few studies, in patients with extrapulmonary tuberculosis (EPTB). However, none of the studies have evaluated the course of the adrenal morphology in these patients. Prospective study including 37 patients with EPTB and 37 healthy age- and sex-matched controls. The adrenal function was evaluated by measurement of cortisol levels at baseline and after stimulation with ACTH (Acton Prolongatum) before and 6 months after antituberculosis treatment. The size of both adrenal glands was evaluated using 64-slice computed tomography (CT) scanning before and 6 months after treatment. The findings were compared with those in a group of healthy matched controls. Clinical and biochemical parameters were comparable between groups. The mean baseline serum cortisol level was significantly lower in the EPTB group (397.1 ± 184.9 nmol/L) compared with the control group (696.3 ± 101.8 nmol/L). Compared with controls, patients with EPTB had significantly lower mean cortisol levels at baseline and 1 hour after ACTH, both before (397 ± 184.9 nmol/L and 750.7 ± 176.8 nmol/L, respectively) and after (529.7 ± 100.4 nmol/L and 1017.2 ± 119.7 nmol/L, respectively) antituberculosis treatment. Both the length and thickness of the right and left adrenal glands were greater in patients with EPTB than in controls but became comparable to those in controls after treatment completion. Patients with EPTB have an enlarged adrenal size and low baseline and stimulated serum cortisol levels. After treatment completion, cortisol levels increased significantly, and the adrenal size normalized in these patients.

Adrenal volumes in fetuses delivering prior to 32 weeks' gestation: An MRI pilot study.

Spontaneous preterm birth prior to 32 weeks' gestation accounts for 1% of all deliveries and is associated with high rates of morbidity and mortality. A total of 70% are associated with chorioamnionitis which increases the incidence of morbidity, but for which there is no noninvasive antenatal test. Fetal adrenal glands produce cortisol and dehydroepiandosterone-sulphate which upregulate prior to spontaneous preterm birth. Ultrasound suggests that adrenal volumes may increase prior to preterm birth, but studies are limited. This study aimed to: (i) demonstrate reproducibility of magnetic resonance imaging (MRI) derived adrenal volumetry; (ii) derive normal ranges of total adrenal volumes, and adrenal: body volume for normal; (iii) compare with those who have spontaneous very preterm birth; and (iv) correlate with histopathological chorioamnionitis. Patients at high risk of preterm birth prior to 32 weeks were prospectively recruited, and included if they did deliver prior to 32 weeks; a control group who delivered an uncomplicated pregnancy at term was also recruited. T2 weighted images of the entire uterus were obtained, and a deformable slice-to-volume method was used to reconstruct the fetal abdomen. Adrenal and body volumes were obtained via manual segmentation, and adrenal: body volume ratios generated. Normal ranges were created using control data. Differences between groups were investigated accounting for the effect of gestation by use of regression analysis. Placental histopathology was reviewed for pregnancies delivering preterm. A total of 56 controls and 26 cases were included in the analysis. Volumetry was consistent between observers. Adrenal volumes were not higher in the case group (p = 0.2); adrenal: body volume ratios were higher (p = 0.011), persisting in the presence of chorioamnionitis (p = 0.017). A cluster of three pairs of adrenal glands below the fifth centile were noted among the cases all of whom had a protracted period at risk of preterm birth prior to MRI. Adrenal: body volume ratios are significantly larger in fetuses who go on to deliver preterm than those delivering at term. Adrenal volumes were not significantly larger, we hypothesize that this could be due to an adrenal atrophy in fetuses with fulminating chorioamnionitis. A straightforward relationship of adrenal size being increased prior to preterm birth should not be assumed.

FRI178 The Clinicopathological Distinction And Malignant Potential In Patients With Lipid-rich and Lipid-poor Non-functioning Adrenal Adenoma

Abstract Disclosure: P. Pengkhum: None. S. Lertlam: None. P. Cheunsuchon: None. V. Suvannarerg: None. S. Sirinvaravong: None. T. Wannachalee: None. Introduction: Adrenal incidentaloma (AI) is defined as an adrenal mass detected during imaging performed for conditions unrelated to suspected adrenal diseases. The latest evidence shows that most AIs are non-functioning adrenocortical adenomas (NFA). Of these, 70% are lipid-rich adenomas (LRA) and 30% are lipid-poor adenomas (LPA). Current guidelines do not recommend further follow-up imaging in patients with an adrenal mass size &amp;lt;4 cm with clear benign features. But some non-functioning lipid-poor lesions may carry malignant potential and proper management including surgical resection should be offered. However, the natural history and optimal specific follow-up surveillance of non-functioning LPA have not been well characterized. Objectives: We aimed to evaluate the clinical characteristics, natural courses, and histopathological data in NFA, and compared the malignant potential between LRA and LPA. Methods: We retrospectively studied all patients with AI between Jan 2005 to June 2022. Only patients with NFA who underwent adrenalectomy or were followed up by imaging for at least 6 months were included. The demographic, radiographic, and follow-up data were evaluated in all patients. Available adrenal tissues were performed for pathological assessment by using the Weiss score, Ki-67, and reticulin algorithm to identify the malignant potential. Results: Of 303 patients with AIs, 146 patients (48%) with NFAs were recruited, including 79 masses in LRA group and 77 masses in LPA group. Of these, the median age was 61 years, 43% were men, and the median follow-up period was 47 months. The initial median adenoma size was 1.6 cm [1.2-2.1]. During the follow-up period, only 3 LPAs developed significant interval enlargement. However, none of these were neither treated by surgical resection nor demonstrated malignant transformation based on imaging appearance. Overall, there was no difference in tumor growth between both groups by radiological assessment. Furthermore, 27 patients of NFAs underwent adrenalectomy; 8 masses in LRA group and 19 masses in LPA group. Of these, no difference in histological assessment in both groups. However, two large LPAs which size ≥4 cm revealed a Weiss score ≥3 with the presence of reticulin algorithm indicating potential malignant behavior. In contrast to LRA. Regardless of the adrenal mass size, the histopathological results revealed no suggestive malignant features. Conclusions: There was no significant difference in characteristics and tumor growth in patients with non-functioning LRA and LPA across 4-year interval follow-up data. Significant enlargement of adenomas was observed in few small LPAs, therefore periodic follow-up imaging should be offered in small LPAs with evidence of interval enlargement. According to our histopathological data, surgical resection should be considered in the large LPA (≥4 cm) due to its malignant potential. Presentation: Friday, June 16, 2023

FRI249 New Onset Heart Failure In A Patient With Rapidly Progressive Adrenocortical Carcinoma

Abstract Disclosure: J. Peeples: None. S. Shu: None. K.G. Romo: None. J. Tereul: None. B.B. Grissett: None. Background: Adrenocortical carcinomas (ACC) are rare, relatively large (&amp;gt;4cm), lipid-rich, and often aggressive tumors. They may be functional, which typically presents as Cushing’s syndrome and/or virilization, or non-functional, which typically presents as an abdominal mass or incidental finding. They occur in two peak incidences: at the first decade of life and between 40-50 years of age. Over half of adult patients with ACC present with an advanced tumor stage. This case describes a young man with new onset heart failure and adrenal mass with metastases who was found to have biopsy-confirmed ACC. Clinical Case: A 20-year-old man with a history of cigarette smoking and marijuana use, but otherwise in prior good health, presented as a transfer for new onset heart failure in the setting of hypertensive emergency (SBP 260s), and CT findings of left adrenal mass, with multiple lung and liver masses. He noted 2 months of rapidly progressive weight gain, easy fatigability, dyspnea on exertion, and leg swelling. Exam revealed central adiposity with abdominal striae, bilateral clavicular and cervical fat pad, and bilateral lower extremity swelling. Investigations revealed hypercortisolism and ventricular ejection fraction 20-25%. Liver mass biopsy revealed metastatic ACC. Family history was significant for multiple members with early onset hypertension and congestive heart failure, including the death of maternal grandmother at age 40. The patient was initially managed in the ICU with an etomidate drip for adrenal suppression. Cortisol levels appropriately decreased to goal. Additionally, he started IV dexamethasone while inpatient. He was discharged once euvolemic on PO furosemide and follow-up was scheduled with cardiology, oncology, and endocrinology. At discharge, he transitioned to PO hydrocortisone (HC) and was placed on trimethoprim/sulfamethoxazole for PJP prophylaxis, doxazosin, and ketoconazole. He also started mitotane for his cancer treatment, with HC to prevent adrenal insufficiency while on mitotane. Subsequently, he started and failed carboplatin plus etoposide palliative chemotherapy with a continued increase in adrenal mass size. Now, he is on second line pembrolizumab with an ECOG score of 2. Conclusion: ACC is a rare and often aggressive tumor that should be considered in the setting of hypercortisolism and cushingoid features. This is particularly important for patients with a relatively unremarkable history and new onset heart failure with dyspnea on exertion. In these cases, mitotane can be used for hypercortisolism associated with ACC. Unfortunately, these tumors are usually diagnosed when they have already progressed to a late stage, and the prognosis for ACC is poor. Presentation: Friday, June 16, 2023

FRI234 A Pregnancy With Two Special Surprises A Baby And A Nonhemorrhagic Adrenal Infarction During Pregnancy

Abstract Disclosure: S. Idriss: None. N. Barua: None. I. Jamal: None. A. Jabiev: None. Introduction: Unilateral Acute adrenal infarction (AAI) is a rare cause of acute abdomen in pregnancy, with a reported incidence of 1.3%. It usually presents with sudden, severe, and unremitting flank pain. The most common cause of AAI is adrenal vein thrombosis. We present a 26-year-old pregnant female who presents with right flank and back pain, found to have AAI without hemorrhage. Case: 26-year-old female Primigravida without significant past medical history presented to the emergency room at 33 weeks of gestation with sudden onset of RUQ flank and back pain. She was afebrile and normotensive. Physical exam was positive for right flank point tenderness. She underwent multiple investigations including an abdominal US which did not reveal an acute pathology. She was admitted and started on opioids which failed to control her pain. An abdominal MRI was obtained subsequently revealing 4.6cm right adrenal gland lesion suspicious for AAI without hemorrhage and normal left adrenal gland. The pain was poorly controlled warranting Dilaudid drip and repeat imaging/CT showed adrenal gland mass with density of 41-52 HU suspicious for lipid poor adenoma versus adrenal hematoma on CT scan. Initial AM Cortisol level was 46 ug/dl, then it trended down to 31.7. DHEAS was low at 94.2 ug/dl. Plasma metanephrines and normetanephrines were normal. Course was complicated with hypotension and worsening pain on day 10 of admission, repeat MRI showed increase in right adrenal lesion size and cystic transformation, containing some T2 hypointense septations and debris without notable intrinsic T1 hyperintensity to suggest blood products, and restricted diffusion which is a finding compatible with AAI. Repeat AM Cortisol and DHEAS were low at 12 and 61.3 respectively. Despite normal left adrenal gland, clinical picture was consistent with adrenal insufficiency and she was started on stress steroids. Thrombophilia workup was negative. She ultimately underwent c-section on day 13 of admission. She was discharged on physiologic dose of steroids with a pending repeat MRI and outpatient follow up. Discussion: Adrenal glands, especially with preexisting nodules are predisposed to micro-vascular thrombosis and infarction during procoagulable states. Pregnancy is a hypercoagulable state that predisposes patients to thrombotic events. The relative risk of thrombosis is 5-6 times higher in pregnant than non-pregnant females of the same age. Our patient had evidence of adrenal insufficiency and required steroid replacement. Anticoagulation was not started due to possible subtle hematoma on CT scan on initial imaging. Follow up imaging is planned. Conclusion: Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. Adrenal insufficiency if found should be addressed to prevent circulatory collapse. Presentation: Friday, June 16, 2023

DIAGNOSTIC IMAGING AND OROTRACHEAL INTUBATION IN CLINICALLY HEALTHY WILD SUNDA PANGOLINS (MANIS JAVANICA) IN SINGAPORE.

Pangolins are amongst the most overexploited species in the world and all eight species of pangolins are threatened with extinction. These animals are rare in zoological collections and often suffer high mortality rates in captivity. Maintaining healthy populations in captivity has become more important with the declining populations in the wild, but knowledge of veterinary care of these animals is limited. Interpreting radiography and ultrasonography images in a patient can be challenging without knowledge of normal findings. The Wildlife Healthcare and Research Center (WHRC) at Mandai Wildlife Reserve (MWR) admits an average of 25 Sunda pangolins (Manis javanica) annually, which is a Critically Endangered species native to Singapore. All the pangolins are triaged on admission and anesthetized for a health assessment before release into the wild. Endotracheal intubation using an otoscope and stylet is a novel technique in the species that has been developed and is commonly performed with these pangolins. A retrospective study was done on 20 clinically healthy wild pangolins to determine normal ultrasonography and radiography findings in the species. Notable findings include the presence of radio-opaque particles in the stomachs of all pangolins, the presence of free fluid cranial to the left kidney (13/20), a spleen with multifocal hypoechoic regions (6/20), and open epiphyseal plates of long bones even in large individuals weighing as heavy as 6.8 kg. Ultrasonographic images and measurements of kidney, spleen, and adrenal gland sizes as well as intestinal, gallbladder, and urinary bladder wall thickness were also described. These diagnostic imaging findings can advance the veterinary care of captive and wild pangolins.

The Effect of Maternal Behçet's Disease on Fetal Adrenal Gland Sizes

Amaç: Maternal Behçet Hastalığı (BH) ile komplike gebeliklerde artmış inflamasyonun fetal adrenal bezin erken olgunlaşmasına neden olabileceğini, dolayısıyla fetal adrenal bez boyutunun değişebileceğini hipoteze ederek, maternal BH’li gebeliklerde fetal adrenal bez boyutlarını incelemeyi amaçladık.&#x0D; Gereç ve Yöntemler: Kesitsel tasarımda ki bu çalışma, Mayıs 2022-Mayıs 2023 tarihleri arasında Ankara Şehir Hastanesi perinatoloji kliniğinde yürütüldü. Çalışmaya 31-34 gebelik haftalarında başvuran BH tanısı almış 21 gebe ve gebelik yaşı vaka grubu ile eşleştirilmiş ve rastgele seçilmiş 63 sağlıklı gebe dahil edildi. Her iki adrenal bez ile fetal zonun genişliği ve uzunluğu transvers kesitte ölçülerek uzunluk x genişlik x π formülü ile transvers adrenal alan (TAA), transvers fetal zon alanı (FZA) ve fetal zon alanının transvers adrenal alana oranı (FZA/TTA) hesaplandı. Vaka ve kontrol grupları arasında ayrıca atak geçiren ve geçirmeyen BH alt gruplarında fetal adrenal ölçümler karşılaştırıldı. &#x0D; Bulgular: Sol adrenal bezde toplam adrenal genişlik, TTA, fetal zon genişlik ve FZA vaka grubunda anlamlı olarak yüksek bulundu. Ayrıca sol FZA/TTA oranı vaka grubunda istatistiksel olarak anlamlı oranda yüksek saptandı. Sağ adrenal bezde ise fetal zon genişliği, FZA ve FZA/TTA oranı vaka grubunda anlamlı oranda yüksek izlendi. Ayrıca atak geçiren grupta sol adrenal bezde fetal zon genişliği, FZA ve FZA/TTA oranı anlamlı ölçüde yüksek ve sağ adrenal bezde ise toplam adrenal uzunluk, TTA, fetal zon genişliği ve FZA istatiksel olarak anlamlı oranda yüksek izlendi.&#x0D; Sonuç: Maternal BH ile komplike gebeliklerde fetal adrenal bez boyutları etkilenebilmektedir. Bu etkinin daha çok adrenal bezin fetal zon bölümünde olduğu ve gebeliğinde atak geçiren grupta daha belirgin olduğu görülmektedir. BH gebeliklerinde artmış inflamasyon ve sitokin seviyeleri nedeniyle intrauterin strese maruz kalan fetuslarda adrenal bezin daha erken matürasyonu söz konusu olabilir.