Original Article: Clinical Investigation
Contralateral adrenal width predicts the duration of prolonged post-
surgical steroid replacement for subclinical Cushing syndrome
and Tomohiko Ichikawa
Department of Urology, and
Department of Clinical Cell Biology, Chiba University Graduate School of Medicine, Chiba, Japan
Abbreviations & Acronyms
ACTH = adrenocorticotropic
AUC = area under the curve
BMI = body mass index
CRH = corticotropin-
CS = Cushing syndrome
DST = dexamethasone
HPA axis = hypothalamic–
ROC = receiver operating
SCS = subclinical Cushing
Imamura M.D., Ph.D.,
Department of Urology, Chiba
University Graduate School of
Medicine, 1-8-1 Inohana, Chuo-
ku, Chiba-shi, Chiba 260-8670,
Japan. Email: you-i@wa3.
Received 28 November 2017;
accepted 16 February 2018.
Online publication 12 April
This study was presented at the
Association 2017 annual
meeting and is already included
in Abstracts of the Conference
of the Society.
Objectives: To identify pre-treatment factors affecting the duration of post-surgical
steroid replacement in patients undergoing adrenalectomy for subclinical Cushing
Methods: The present retrospective analysis included 64 patients who underwent
unilateral laparoscopic adrenalectomy for subclinical Cushing syndrome. Adrenal tumor
and contralateral adrenal sizes together with various clinical factors were studied in
association with the duration of post-surgical steroid replacement. Adrenal tumor and
contralateral adrenal size were measured at the level of the maximum transverse plane
of the adrenal glands using computed tomography scan or magnetic resonance imaging.
Cox’s proportional hazards model was used for the statistical analysis.
Results: All 64 patients were treated with post-surgical steroid replacement after
adrenalectomy. The median duration of the steroid treatment was 6 months. When
assessing the duration of post-surgical steroid replacement, contralateral adrenal volume
, contralateral adrenal width <6.15 mm and serum cortisol after a 1-mg
dexamethasone suppression test >2.65 lg/dL were signiﬁcant predictors of prolonged
post-surgical steroid treatment on univariate analysis. On multivariate analysis,
contralateral adrenal width <6.15 mm was the only independent predictive factor for the
prolonged post-surgical steroid replacement.
Conclusions: Contralateral adrenal width seems to represent a signiﬁcant predictive
factor for the duration of post-surgical steroid replacement in subclinical Cushing
syndrome patients. Pre-surgical assessment of image ﬁndings might help clinicians
determine the total duration of steroid therapy after adrenalectomy.
Adrenalectomy, adrenal insufﬁciency, contralateral adrenal width, steroid
replacement, subclinical Cushing syndrome.
SCS is a deﬁned condition of cortisol excess in patients with adrenal adenoma without the
typical clinical signs and symptoms of CS. In 1981, Charbonnel et al. reported a patient with
no clinical features of CS as pre-CS.
As SCS is asymptomatic, it is often found as adrenal
incidentaloma. Recently, improvements in abdominal imaging techniques have increased the
detection of adrenal incidentalomas.
SCS is reported in 2.9–20% of patients with inciden-
tally discovered adrenal masses.
Laparoscopic adrenalectomy has become a standard
approach for adrenal tumors, even for SCS patients. Laparoscopic adrenalectomy is safe, fea-
sible and beneﬁcial with the improvement of hypertension, bodyweight and glucose toler-
In SCS patients, the HPA axis has been suppressed by the activity of the tumor, thereby
the contralateral adrenal cortex has undergone atrophic change at the time of diagnosis.
Although suppression of endogenous cortisol production varies among patients, postoperative
steroid replacement is recommended, as adrenal insufﬁciency can be critical.
it is difﬁcult to predict the total duration of postoperative steroid replacement before surgery.
A precautionary steroid treatment has been proposed for all SCS patients after unilateral
© 2018 The Japanese Urological Association
International Journal of Urology (2018) 25, 583--588 doi: 10.1111/iju.13566