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Laparoscopic surgical removal of the adrenal tumor

Standardized medical treatment of hypertension by SAHR.

Standardized anti-hypertensive drug regimen has been established according to international recommendations and includes the following steps:

* step 1: Angiotensin converting enzyme inhibitor (ACE-I) or angiotensin II receptor antagonist (ARBs) at half-dose (Ranipril 5mg or Ibesartan 150 mg )
* step 2: CEI or ARA2 at full dose (Ranipril 10 mg or Ibesartan 300 mg)
* step 3: Add-on of Amlodipine 10 mg or Diltiazem LP 300 mg
* step 4: Add-on of Indapamide LP 1.5 mg
* step 5: Add-on of Spironolactone 25 mg
* step 6: Add-on of Bisoprolol 10 mg
* step 7: Add-on of Prazosine LP 5mg/day.

Standardized medical treatment of hypertension by SAHR

Eric FRISON, Dr

The general objective is to evaluate the consequences of surgical removal of SCSI on hypertension and cardiovascular risk factors in order to determine on an evidence-based basis if surgical excision of SCSI is preferable to an intensive medical regimen in patients with hypertension.

Adrenal incidentalomas are unsuspected adrenal masses found during abdominal imaging. With the widespread use of computed tomography and MRI, adrenal incidentalomas are found in approximately 2% of patients. In an endocrinology setting, the majority of these masses are benign adenomas of the adrenal cortex. Approximately 10% of these adenomas display little excess of cortisol secretion associated to some degree of secretory autonomy but that are insufficient to generate overt Cushing's syndrome ("Subclinical Secreting Cortisol incidentalomas" or SCSI). However, hypertension and to a lesser degree obesity and impaired glucose tolerance are very frequent amongst patients with SCSI. The hypothesis that the mild hypercortisolism associated with SCSI is responsible for these clinical consequences is substantiated by few studies describing improvement after resection of SCSI. However, these studies were retrospective, uncontrolled and suffered from imprecision and numerous methodological bias. Thus, whether surgery is more beneficial than medical treatment is currently unknown and there is no consensus on the appropriate treatment for SCSI.

Patient selection Run-In period. Discontinuation of previous antihypertensive treatments and prescription of a standardized anti-hypertensive drug regimen (SAHR). Monthly Blood Pressure (BP) measurement using home BP monitoring. The duration of the Run-In periods will be ≤ 6 months and will end when BP will be controlled with the SAHR at two consecutive visits.

End of RI Second endocrine assessment for eligibility Randomization (Ra): 24h Ambulatory BP measurement, anthropometric and metabolic evaluation. Quality of life and cognition questionnaires. Randomization in 2 groups : Gr 1 Treatment group : Surgery followed by intensive medical care ; Gr 2 : Control Group : intensive medical care only.

Ra + 1Mo: Surgery in Group 1 Ra + 2.5 Mo to Ra + 13 Mo: 6 weeks interval follow-up Evaluation of home BP monitoring and adaptation of the SAHR. A step by step reduction of the SAHR will be attempted in the two patient groups at Ra+2.5Mo. A second attempt will systematically be performed in both groups at Ra+8.5 Medical evaluation of associated metabolic conditions (obesity, diabetes, dyslipidemia) and adaptation of treatments Record of medical events and side effects of treatments Ra + 13Mo: Final evaluation. Endocrine assessment. 24h Ambulatory BP measurement, anthropometric and metabolic evaluation. Quality of life and cognition questionnaires.

Surgery of Subclinical Cortisol Secreting Adrenal Incidentalomas

Treatment response will defined as a reduction of at least 1 step of SAHR at the end of the study, with BP maintained within the study objectives (\<135 mm Hg systolic and \<85 mm Hg diastolic) according to self-measurement at home.

age, family history of hypertension, duration of hypertension, kidney function, biochemical endocrine abnormalities, urinary steroid profile

Comparison of the two therapeutic strategies with regard to cardiovascular risk factors/markers: BMI, body composition evaluated by DEXA, abdominal fat evaluated on CT-scan, fasting blood glucose and insulin, HbA1C, HOMA-IR (homeostasis model of assessment of insulin resistance) and OGTT (oral glucose tolerance test), blood lipids, pro-inflammatory adipokines

Comparison of the two therapeutic strategies with regard to quality of life

University Hospital, Bordeaux

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Surgery of Subclinical Cortisol Secreting Adrenal Incidentalomas	NCT02364089	Adrenal Inciden...	Laparoscopic su... Standardized me...	18 Years - 80 Years	University Hospital, Bordeaux
Surgery of Subclinical Cortisol Secreting Adrenal Incidentalomas	NCT02364089	Adrenal Inciden...	Laparoscopic su... Standardized me...	18 Years - 80 Years	University Hospital, Bordeaux

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