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Endocrine Care |
Division of Endocrinology (G.G.M.G., P.P., G.A., E.F.), University of Ancona, I-60100 Ancona, Italy; and Division of Endocrinology (F.M.), University of Padua, 35121 Padua, Italy
Address all correspondence and requests for reprints to: Dr. Emanuela Faloia, Clinica di Endocrinologia, Ospedale Regionale Torrette, Via Conca 1, 60100 Ancona, Italy.
Abstract
The aim of this study was to evaluate body composition and metabolic features in women with nonhypersecretory adrenal cortical incidentaloma (AI) and women with Cushing’s syndrome (CS) compared with healthy control (C) women matched for age, menopausal status, and body mass index. We examined 15 females with CS, 22 with AI, and 20 C. We evaluated anthropometric, hormonal, and metabolic parameters in all subjects. Body composition was measured by dual-energy x-ray absorptiometry for total body (TB); in addition, abdominal fat was measured between L2 and L4 vertebrae. Women with CS and AI were overweight; waist to hip ratio mean values showed that women with CS and AI had a central fat distribution. TB fat was significantly higher in CS than in C women, however, AI women also had high fat values. Abdominal fat was significantly more increased in CS than in AI and C women. Eighty percent of CS women and 50% of AI women were hypertensive. High density lipoprotein cholesterol levels were lower and triglyceride levels were higher in CS and AI women than in C. The area under the curve for glucose after oral glucose tolerance test was significantly higher in CS and AI than in C. AI had urinary free cortisol values slightly higher than C and than the normal range.
In conclusion, these data indicate that AI are at an intermediate state between normal and pathological. These alterations suggest that a subtle cortisol hypersecretion is probably present in AI and it may be the factor promoting alterations of body composition and metabolic parameters.
THE ADRENAL INCIDENTALOMA (AI) is an adrenal mass discovered by noninvasive abdominal imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound] performed for reasons other than suspected adrenal disease (1, 2). The majority of AI are nonhypersecretory cortical adenomas, although in some cases they are indeed secretory and may cause catecholamine excess, hyperaldosteronism, hyperandrogenism, or preclinical Cushing’s syndrome (PCCS) as defined by the presence of two or more abnormal functional tests of the hypothalamic–pituitary–adrenal (HPA) axis in patients without most of classic clinical stigmata of hypercortisolism (3).
Although subjects with Cushing’s syndrome (CS) have clearly established complications, the natural history of patients with nonhypersecretory masses is unknown. Recently, a high prevalence of hypertension, diabetes, and obesity was observed in AI (3). There are few observations about this finding: some authors suggest that patients with AI meet the criteria of the metabolic syndrome and that hyperinsulinemia is a major factor promoting tumor growth (4). Other authors have hypothesized that subtle cortisol overproduction in subjects with AI may impact on carbohydrate metabolism (5). Moreover, weight loss, improvement of hypertension, or glycemic control are frequent findings after unilateral adrenalectomy (1).
CS is associated with an increase in the size of intra-abdominal fat stores compared with sc fat (6, 7), and it is well known that the accumulation of visceral fat rather than sc fat is more frequently associated with premature death from cardiovascular disease. Evaluation of body fat depots, which are closely associated with the insulin-resistance syndrome, is important for the management and prevention of its associated complications. Thus, there is increased interest in the evaluation of various methods for assessing body fat distribution. Dual-energy x-ray absorptiometry (DEXA) is becoming increasingly popular for the measurements of soft tissue composition as well as bone mineral density. It appears to offer a precise and simple way of measuring total and regional body fat and lean masses (8, 9). DEXA cannot determine visceral fat, but it can measure central abdominal fat. Central abdominal fat includes the visceral fat at this region plus anterior and posterior sc fat. Published studies have shown a good correlation between central abdominal fat by DEXA and visceral fat by CT (10) or MRI (11, 12).
There are no published studies about body composition in AI. The first study concerning the measurements of body composition in CS using DEXA was published a few years ago (13). A reduction of the total adipose tissue volume and a redistribution of adipose tissue from visceral to peripheral depots were found using a multiscan CT technique after normalization of the hypercortisolic state in seven women with CS (14).
The aims of the present study were: 1) to evaluate lipids, glucose tolerance, body composition, and fat distribution, as measured by DEXA, in women with AI and in women with CS compared with healthy C women matched for age, menopausal status and body mass index (BMI); and 2) to seek a possible link between the size and steroid secretion of the tumor, metabolic parameters, and body composition.
Subjects and Methods
Subjects
We evaluated, prospectively, between January 1998 and October 1999, 57 women subdivided in three groups: 15 consecutive patients with CS (age, mean ± SEM, 46.5 ± 3.8 yr), 22 consecutive patients with nonhypersecretory AI (age 57.6 ± 2.3 yr), and 20 healthy C (age 51.5 ± 2 yr) matched for age, menopausal status, and BMI.
Six CS patients had pituitary adenomas, seven had cortical adrenal adenomas, and two were cases of ectopic secretion of ACTH (one bronchial carcinoid and one of occult origin). Eight of them were postmenopausal, and seven were premenopausal but amenorrhoic at the time of the study. CS women had not received any treatment at the time of assessment. All had typical signs and symptoms of CS, elevated urinary free cortisol (UFC) excretion, absent cortisol rhythm, and cortisol unsuppressibility after 1 mg dexamethasone (DXM).
We also evaluated 22 women with AI that was discovered by noninvasive abdominal imaging techniques (ultrasound, CT scan, or MRI) performed for reasons other than suspected adrenal disease. Inclusion criteria were: 1) female patients, 2) absence of specific signs and/or symptoms of hormone excess, 3) tests of HPA axis function all normal or not more than one abnormal test, and 4) morphological aspect of the tumor suggesting that the presence of a benign mass (size less than 4 cm, round with smooth margins, homogeneous with relatively low density).
In patients who previously had undergone only abdominal ultrasound, a CT or MRI scan was also performed. The adrenal mass size was 3.2 ± 0.3 cm (mean ± SEM), with a range from 0.6–4 cm. Seven of them were premenopausal eugonadal females and 15 were postmenopausal at the time of the study. None of the patients with AI showed specific signs and/or symptoms of hormone excess. All subjects had received an extensive endocrine evaluation (clinical and hormonal), before inclusion in this study, to eliminate a functioning adrenal tumor. Baseline data included determinations of UFC, plasma ACTH, serum dehydroepiandrosterone sulfate, serum 17-hydroxyprogesterone, serum testosterone, upright plasma aldosterone and plasma renin activity, catecholamine, and vanillylmandelic acid urinary excretion, 24-hour cortisol plasma levels. Dynamic tests included overnight 1 mg DXM test, CRH test, and ACTH test (250 µg). Even if some patients with AI had UFC excretion above normal, this was a single and isolated alteration of the HPA axis function. All women with AI had normal ACTH values both in the morning and after CRH test. Cortisol suppression after 1 mg DXM test was complete in all subjects with AI. On the basis of the morphological aspect of the tumor and the hormonal screening evaluation, AI patients were all classified as nonhypersecretory adrenal cortical adenomas. Subjects with PCCS, as defined by the presence of two or more abnormal functional tests of the HPA axis in patients without most of the classic clinical stigmata of hypercortisolism, were not included.
Twenty C women (7 premenopausal and 13 postmenopausal) with no diabetes mellitus, hypertension, or chronic diseases and no alcohol consumption were also studied. Subjects taking any medication or doing excessive exercise were excluded from the study. C women had a stable weight for at least several months before being included in the study. Their BMI and age were comparable to that of subjects with CS and AI.
The study was designed in accordance with the Helsinki Declaration; full informed consent was obtained from each subject. The study was approved by our Institution Ethics Committee.
Methods
Clinical evaluation. For all subjects, weight, height, waist
to hip ratio (WHR), BMI, systolic blood pressure (SBP), and diastolic
blood pressure (DBP) were evaluated. BMI was calculated with the
following formula: weight (kg)/height (m2). To
obtain WHR, the waist was measured at the lowest value between the
xyphoid process and the umbilicus, and the hip was measured at the
highest value over the great trochanters, according to World Health
Organization criteria. Anthropometric and blood pressure (BP)
measurements were performed by the same medical doctor and are reported
in Table 1
.
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Dynamic tests included an overnight 1 mg DXM test; adequate DXM
suppression was demonstrated when morning cortisol levels fell below
0.14 µmol/liter. Serum cortisol and UFC were determined using a
commercial RIA (Immulite, DPC, Los Angeles, CA); the intra- and
interassay coefficients of variation were 4.1 and 6.3, respectively;
the detection limit of the assay is 
0.0056 µmol/liter. UFC normal
range was 96.56–344.87 nmol/d.
Body composition. Body composition (fat mass, lean tissue,
and bone mineral content) was measured with the same total-body DEXA
scanner (DPX, Lunar Corp., Madison WI; software version
3.61) for TB and three standard regions: trunk (chest, abdomen, and
pelvis), arms and legs. In addition, abdominal fat content was measured
between L2 and L4 vertebrae (standard software option), an area shown
by MRI to contain a relatively high visceral and low sc fat content.
Therefore, DEXA has been used to assess central abdominal fat that
comprises intra-abdominal fat, in addition to anterior and posterior sc
fat, excluding 30% of the abdominal sc fat (15). To
exclude some sc fat, the lateral margins of the abdominal regions were
aligned with the outer edge of the rib cage (8, 15).
Unlike CT (the gold standard method for intra-abdominal fat),
DEXA-measured fat mass is not solely adipose tissue but is the sum of
fatty elements in soft tissue. Despite this, DEXA-measured abdominal
fat accounts for 80% of the variation in intra-abdominal fat measured
by CT in postmenopausal women (8), and measures of total
(visceral plus anterior and posterior sc fat) abdominal fat by DEXA are
highly correlated with intra-abdominal fat measured by CT (8, 10) or MRI (11, 12). DEXA scans require 30 min
and have a 2–3% precision for soft tissue assessments
(16). The soft tissue assessments were: % fat, total
grams of fat, and lean tissue mass. All subjects were weighed and
measured without shoes and while wearing light clothing. The entire
body of each subject was scanned, beginning at the top of the head. A
different scan mode was chosen with respect to each subject’s body
size. With this technique, subjects undergo a small total radiation
exposure of 0.015–0.06 mrem dependent on the anteroposterior thickness
of the subject. Total body scans were performed and analyzed by the
same person blinded to the clinical status of the patients.
Statistical analysis.Data are expressed as mean ± SEM. Statistical comparisons between groups were made by ANOVA (Fisher’s test). Correlations were examined by Spearman analysis. Levels of statistical significance were set at P < 0.05. Areas under the curve (AUCs) for insulin and glucose were calculated with the trapezoidal method. Statistical analyses were performed with the Statview 4.1 statistical package (Abacus Concepts Inc., Berkeley, CA).
Results
Endocrine evaluation
Women with CS had UFC levels significantly higher than AI and C.
Moreover, AI had UFC values slightly higher than C and than the normal
range (n.r.) (CS, 1731.5 ± 245.8, median, 1434.6 nmol/d; AI,
435.9 ± 53.8, median, 380.7 nmol/d; C, 201.4 ± 25.1,
median, 226.2 nmol/d; n.r., 96.5–344.8 nmol/d). Fifty percent of AI
had UFC levels above normal (Fig. 1).
Cortisol suppression after 1 mg DXM was normal in AI (AI, 0.058 ±
0.008; range, 0.028–0.126 µmol/liter; CS, 0.744 ± 0.120;
range, 0.448–1.68 µmol/liter; C, 0.042 ± 0.005; range,
0.028–0.098 µmol/liter).
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There were no differences in the levels of total cholesterol
between the three groups of subjects; CS and AI had HDL cholesterol
levels significantly lower than C. Triglyceride mean values were normal
but significantly higher in CS and AI vs. C. There were no
differences in uric acid levels between the three groups (Table 2).
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Two subjects with CS had clinical diabetes mellitus; type 2
diabetes mellitus was diagnosed in three CS and one AI, whereas glucose
intolerance was detected in two CS and six AI subjects. Serum glucose
levels during OGTT were significantly higher in CS and AI
vs. C at some specific times (Fig. 2), whereas serum insulin levels were
significantly higher in CS vs. C at 120 min (Fig. 2). The
AUC for glucose after OGTT was significantly higher in CS and AI
vs. C; the AUC for insulin was higher in CS and AI, but not
significantly different from the control group (Fig. 2).
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SBP mean values were significantly higher in CS and AI
vs. C; CS had the highest DBP mean values, whereas AI had
DBP levels significantly higher than C (Table 1
). Twelve CS (80%) and
eleven AI (50%) had high blood pressure.
Body composition
Anthropometric data. CS and AI women were overweight (BMI: CS,
28.7; AI, 27.9; range, 21.3–37.6 and 20.9–35.4
kg/m2, respectively); C women were matched for
BMI (26.1 ± 0.6; range, 22.3–35 kg/m2).
WHR and waist circumference mean values show that CS and AI had a
central fat distribution (Table 1).
Fat data. Total fat mass, trunk and arms fat mass percentages
were significantly higher in CS than C; women with AI had mean fat
percentage values between those of the two former groups
(P = NS). Abdominal fat percentage was significantly
higher in CS than AI and C. Leg fat masses were not significantly
different in the three groups (Table 3).
|
).
Bone mineral content (BMC). BMC was significantly decreased in
CS vs. C (Table 3); in AI, BMC values were intermediate
between C and CS.
To assess whether differences in body composition could be due to
estrogenic status, we compared, within and between groups, pre-
and postmenopausal women. Our results show that within groups, there
are differences in body composition only in the C group: premenopausal
C women had higher BMC and lower abdominal and trunk fat masses than
postmenopausal C women. There were no differences in the other two
groups. Comparison between groups shows that premenopausal C women had
significantly higher BMC and lower abdominal and trunk fat masses than
premenopausal CS and premenopausal AI (Table 4).
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Correlations
We did not find any correlations between UFC, serum cortisol after 1 mg DXM, duration of disease, insulin after OGTT, and percentage body fat mass (total, abdominal, trunk, arms, and legs). The size of the tumor did not correlate with serum cortisol after DXM or with UFC.
There were positive correlations between WHR and abdominal fat mass (r = 0.65; P < 0.009) and between waist circumference and abdominal fat mass (r = 0.86; P < 0.0001).
Discussion
To our knowledge, this is the first study that has evaluated body composition and fat distribution, as measured by DEXA, in women with AI (nonhypersecretory adrenal adenomas) and in women with CS compared with healthy C women matched for age, menopausal status, and BMI. Because the mean values of BMI indicated that CS and AI subjects were overweight, C were selected also to be overweight so that the differences in body composition between patients and controls would not be due to different amounts of adiposity. The mean values of WHR and waist circumference both in CS and AI show a central fat distribution, and they are significantly correlated with abdominal fat. The WHR is the traditional method of identifying subjects at increased risk for cardiovascular disease due to the accumulation of excess intra-abdominal fat. However, recent studies indicate that measurement of waist circumference is preferable because it reflects the intra-abdominal fat and is more strongly related than WHR to the health risks associated with obesity. Our results show that women with AI and CS had large waist circumferences that are also likely to be associated with impaired quality of life (17).
Total, trunk, and arms fat mass was significantly increased in CS vs. C, however, women with AI had mean fat percentage slightly higher than our C women and than C women who were matched for age, reported in the literature (18). Abdominal fat content was measured between L2 and L4 vertebrae. DEXA allows the determination of total as well as regional body composition, especially at the abdominal level (8, 15), but is unable to calculate the intra-abdominal adipose tissue content independently from the sc content. We did not determine visceral fat. However, a recent study has suggested that central fat distribution measured with DEXA is a useful marker of insulin sensitivity in healthy subjects, and that a simple measurement of total (visceral plus anterior and posterior sc fat) abdominal fat mass is highly predictive of health risks and may be as valuable as measuring intra-abdominal fat depots (19). Recently, a good correlation between central abdominal fat measured by DEXA and visceral fat measured by CT (10) or MRI (11, 12) was described. Abdominal fat percentage was found to be significantly higher in CS than AI and C, suggesting that glucocorticoids play a pivotal role in the pathogenesis of central obesity. In addition to this effect on fat distribution, glucocorticoids are known to regulate the differentiation of adipose stromal cells and affect the function of adipocytes (20).
To assess whether differences in body composition were due to estrogenic status, we compared, within and between groups, pre- and postmenopausal women. Our results show that there were differences in body composition only for the C women; premenopausal C women had higher BMC and lower abdominal and trunk fat masses than postmenopausal C women. Furthermore, there were no differences in body composition between premenopausal AI and premenopausal CS, although they had significantly higher abdominal and trunk fat masses than premenopausal C women. It is a surprising finding that premenopausal AI, even if they were eugonadal, had features similar to postmenopausal AI women and premenopausal CS (which were estrogen deficient for their clinical status). This suggests that the increase of fat mass in CS and AI may be more influenced by the disease than by the estrogenic status. It is well known that fat distribution in women may become more android after menopause (21); in fact, central body fat distribution is correlated with age, gender, and sex hormones (22, 23).
Our results show that BP values were higher in CS and AI than in C and that 80% of CS and 50% of AI were hypertensive. Lipid profiles showed that HDL cholesterol levels were lower and triglyceride mean values higher in CS and AI than in C. The AUCs for glucose and insulin after OGTT were also increased in CS and AI. These observations are in agreement with some recent data that described a high prevalence (61%) of abnormal glucose tolerance in AI (5). The authors found that the prevalence was lower than that observed for CS but higher than expected in a population of similar age; therefore, they suggest that patients with AI should be tested for glucose tolerance. They also hypothesize that the adrenal tumor acquires some degree of autonomy after reaching a given size, as suggested by the correlations between tumor size and serum cortisol and UFC after DXM (5). We did not find any relationship between tumor size or steroid pattern and body composition; however, AI had UFC values slightly higher than C and the normal range, but cortisol suppression after DXM was normal in all subjects. Even if some patients with AI had UFC excretion above normal, this was a single and isolated alteration of the HPA axis function that did not identify them as having PCCS. Indeed, although the definition of PCCS is not standardized, we base our own definition on the finding of at least two abnormal tests of HPA axis function in patients with AI but without classic clinical stigmata of hypercortisolism, in accordance with the criteria of the National Italian Study Group on Adrenal Tumors (3). Patients who according to these criteria qualified for the definition of PCCS were not included in the present study. The high percentage of abnormal UFC in AI may suggest a lack of specificity of this test in diagnosing hypercortisolism. In fact, it is probable that RIA methods overestimate true UFC due to the presence of cross-reacting material (24). In support of this hypothesis we found no differences in body composition and metabolic features when, in a subanalysis, AI with UFC levels above normal were compared with AI with normal UFC levels.
It is well established that central fat deposition, hypertension, and low HDL are important predisposing factors for cardiovascular disease; therefore, AI subjects could be at greater risk for cardiovascular disease than the general population. Evaluation of body fat depots, which, when increased, are closely associated with the insulin-resistance syndrome, is important for the prevention of cardiovascular disease. DEXA is useful for the measurement of total and regional body fat; combination of DEXA results with simple anthropometric parameters (BMI, waist, and WHR) can provide additional data to evaluate risk factors. Patients with PCCS also are at risk for hypertension, diabetes, obesity, or osteoporosis (25, 26, 27, 28), and the prevalence of PCCS in obese patients with poorly controlled diabetes appears to be considerably higher than commonly believed (26). For these reasons, it would also be interesting to evaluate in these patients body composition and fat distribution.
In conclusion, body composition and metabolic features in AI indicate that these women are at an intermediate state between normal and pathological. These alterations suggest that subtle disturbances of steroid secretion are probably present also in AI, although they cannot yet be detected with a sufficient degree of specificity. Because the assessment of UFC by RIA lacks specificity (24), the hypothesis that a subtle cortisol hypersecretion is present also in apparently nonhypersecretory AI could better be proven by a more accurate method of evaluating cortisol secretion, such as by HPLC (29). Furthermore, an evaluation during a long-term follow-up of nonoperated and of adrenalectomized patients could allow us to determine whether subtle hormonal abnormalities linked to the tumor are the main factor responsible for the alterations described in this study.
Acknowledgments
We thank Prof. Robert Collu for critical review of the manuscript.
Footnotes
This work was supported in part by Ministero dell’Università e della Ricerca Scientifica e Tecnologica Grant 9806261488.
Abbreviations: AI, Adrenal cortical incidentaloma; AUC, area under the curve; BMC, bone mineral content; BMI, body mass index; C, control; CS, Cushing’s syndrome; CT, computed tomography; DBP, diastolic blood pressure; DEXA, dual-energy x-ray absorptiometry; DXM, dexamethasone; HPA, hypothalamic–pituitary–adrenal; MRI, magnetic resonance imaging; n.r., normal range; OGTT, oral glucose tolerance test; PCCS, preclinical CS; SBP, systolic blood pressure; TB, total body; UFC, urinary free cortisol; WHR, waist to hip ratio.
Received April 3, 2001.
Accepted July 26, 2001.
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) and the SEM (•) in women with
Cushing’s syndrome (CS) or adrenal incidentaloma (AI) and in healthy
control women (C). *, P < 0.05 vs.
C; 
, P < 0.05 vs. AI; n.r.,
normal range.