Adrenal Adenoma Resection and Weight Loss

Vladamir is a 75-year-old male with a history of high blood pressure, atrial fibrillation and difficulty losing weight.  He is exceedingly cool and managed hard rock bands until his retirement several years ago.  Despite his best efforts, his weight crept up by about 50 pounds over a 2-3 year period, and his blood pressure stubbornly refused to normalize despite multiple medications. In the setting of resistant blood pressure readings, I checked a hormone called aldosterone, which is a relatively common hormonal cause of hypertension (high blood pressure).

Aldosterone is a hormone that helps regulate blood pressure by controlling the balance of sodium and potassium in the body.  Aldosterone is produced by the adrenal glands, which sit on top of the kidneys.  Excess aldosterone can lead to high blood pressure and fluid buildup in body tissues.

Vladamir’s aldosterone was clearly elevated, so I sent him for a CT scan of his adrenal glands.  The CT scan revealed a 1.9cm left adrenal adenoma.  Whenever there is a mass in the adrenals, the endocrinologist needs to check other hormones that can potentially be oversecreted by the adrenal adenoma. These hormones include adrenaline (we call it metanephrine) and cortisol.  His adrenaline levels were normal, but to my surprise, Vladamir’s cortisol levels were clearly elevated as well, giving him a secondary diagnosis of subclinical Cushing’s syndrome. 

Subclinical Cushing’s syndrome presents with excess cortisol production, typically from an adrenal tumor, in the absence of the classical signs and symptoms of Cushing’s (buffalo hump, mood face, acne, stretch marks, easy bruising).

Subclinical Cushing’s syndrome is a relatively newly discovered condition.  It was first described in 2000, in a large Italian study of over 1000 patients with incidentally found adrenal masses.[1] In this study, the incidence of subclinical Cushing’s syndrome was greater than 9%.  Subsequent studies have placed the accepted incidence at roughly 5-30%.  Since adrenal incidentalomas are discovered in up to 7% of adults, the prevalence of subclinical Cushing’s syndrome is as high as 2%.  There is an increased risk of weight gain, high blood pressure and atrial fibrillation with Cushing’s syndrome (all conditions plaguing Vladamir).  There is also a higher risk of diabetes and bone loss.

I sent Vladamir to one of my favorite adrenal surgeons, Dr. James Lee, at Columbia where he had a left adrenalectomy (adrenal adenoma resection).  Within 6 months of the surgery, Vladamir lost 40 pounds without lifestyle changes or new medications.  In addition, I was able to stop 2 out of 3 of his blood pressure medications.  Finally, his atrial fibrillation, which recurred shortly after an ablation in 2023, finally went into remission.  With his newfound health, Vladamir and his wife are back out on the town enjoying the hard rock scene in New York City.

[1] Subclinical Cushings. Endocrinology and Metabolism Clinics. Volume 29, Issue 1 p43-56March 01, 2000