CONGENITAL ADRENAL HYPERPLASIA DUE TO 21-HYDROXYLASE DEFICIENCY PRESENTING AS ADRENAL INCIDENTALOMA: A SYSTEMATIC REVIEW AND META-ANALYSIS
Henrik Falhammar, MD, PhD, FRACP1,2; David J. Torpy, MBBS, FRACP, PhD3
ABSTRACT
Objective: Adrenal incidentalomas (AIs) may be due to congenital adrenal hyperplasia (CAH) due to homozygous CYP21A2 mutations, or perhaps from heterozygous carri- er status. It is unclear if genetic or biochemical testing of CYP21A2 status in AI is justified, despite its potential for avoiding adrenal crises in those referred for adrenalectomy.
Methods: We systematically searched PubMed/ MEDLINE for articles published up to October 19, 2015 containing all terms associated with adrenal tumors and CAH. Meta-analyses were used to estimate the CAH or carrier prevalence in AI and assess clinical factors that may guide testing.
Results: Thirty-six publications were included. Of AI patients biochemically screened for CAH, 58/990 (5.9%) were diagnosed with CAH. Genetic screening of all AIs revealed only 2/252 (0.8%) with clear CAH. The carrier prevalence was 10.2% (36/352). The rate of 0.8% (8/1,000) genetically confirmed CAH is higher than the 1/15,000 affected by classic CAH or 1/1,000 by nonclassic CAH in the Caucasian population. The rate of heterozygous CYP21A2 mutation frequency is similar to those in reported in population studies. Levels of both basal and stimulated 17-hydroxyprogesterone positively correlated with AI diam-
From the 1Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; 2Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; 3Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA, Australia.
Address correspondence to Associate Professor Henrik Falhammar, MD, PhD, FRACP; Department of Molecular Medicine and Surgery, D02:04, Karolinska University Hospital; SE-171 76 Stockholm, Sweden.
E-mail: henrik.falhammar@ki.se.
Published as a Rapid Electronic Article in Press at http://www.endocrine practice.org on February 26, 2016. DOI:10.4158/EP151085.RA
To purchase reprints of this article, please visit: www.aace.com/reprints. Copyright @ 2016 AACE.
eter. Although bilateral incidentalomata were frequent in CAH, their presence did not predict CYP21A2 status.
Conclusion: The presence of an AI does not increase the probability of detection of CAH or CYP21A2 carrier status to the extent routine genetic testing is justified. Screening with 17-hydroxyprogesterone levels appears to lack specificity in the setting of an AI. CYP21A2 muta- tion analysis is probably the only reliable method for CAH diagnosis in AIs. (Endocr Pract. 2016;22:736-752)
Abbreviations:
ACC = adrenocortical carcinoma; ACTH = adrenocor- ticotropic hormone; AI = adrenal incidentaloma; CAH = congenital adrenal hyperplasia; NCAH = nonclassic congenital adrenal hyperplasia; 17OHP = 17-hydroxy- progesterone; SV = simple virilizing.
INTRODUCTION
An adrenal incidentaloma (AI) is an asymptomatic adrenal tumor discovered on an imaging test performed for a nonadrenal indication. Increased use of computed tomogra- phy, ultrasonography, and magnetic resonance imaging has led to higher reported rates of AI. AI prevalence increases with age, from <1% of young individuals to 15% in >70 years (1). In early series, 71 to 84% of AIs were nonfunc- tional adenomas, and 1.2 to 11% were adrenocortical carci- noma (ACC) (2). However, in recent unselected series, 85 to 94% of AIs are nonfunctional tumors, and 0 to 0.6% were ACC (3,4). Thus, very few AIs require surgical excision.
Congenital adrenal hyperplasia (CAH) is due to impaired function of the 21-hydroxylase enzyme in 95% of cases, leading to impaired cortisol and aldosterone synthesis with excess production of precursors such as 17-hydroxyprogesterone (17OHP) and androgens (5-7). CAH develops in individuals with homozygous loss-of- function mutations of the gene encoding 21-hydroxylase (CYP21A2). There are various mutations, and a good genotype-phenotype correlation exists (8), at least in the
severe and mild forms; the correlation in the intermediate forms is poorer. It is possible that non-CYP21A2 genetic or epigenetic factors may contribute to phenotypic variations in CAH. Heterozygous carriers of CYP21A2 mutations are asymptomatic, hence CAH is autosomal recessive. Diagnosis of CAH requires CYP21A2 gene sequencing or measurement of 17OHP either under basal conditions or more definitively, after adrenocorticotrophic hormone (ACTH) injection (9).
Life-long glucocorticoid replacement is usually required for survival in classic CAH (i.e., the salt-wasting [SW] and the simple virilizing [SV] phenotypes), while enzyme activity is only moderately reduced in the nonclas- sic form (NCAH), leading to hyperandrogenic symptoms (5-7,10,11). The presentation of NCAH can be identical to that of the common polycystic ovary syndrome (PCOS) (12,13), leading to misdiagnosis (11).
Classic CAH due to 21-hydroxylase deficiency has been estimated to occur in 1 in 15,000 live-births (0.007%) according to data from millions of participants in neonatal screening programs worldwide (6). The carrier frequency of a classic CAH mutation is 1 in 60 individuals (1.7%). However, NCAH is far more common with frequencies between 0.1 and 3.7% depending on ethnicity (11), corre- sponding to a carrier prevalence of 1 in 16 to 1 in 3 (6.3- 33%). Thus, CYP21A2 mutations are common, but classic CAH is uncommon.
The development of adrenal tumors in CAH is thought to be due to pituitary ACTH hypersecretion, resulting in adrenal cortex hyperplasia (5) and eventual tumor forma- tion (14-16). Adrenal tumors in known CAH patients has been reported at 11 to 82% (14,17,18), with both tumor size and adrenal volumes being positively correlated with 17OHP and pregnanetriol levels (17,18). However, the adrenal tumor size has not consistently been proven to correlate with 17OHP (14). Moreover, adrenal nodules have been reported in 45% of CAH carriers (14). Thus, undiagnosed CAH individuals and even CAH carriers may be overrepresented in cohorts of patients with AIs (11). CAH screening has been recommended in children with AI (10). Adrenalectomy without knowledge of CAH may lead to adrenal crisis due to lack of a normal cortisol response to surgery. However, it is unclear if biochemi- cal or genetic testing is justified in adult AI patients to detect undiagnosed CAH. We performed a meta-analysis to evaluate the prevalence of CAH or carrier status in cohorts of AIs and detect clinical clues that may guide CAH testing.
METHODS
Search Strategy and Selection Criteria
Systematic searches for eligible studies were conduct- ed using PubMed/MEDLINE up to October 19, 2015, using the following strategy: (“adrenal incidentaloma”[All
Fields] OR “adrenal incidentalomas”[All Fields] OR “adre- nal tumor”[All Fields ] OR “adrenal tumors”[All Fields] OR “adrenal tumour”[All Fields] OR “adrenal tumours”[All Fields] OR “adrenal nodule”[All Fields] OR “adrenal nodules”[All Fields] OR “adrenal neoplasm”[All Fields] OR “adrenal mass”[All Fields] OR “adrenal masses”[All Fields]) AND (“congenital adrenal hyperplasia”[All Fields] OR “21-hydroxylase deficiency”[All Fields] OR “CYP21A2”[All Fields]). In addition, the reference lists of the retrieved full-text studies were scanned to identify other potentially relevant studies. The relevance of the articles was first determined by reviewing the title, then the abstract, and if necessary, full-text retrieval. No language restriction was applied. Studies were eligible for inclu- sion if patients had presented as AI with abnormal 17OHP levels (basal and/or stimulated), CYP21A2 mutation, and/ or had a clear diagnosis of CAH due to 21-hydroxylase deficiency. CAH was diagnosed if 17OHP was ≥30 nmol/L and/or CYP21A2 mutations were found on both alleles. Carriers were identified by a single allele CYP21A2 muta- tion as 17OHP levels are unreliable for carrier identifica- tion (19,20). Studies were excluded if adrenal tumors had been found in the work-up for a suspected adrenal tumor or in the staging and follow-up of a known malignancy. The following information was extracted from each study: first author, publication year, country, title, diagnostic strat- egy for CAH, number of CAH cases or carriers of total screened AI case, and genetic analysis. The following information was also extracted from the CAH cases: age and sex, ethnicity (if not clearly described the ethnicity was assumed to be the same as the majority in that particular country), number of offspring, signs of increased andro- gens, maximum diameter of the largest AI, bilateral AIs, basal and stimulated 17OHP and cortisol values, CYP21A2 mutations, diagnosis, and treatment.
A quality assessment of the studies of AIs with screen- ing for CAH or carrier status was incorporated with the strength and limitations noted in free text. Assessment using, the Newcastle-Ottowa Scale (www.ohri.ca/ programs/clinical_epidemiology/oxford.asp), for example, was considered inappropriate as it was not developed to study prevalence studies or case reports. Studies were considered of high quality when confirmation of CAH was done with CYP21A2 mutation analysis, basal and stimu- lated 17OHP were measured and reported in detail, and an unselected group presenting with AI was used. There is a risk of publication bias when a study is retrospective or when no CAH case was found. It is difficult to know exactly how much publication bias there was, but as there were quite a few studies with negative findings (both larger and smaller studies), and many did not have the prevalence of CAH as the primary outcome, we considered the impact to be low. Because we did not have any language exclusion and all appropriate studies were retrieved, other associated biases were also deemed low.
We did not conduct formal weighting of the stud- ies, but when calculating the prevalence of CAH in AIs we did 4 different calculations with increasing quality of the analysis: including all studies, including only studies where at least CYP21A2 mutations were done in CAH, including only studies where all AIs had CYP21A2 muta- tions analysis done, and including only studies where all AIs had CYP21A2 mutations analysis done and only clear homozygotes were diagnosed with CAH. If the same group had presented several studies, effort was made to exclude repeat reports of the same patients. Biochemical parameters were converted and reported in SI units. The meta-analyses considered biochemical and genetic CAH diagnoses separately. Both authors did the litera- ture search independently, and included and excluded articles were agreed on together with reference to the criteria described. The systematic review and meta- analyses were performed according to the guidelines in the PRISMA statement (21) (see Supplemental Table: PRISMA Checklist).
Statistical Analysis
Results were calculated after pooling the results of all studies. Results are presented as the mean ± SD and/ or median and range. In 2 studies, not all individual data could be extracted (1 sex and age, 1 17OHP values), so the mean was used and each individual was assumed to have the mean value, except in regression analysis. Comparisons between 2 groups were made using the unpaired t test or the Mann-Whitney rank-sum test (if not normally distributed). Fisher exact test was used in frequency table calculations. Correlations between variables were assessed using linear regression analysis. Statistical significance was defined as P <. 05. Data were analyzed using SigmaStat for Windows (Systat Software, Inc, San Jose, CA).
RESULTS
Study Inclusion and Exclusion; Summative Data
The PubMed/MEDLINE searches identified 171 publications, of which 36 were considered eligible for inclusion. Twenty studies reported on cohorts of AIs where the number of CAH cases or carriers were investigated (4,22-40), and 16 were case reports or series (15,41-55). Studies with recruitment overlap were excluded, such as those evident in a case report (56), also seen in other reports (4,15), and 1 study (57) that contained some patients from a more detailed study (25). Reviewing the reference lists of all retrieved articles did not result in any additional studies. The detailed procedure used to include or exclude articles is presented in Figure 1.
The characteristics of all AI cohort studies are report- ed in Table 1. Quality assessments are described in Table 2. The characteristics of each individual CAH case are shown in Table 3.
Meta-Analysis Results
Clinical, biochemical, genetic, and imaging data of individual CAH cases are shown in Table 4. CAH was diagnosed on biochemical or genetic criteria in 58/990 (5.9%) of AI patients. Of these patients, 5 (0.8%) had CYP21A2 mutation analysis confirming CAH. Taking into account those studies with consecutive CYP21A2 testing, 5/352 (1.4%) had CAH. However, 1 study (22) tested for 3 specific NCAH mutations, limiting the capacity to exclude CYP21A2 mutations. Excluding this study, 2/252 (0.8%) of AI patients had CAH. The carrier prevalence was 10.2% (36/352) (Table 1).
Two studies compared CYP21A2 mutation frequency in AIs with healthy controls from the same geographical area. One reported that 9.6% of patients with AI carried 1 of 6 measured mutations compared to 10.3% of controls (24), while the other reported 8% carrying 1 of 3 measured mutations compared to 0% in controls (22).
Detailed individual clinical data were unavailable in many reports. The mean age was 57.5 + 11.8 years, and slightly less than half were male. However, 19% of the males were 46XX males, indicating severe hyperandrogen- ism. The studies did not describe rates of hyperandrogen- ism; only 6 of 10 female cases with detailed examinations had hyperandrogenic features. The majority of cases were Caucasian and median number of offspring was one. The median size of the AIs was 31.5 mm (range 10-150), and 35% had bilateral AIs (37 mm, range 12-150).
Median 17OHP levels rose from 24.8 to 61 nmol/L and cortisol levels from 278 to 428 nmol/L after ACTH injection. The most common genotypes in CAH patients were I2 splice, I172N and V281L with similar frequency; however, only 17 were genetically verified (23%), and the remainder either had no CYP21A2 mutations detected (4%, stimulated 17OHP levels between 17-57 nmol/L), or did not have genetic testing (73%). Of all individual mutations reported in the CAH cases, 9 were mild and 18 were severe (i.e., would result in a classic CAH phenotype if found on both alleles). One-fifth was diagnosed with SVCAH and the rest NCAH. In those with treatment details reported, half were taking glucocorticoids and half had undergone adrenalectomy.
Comparing genetically confirmed CAH and CYP21A2 mutation negative cases, those with genetically confirmed CAH had larger AIs, higher basal and stimulated 17OHP levels and lower stimulated cortisol levels. Correlations were found between basal 17OHP level and the largest diameter of the AI (r = 0.356, P = . 015), but not between stimulated 17OHP and the AI size (r = 0.248, P = . 100) (Fig. 2). However, when all cases with 17OHP >300 nmol/L were excluded (i.e., the cut-off usually used for diagnosing classic CAH) (10), significant correlations were found both with basal and stimulated 17OHP and AI size (r = 0.743 and r = 0.593, respectively, both P <. 001; Fig. 2). A trend was found between basal cortisol levels and
the largest diameter of the AI (r = - 0.402, P = . 088), which became significant with stimulated cortisol levels (r =- 0.579, P = . 038).
DISCUSSION
This is the first systematic review and meta-analysis of the relationship between AIs and CAH as determined by CYP21A2 mutation status (CAH or carriers) or 17OHP levels. The frequency of biochemically diagnosed CAH in AI cohorts was 5.9% (n = 990); however among those genetically assessed, only 0.8% (n = 662) had CAH. The discrepancy in biochemical and genetic diagnosis is likely to reflect low specificity of 17OHP levels. Basal 17OHP levels correlated significantly with AI tumor size. Approximately 10% of patients with AI were carriers of a CYP21A2 mutation. The rate of 0.8% (8/1,000) genetically confirmed CAH is higher than the 1/15,000 affected by
classic CAH or 1/1,000 by NCAH in the Caucasian popu- lation (6,11). In contrast, the carrier prevalence in AIs is similar to the background prevalence.
CAH diagnosis was made by basal and/or stimulated 17OHP levels and/or CYP21A2 mutation analyses. A basal 17OHP level <6 nmol/L is said to exclude CAH in adults (6), and a basal 17OHP value >15 nmol/L or a stimulated value >30 nmol/L is considered diagnostic for CAH (9,58). Carriers have a stimulated 17OHP value between 6 and 30 nmol/L, but there is overlap between carriers and normal subjects (5). However, these 17OHP ranges have been developed without the inclusion of AI patients, in whom tumors may be associated with altered steroidogenesis lead- ing to high 17OHP levels without heritable CAH due to homozygous germline CYP21A2 mutations. This systematic review showed exaggerated stimulated 17OHP levels (range 31-57 nmol/L) in 3 AI patients in whom no mutations could be detected on CYP21A2 mutation analysis.
Identification
171 articles identified through database searching
0 additional articles identified through scanning reference lists
171 articles after duplicates removed
Screening
171 articles screened
110 articles excluded
25 full-text articles excluded
Eligibility
61 full-text articles assessed for eligibility
6 did not try to diagnose CAH and/or no individual 17OHP levels shown
6 not presented with AI 5 previous CAH diagnosis
36 articles included in qualitative synthesis
5 reviews or comments
2 data overlapping with other articles
1 11₿ hydroxylase deficiency
Included
20 articles included in the meta-analysis of prevalence of CAH in AIs
28 articles included in the meta-analysis of the characteristics of CAH patients
9 articles included in the meta-analysis of prevalence of genetically verified CAH in AIs
12 articles included in the meta-analysis of the characteristics of genetically verified CAH patients
| Table 1 Studies of AIs with Screening for CAH due to 21-Hydroxylase Deficiency and/or Carrier Status | |||||||
|---|---|---|---|---|---|---|---|
| First author (reference) | Year | Country | Title | Screening method | CAH cases of total screened AI cases | CYP21A2 mutations verification | Carrier (1 CYP21A2 mutation/AI cases) |
| Patrova (4) | 2015 | Sweden | Clinical outcomes in adrenal incidentaloma - experience from one centre | Basal 17OHP or u-steroid profile | 2/68 (2.9%) | Yes | ND |
| Kiedrowicz (22) | 2015 | Poland | Prevalence and clinical outcome of CYP21A2 gene mutations in patients with nonfunctional adrenal incidentalomas | Basal and stimulated 17OHPª CYP21A2 mutation analysis for P30L, P453S, and V281L | 3/100 (3.0%) | No | 8/100 (8.0%) |
| Askitis (23) | 2015 | Germany | Complete evaluation of adrenal tumours in a tertiary care institution in Thuringia, Germany | Basal 17OHP | 1/24 (4.2%) | ND | ND |
| Doleschall (24) | 2014 | Hungary | Common genetic variants of the human steroid 21-hydroxylase gene (CYP21A2) are related to differences in circulating hormone levels | CYP21A2 mutation analysis for the 6 most common mutations | 0/125 (0%) | Yes | 12/125 (9.6%) |
| Wagnerova (25) | 2008 | Slovakia | The prevalence of 21-hydroxylase deficiency in adrenal incidentalomas - hormonal and mutation screening | Stimulated 17OHP | 5/40 (12.5%) | No | ND |
| Chervin (26) | 2007 | Argentina | Estudio de 34 pacientes con incidentaloma suprarrenal [A study of 34 cases of adrenal incidentaloma] Spanish | Basal 17OHP (9/34) | 1/34 (2.9%) | ND | ND |
| Patócs (27) | 2002 | Hungary | Hormonal evaluation and mutation screening for steroid 21-hydroxylase deficiency in patients with unilateral and bilateral adrenal incidentalomas | Stimulated 17OHP & CYP21A2 mutation analysis for the 8 most common mutations | 1/50 (2.0%) | Yes | 7/50 (14.0%) |
| Baumgartner- Parzer (28) | 2002 | Austria | Increased prevalence of heterozygous 21-OH germline mutations in patients with adrenal incidentalomas | CYP21A2 mutation analysis | 1/50 (2.0%) | Yes | 8/50 (16.0%) |
| Grossrubatscher (29) | 2001 | Italy | The natural history of incidentally discovered adrenocortical adenomas: a retrospective evaluation | Basal and stimulated 17OHP | 10/53 (18.9%) | ND | ND |
| Ozgen (30) | 2001 | Turkey | Low basal androstenedione levels plus augmented 17alpha-hydroxyprogesterone and low dehydroepiandrosterone sulfate responses to adrenocorticotropic hormone stimulation in patients with adrenal incidentaloma | Basal and stimulated 17OHP | 12/23 (52.2%) | ND | ND |
| Maser-Gluth (31) | 2000 | Germany | Metabolism of glucocorticoids and mineralocorticoids in patients with adrenal incidentalomas | Stimulated 17OHP & CYP21A2 mutation analysis | 0/25 (0%) | Yes | 1/25 (4.0%) |
| Beuschlein (32) | 1998 | Germany | Steroid 21-hydroxylase mutations and 21-hydroxylase messenger ribonucleic acid expression in human adrenocortical tumors | CYP21A2 mutation analysis | 0/2 (0%) | Yes | 0/2 (0.0%) |
| Table 1 Continued | |||||||
|---|---|---|---|---|---|---|---|
| Barzon (33) | 1998 | Italy | Incidentally discovered adrenal tumors: endocrine and scintigraphic correlates | Basal and stimulated 17OHP | 1/202 (0.5%) | Yes | ND |
| Bondanelli (34) | 1997 | Italy | Evaluation of hormonal function in a series of incidentally discovered adrenal masses | Basal and stimulated 17OHP | 2/38 (5.3%) | ND | ND |
| Bernini (35) | 1996 | Italy | 17-Hydroxyprogesterone response to ACTH in bilateral and monolateral adrenal incidentalomas | Basal and stimulated 17OHP | 6/27 (22.2%) | ND | ND |
| Terzolo (36) | 1996 | Italy | Different patterns of steroid secretion in patients with adrenal incidentaloma | Basal and stimulated 17OHP | 6/20 (30%) | ND | ND |
| Del Monte (37) | 1995 | Italy | Increased 17 alpha-hydroxyprogesterone response to ACTH in silent adrenal adenoma: cause or effect? | Basal and stimulated 17OHP | 0/15 (0%) | ND | ND |
| Ambrosi (38) | 1995 | Italy | Abnormalities of endocrine function in patients with clinically "silent" adrenal masses | Basal and stimulated 17OHP | 0/30 (0%) | ND | ND |
| Seppel (39) | 1994 | Germany | Augmented 17 alpha-hydroxyprogesterone response to ACTH stimulation as evidence of decreased 21-hydroxylase activity in patients with incidentally discovered adrenal tumours ('incidentalomas') | Basal and stimulated 17OHP | 7/52 (13.4%) | ND | ND |
| Turton (40) | 1992 | USA | Incidental adrenal nodules: association with exaggerated 17-hydroxyprogesterone response to adrenocorticotropic hormone | Basal and stimulated 17OHP | 0/12 (0%) | ND | ND |
| Prevalence of CAH in AIs (all studies) | 58/990 (5.9%) | ||||||
| Prevalence of CAH in AIs (at least CYP21A2 mutations done in CAH) | 5/662 (0.8%) | ||||||
| Prevalence of CAH in AIs (all AIs had CYP21A2 mutations analysis done) | 5/352 (1.4%) | ||||||
| Prevalence of CAH in AIs (all AIs had CYP21A2 mutations analysis done and only clear homozygous diagnosed with CAH) | 2/252 (0.8%) | ||||||
| Prevalence of carrier (one CYP21A2 mutation) in AIs | 36/352 (10.2%) | ||||||
| Abbreviations: ACTH = adrenocorticotropic hormone; AI = adrenal incidentaloma; ND = not done; 17OHP = 17-hydroxyprogesterone a Stimulated 17OHP was only performed in those with a CYP21A2 mutation. The diagnosis was assumed to be CAH if 17OHP was ≥30 nmol/L. | |||||||
| Table 2 Quality Assessment of the Studies of AIs with Screening for CAH Due to 21-Hydroxylase Deficiency and/or Carrier Status | |||
|---|---|---|---|
| First author (reference) | Year | Strength | Limitations (and comments) |
| Patrova (4) | 2015 | All AI cases presented consecutively to 1 center (i.e., unselected cases). All CAH cases were verified with CYP21A2 mutation analysis. The CAH cases are described in great details in other publications. | Retrospective study. Only 68/637 (11%) of AIs were screened. Basal 17OHP was used in 47 and/or u-steroid profile in 26. |
| Kiedrowicz (22) | 2015 | AI cases consecutively referred to 1 center. All were screened with CYP21A2 mutation analysis, those with mutations had stimulated 17OHP done. Healthy neonates from the same hospital had also CYP21A2 mutation analysis. | Only NFAI included. Unclear if any more selection. Only three CYP21A2 mutations were search after (the typical NCAH ones, i.e., P30L, V281L, P453S). Three of the carriers had a stimulated 17OHP >30 nmol/L indicating NCAH but may have had a nonscreened CYP21A2 mutations on the other allele. Remarkable that no healthy neonate had any of the search mutations. Just a few details taken from a table of the CAH cases (those with 17OHP >30 nmol/L). |
| Askitis (23) | 2015 | All AI cases presented consecutively to 1 center (i.e., unselected cases). | Retrospective study; 19.0% of all AIs may not have been AIs (abdominal X-ray due to hypertension or weight gain). Only bilateral AIs 24/187 (12.8%) were screened with basal 17OHP. No CYP21A2 mutation analysis. No detailed description of 17OHP values or patient diagnosed with CAH. |
| Doleschall (24) | 2014 | All were screened with CYP21A2 mutation analysis. In healthy controls 7/68 (10.3%) had a mutation (P = NS, compared to AI) | Retrospective study. Only NFAI included. The screening was done to exclude carriers and was not a main aim of the study. |
| Wagnerova (25) | 2008 | Stimulated 17OHP CYP21A2 mutation analysis | All individuals underwent a careful hormonal evaluation. Only stimulated 17OHP on 18/40 (45%) of AIs. Used an increment of 17OHP>12 mmol/L or a final value >30 nmol/L as an indication of CAH. CYP21A2 mutation analysis in those with increased 17OHP values. |
| Chervin (26) | 2007 | All cases presented consecutively at 1 center (i.e., unselected cases). | Retrospective study. Unclear why only some had basal 17OHP done. Only 34 cases with AI presented during 9 years. No CYP21A2 mutation analysis. No detailed description of the NCAH case. |
| Patócs (27) | 2002 | Stimulated 17OHP. All were screened with CYP21A2 mutation analysis. | Bilateral AI cases and cases that had had adrenalectomy were selected, only NFAI was included. The ACTH stimulation test used 2 mg intramuscular at 2:00 PM, 17OHP (and cortisol) measured next day at 8-9 AM. No detailed description of the NCAH case. |
| Baumgartner- Parzer (28) | 2002 | Screening was done with CYP21A2 mutation analysis for the 11 most common mutations and Southern blot. | Nonconsecutive AI cases, only NFAI were included. 17OHP only done in the CAH case. Only few details of the CAH case. |
| Grossrubatscher (29) | 2001 | Most had both basal (52/53) and stimulated 17OHP (48/53). | Retrospective study. Only NFAI. No CYP21A2 mutation analysis. Only few details of the NCAH cases. |
| Ozgen (30) | 2001 | Basal and stimulated 17OHP. Prospective study. | No CYP21A2 mutation analysis. The 17OHP values taken from figure. No detailed description of CAH cases just summaries. In the abstract and results, it is reported that 16 patients were diagnosed with NCAH, in table and figures only 12 patients can be seen. Selection of the AIs? |
| Maser-Gluth (31) | 2000 | Stimulated 17OHP CYP21A2 mutation analysis. | Selected 29 cases of NFAI and 6 cases of SCS, of the NFAI, 25 had ACTH stimulation test. Unclear if any/how many had 17OHP >30 nmol/L. |
| Beuschlein (32) | 1998 | CYP21A2 mutation analysis in both leukocytes and tumor tissue. | Selected 19 cases of adrenalectomy in different adrenal tumors. NFAI n = 2 (no mutations), cortisol-producing adenoma n=7 (carrier n = 1 [V281L]), aldosterone-producing adenoma n = 6 (no mutations in leukocytes), adrenal carcinoma n = 4 (carrier n = 1 [V281L]) |
| Table 2 Continued | |||
| Barzon (33) | 1998 | Basal and stimulated 17OHP. Consecutive patients with AI. CAH case had CYP21A2 mutation analysis. | The 17OHP values are not reported in detail. Unclear if any of the patients had missing data concerning 17OHP. Only few details of the CAH case. |
| Bondanelli (34) | 1997 | Basal and stimulated 17OHP. Consecutive patients with AI. | No details of the CAH cases, data on 17OHP and how many CAH cases taken from figure in the article. No CYP21A2 mutation analysis. |
| Bernini (35) | 1996 | Basal and stimulated 17OHP. | Selected patients with AI. Large proportion of bilateral AI (15/27, 55.6%). No CYP21A2 mutation analysis. No details of the CAH cases, data on 17OHP and how many CAH cases taken from the figure in the article. |
| Terzolo (36) | 1996 | Basal and stimulated 17OHP. Consecutive patients with AI. | Some selection of cases in spite of the claim of consecutive patients with AI? Only 20 cases of AI during 3 years. No CYP21A2 mutation analysis. Only few details of the CAH case. |
| Del Monte (37) | 1995 | Basal and stimulated 17OHP. Six cases had basal and stimulated 17OHP before and after adrenalectomy. | Unclear if selected AI. No details on the exact 17OHP values on all individual patients; however, all seemed to have 17OHP <30 nmol/L. One is claimed to be CAH as stimulated 17OHP was still high after adrenalectomy, however, only 18 nmol/L. No CYP21A2 mutation analysis. |
| Ambrosi (38) | 1995 | Basal and stimulated 17OHP. Controls. | Unclear if selected AI. No details on the exact 17OHP values on all individual patients, however, all seemed to have 17OHP <30 nmol/L. Increased 17OHP response compared to normal subjects, claims high frequency of carriers but no CYP21A2 mutation analysis. |
| Seppel (39) | 1994 | Basal and stimulated 17OHP. Two patients had 17OHP both before and after adrenalectomy (both normalized, the one with >30 nmol/L before excluded in frequency calculations). | Details on the 17OHP values from the figure. No details could be retrieved on those with >30 nmol/L. No CYP21A2 mutation analysis. |
| Turton (40) | 1992 | Basal and stimulated 17OHP. A lot of details of the patients. Controls. | Unclear how the 12 patients were selected, compared to 10 controls. Patients with AI had significantly increased stimulated 17OHP compared to controls. |
| Abbreviations: AI = adrenal incidentaloma; CAH = congenital adrenal hyperplasia; NFAI = nonfunctional AI; NS = nonsignificant; 17OHP= 17-hydroxyprogesterone; SCS = subclinical Cushing syndrome. | |||
Conversely, some gene testing algorithms may miss CYP21A2 mutations. For example, analysis of selected point mutations may miss large gene conversions and dele- tions or rarer mutations. Ideally screening of at least the 10 most common mutations in the studied geographical area should be performed, followed by Sanger sequencing of all exons and regulatory regions to detect large gene conver- sions and deletions and rare mutations. It has previously been stated that most AIs with CAH have mild mutations (59); however, severe mutations were twice as common as mild ones in this meta-analysis (Table 4).
Elevated 17OHP levels after ACTH stimulation were found in 20 to 71 % of AIs (29,34,37,39,60,61). Caution in interpretation is needed. For example, AIs are associated with an exaggerated 11-deoxycortisol, progesterone, and 11-deoxycorticosterone response to ACTH, compared to controls. This suggests impaired 11 beta-hydroxylase activ- ity in AIs (62). Our meta-analysis found that both basal and stimulated 17OHP correlated with AI size, especially if those with a 17OHP level in the range of classic CAH (i.e., >300 nmol/L) were excluded. This suggests that AI tumors
could be responsible for an exaggerated 17OHP response, with an effect of tumor size, perhaps due to an acquired deficit of 21-hydroxylase activity in AI. Untreated classic CAH will have very high 17OHP even without adrenal tumors, so we excluded these individuals to demonstrate a more typical and clinically relevant relationship between 17OHP and tumor size. Our findings confirm previous smaller studies (15,29,35,38,39,61,63). Moreover, this exaggerated response disappeared in most patients after adrenalectomy (37,38,61). Furthermore, measurements of 17OHP are mainly performed by radioimmunoassay and enzyme-linked immunosorbent assay. However, liquid chromatography-tandem mass spectrometry has been reported to have much higher accuracy with less risk of false-positive values (64,65). In addition, 17OHP increases in the luteal phase, thus 17OHP should be measured in the follicular phase in menstruating females (9). Many indi- viduals with 17OHP levels in the range of 30 to 45 nmol/L have CYP21A2 mutation carrier status rather than NCAH (66). Hence, taking into account the limitations of 17OHP testing, we propose that CYP21A2 mutation analysis is
| Table 3 Cases Presented as an AI Subsequently Diagnosed with CAH due to 21-Hydroxylase Deficiency | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| First author (reference) | Year | Country | Age and sex (yr) | Ethnicity | Offspring (n) | Signs of increased androgens | AI sizeª (mm) | Bilat AIs | 17OHP values (nmol/L)€ | Cortisol values (nmol/L)d | CYP21A2 mutations | Diagnosis | Treatment |
| Kiedrowicz (22) | 2015 | 58 M | Caucasian? | NR | NR | 22 | No | 32.3(S) | ND | P453S | NCAH | NR | |
| Poland | 55 F | Caucasian? | NR | NR | 37 | Yes | 49.6(S) | ND | P30L | NCAH | NR | ||
| 59 F | Caucasian? | NR | NR | 37 | Yes | 58.2(S) | ND | P453S | NCAH | NR | |||
| Askitis (23) | 2015 | Germany | 49 M | Caucasian | NR | NR | 45b | Yes | NR | NR | ND | CAH (NCAH?) | NR |
| Hui (41) | 2014 | China | 65 M (46XX) | Asian | NR | NR | 58 | No | NR | NR | I172N/R483P | SVCAH | Adrenalectomy No GC |
| Kim (42) | 2014 | Korea | 46 F | Asian | No | Yes | NR | Yes | 1,076(B) 1,096(S) | 138(B) 128(S) | I2splice/R357W | SVCAH | NR |
| Falhammar (15) | 2014 | Sweden | 88 F | Caucasian Caucasian | Yes (3) Yes (2) | No Yes | 50 15e | No No | ND 37(B) 120(S) | 529(B) 524(S) 479(B) 693(S) | V281L/I172N V281L | NCAH NCAH | GC |
| 48 F | GC prn | ||||||||||||
| 21 F | Middle | No | Yes | 10 | No | 32(B) 59(S) | 687(B) 792(S) | V281L/V281L | NCAH | None | |||
| 67 M | Eastern Caucasian | Yes (2) | No | 80 | Yes | 338(B) | 177(B) 200(S) | I172N/null | SVCAH | Adrenalectomy GC | |||
| 57 M | Middle Eastern | Yes (3) | No | 12 | Yes | 14(B) 31(S) | 238(B) 499(S) | Not detected | NCAH | None | |||
| 66 M | Caucasian | Yes (1) | No | 15 | Yes | 3.4(B) | 467(B) 824(S) | Not detected | NCAH | None | |||
| 48 F | Caucasian | Yes (3) | Yes | 20 | Yes | 57(S) 6.9(B) 46(S) | 538(B) 832(S) | Not detected | NCAH | None | |||
| Fang (43) | 2013 | China | 64 M (46XX) | Asian | No | No | 50 | No | >750(B) | NR | ND | SVCAH | Adrenalectomy Hysterectomy SOE bilateral No GC |
| Varma (44) | 2013 | India | 42 F | Asian | Yes | Yes | 100 | No | 149(B) 378(S) | 322(B) | ND | NCAH | Adrenalectomy GC |
| Hayashi (45) | 2013 | Japan | 68 M (46XX) | Asian | No | No | 55 | No | 413(B) | 97(B) 141(S) | I2splice/R356W | SVCAH | Adrenalectomy GC |
| Mermejo (46) | 2010 | Brazil | 57 M | Hispanic | Yes (2) | No | 150 | Yes | 261(B) 342(S) | 231(B) 259(S) | I2splice/null | SVCAH | Adrenalectomy GC & MC |
| Nigawara (47) | 2008 | Japan | 66 M | Asian | Yes (1) | No | 40 | Yes | 304(B) 1,329(S) | 95(B) 146(S) | I172N/I2splice | SVCAH | Adrenalectomy No GC |
| Chervin (26) | 2007 | Argentina | NR F | Hispanic? | NR | NR | NR | No | 39(B) | ND | ND | NCAH | NR |
| Patócs (27) | 2002 | Hungary | NR | Caucasian? | NR | No | 43 | Yes | 7.5(B) 159(S) | ND | V281L/V281L | NCAH | NR |
| Baumgartner- Parzer (28) | 2002 | Austria | 70 M | Caucasian | NR | NR | 20 | No | 218(B) 855(S) | 292 (B) 339 (S) | I2 splice/null | SVCAH | NR |
| Table 3 Continued | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Grossrubatscher (29) | Italy | 56 M | Caucasian? | NR | NR | 25 | No | ND | ND | NCAH | NR | ||
| 2001 | 70 M | Caucasian? | NR | NR | 35 | No | ND | ND | NCAH | NR | |||
| 61 F | Caucasian? | NR | NR | 25 | Yes | ND | ND | NCAH | NR | ||||
| 67 M | Caucasian? | NR | NR | 32 | Yes | ND | ND | NCAH | NR | ||||
| 56 F | Caucasian? | NR | NR | 36 | No | For all range | ND | ND | NCAH | NR | |||
| 70 M | Caucasian? | NR | NR | 32 | Yes | 37-62(S) 48 ±10(S) | ND | ND | NCAH | NR | |||
| 51 F | Caucasian? | NR | NR | 20 | No | ND | ND | NCAH | NR | ||||
| 67 F | Caucasian? | NR | NR | 35 | No | ND | ND | NCAH | NR | ||||
| 80 F | Caucasian? | NR | NR | 40 | No | ND | ND | NCAH | NR | ||||
| 60 F | Caucasian? | NR | NR | 31 | No | ND | ND | NCAH | NR | ||||
| Ozgen (30) | 2001 | NR | NR | No | 4(B)38(S) | ND | ND | NCAH | NR | ||||
| NR | NR | No | 4(B)61(S) | ND | ND | NCAH | NR | ||||||
| Turkey | NR | NR | No | 8(B)61(S) | ND | ND | NCAH | NR | |||||
| NR | NR | No | 9(B)61(S) | ND | ND | NCAH | NR | ||||||
| Mean | NR | NR | No | 12(B)49(S) | ND | ND | NCAH | NR | |||||
| 51.2 ±2.4 | Middle | NR | NR | Mean | No | 15(B)32(S) | ND | ND | NCAH | NR | |||
| F(10) | Eastern in all? | NR | NR | 25 ± 2 | No | 16(B)30.1(S) | ND | ND | NCAH | NR | |||
| M(2) | NR | NR | No | 19(B)34(S) | ND | ND | NCAH | NR | |||||
| NR | NR | No | 10(B)61(S) | ND | ND | NCAH | NR | ||||||
| NR | NR | No | 15(B)61(S) | ND | ND | NCAH | NR | ||||||
| NR | NR | No | 12(B)61(S) | ND | ND | NCAH | NR | ||||||
| NR | NR | No | 10(B)61(S) | ND | ND | NCAH | NR | ||||||
| Abo (48) | 1999 | Japan | 72 F | Asian | No | No | 53 | Yes | 207(B) >636(S) | 248(B) 358(S) | I172N/null | SVCAH | GC |
| Barzon (33) | 1998 | Italy | NR,M | Caucasian? | NR | NR | NR | Yes | 172 (B) 190 (S) | NR | Unclear but pres- ent | NCAH | NR |
| Bondanelli (34) | 1998 | 72 M | Caucasian? | NR | No | 40 | No | 5(B)33(S) | Normal | ND | NCAH | No | |
| Italy | 84 F | Caucasian? | NR | No | 40 | No | 1(B)49(S) | High | ND | NCAH | No | ||
| Turpin (49) | 1997 | France | 66 M | Caucasian? | NR | No | 22e | Yes | 60(B)267(S) | NR | ND | NCAH | NR |
| Bernini (35) | 1996 | NR | Caucasian? | NR | NR | NR | No | 2(B)33(S) | NR | ND | NCAH | NR | |
| Italy | NR | Caucasian? | NR | NR | NR | No | 3(B)70(S) | NR | ND | NCAH | NR | ||
| NR | Caucasian? | NR | NR | NR | Yes | 3(B)40(S) | NR | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | Yes | 6(B)49(S) | NR | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | Yes | 8(B)76(S) | NR | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | Yes | 8(B)75(S) | NR | ND | NCAH | NR | |||
| Tóth (50) | 1996 | Hungary | 46M(46XX) | Caucasian? | No | NR | 60 | Yes | 261(B) | NR | ND | SVCAH | NR |
| Ravichandran (51) | 1996 | 51M(46XX) | Caucasian | No | No | 130 | No | 194(B) | 264(B) | ND | SVCAH | Adrenalectomy | |
| USA | 58M(46XX) | Caucasian | No | No | 100 | Yes | 215(B) | 238(B) | ND | SVCAH | Hysterectomy SOE bilateral Intermittently GC None | ||
| Terzolo (36) | 1996 | Italy | 58 F | Caucasian? | NR | NR | 20 | No | 30.3(S) | Normal | ND | NCAH | NR |
| 56 F | Caucasian? | NR | NR | 40 | No | 30(S) | Normal | ND | NCAH | NR | |||
| 68 F | Caucasian? | NR | NR | 27 | Yes | 91.5(S) | Normal | ND | NCAH | NR | |||
| 51 F | Caucasian? | NR | NR | 26 | Yes | 31.8(S) | Normal | ND | NCAH | NR | |||
| 29 F | Caucasian? | NR | NR | 30 | No | 48.3(S) | Normal | ND | NCAH | NR | |||
| 61 M | Caucasian? | NR | NR | 20 | No | 34.9(S) | Normal | ND | NCAH | NR | |||
| Table 3 Continued | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nagasaka (52) | 1996 | Japan | 57 M | Asian | NR | No | 68 | No | 139(B) | 367(B) | ND | NCAH | Adrenalectomy GC |
| Seppel (39) | 1994 | NR | Caucasian? | NR | NR | NR | No | 15(B)100(S) | Normal | ND | NCAH | NR | |
| NR | Caucasian? | NR | NR | NR | No | 15(B)75(S) | Normal | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | No | 5(B)45(S) | Normal | ND | NCAH | NR | |||
| Germany | NR | Caucasian? | NR | NR | NR | No | 5(B)42(S) | Normal | ND | NCAH | NR | ||
| NR | Caucasian? | NR | NR | NR | No | 5(B)38(S) | Normal | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | No | 5(B)32(S) | Normal | ND | NCAH | NR | |||
| NR | Caucasian? | NR | NR | NR | No | 5(B)30(S) | Normal | ND | NCAH | NR | |||
| Mokshagundam (53) | 1993 | USA | 55 M | Caucasian | Yes (2) | No | 50 | Yes | 1311(B) 1520(S) | 497(B) 579(S) | ND | SVCAH | GC |
| Jaresch (54) | 1990 | Germany | 37 M | Caucasian? | NR | No | 43 | No | 30.5(B) 90(S) | 174(B) | HLA genotype data | NCAH | None |
| Miyazaki (55) | 1990 | Japan | 65 F | Asian | NR | Yes | 80 | No | 321(B) | 333(B) | ND | SVCAH | Adrenalectomy GC |
Abbreviations: ? = ethnicity not clearly described thus was assumed to be the same as the majority of that particular country; AI = adrenal insufficiency; B = basal; CAH = congenital adrenal hyperplasia; GC = glucocorticoid; HLA = human leukocyte antigen; MC = mineralocorticoid; NCAH = nonclassic CAH; ND = not done; NR = not reported; prn = as needed; S = ACTH stimulated; SOE, salpingo- oophorectomy.
a Only the largest diameter of the largest AI noted.
b Tumor size reported to be 3-6 cm, an average of 45 mm was assumed.
€ Stimulated levels given at 60 min.
d Stimulated levels given at 30 min if measured at that time, otherwise at 60 min.
e Several AIs unilateral, the individual largest diameter indicated.
Conversion 17OHP: nmol/L = 3.18 x ng/mL. The diagnosis was assumed to be CAH if 17OHP was ≥30 nmol/L. Conversion cortisol: nmol/L = 25.59 mg/dL
probably the only reliable method for CAH diagnosis in AIs and is certainly needed in those with stimulated 17OHP levels between 30 and 60 nmol/L.
Nineteen percent of detected CAH patients had the SV form, although several were severe-5/11 SVCAH males had 46XX karyotyping. Detailed descriptions of the extent of hyperandrogenism were rarely available; in 1 group of 10 females, 6/10 had positive features, some misdiagnosed as PCOS. Fecundity seemed impaired, as the number of offspring was low.
A Middle Eastern ethnic background may increase the probability of CAH among AI patients (15); the meta-anal- ysis revealed a higher rate of CAH (19% biochemical and 6% genetic diagnosis).
Bilateral AIs may predict CAH. One-third of biochemically diagnosed CAH patients with AIs had bilat- eral tumors. Among the group with genetically confirmed
CAH, more than half had bilateral AIs. This compares to a literature range for bilaterality of 11 to 19% (1-4).
In many patients with AI, the initial radiologic suspicion was ACC or metastasis (4,15,41,43-47,51,53,56), and some patients had undergone adrenalectomy performed before the diagnosis of SVCAH was made (15,46). This highlights the need for suspicion of CAH as both undiagnosed classic CAH and diagnosed CAH carry an increased risk of mortal- ity due to adrenal crisis (67,68). Increased steroid metabo- lites could be interpreted as sign of malignancy (4,15). ACC is rare in CAH, and detection of CAH may make ACC less likely (44,69-71). The extent of cortisol deficiency varies in CAH, with NCAH individuals generally having mild corti- sol deficiency: ~ 33% have stimulated cortisol levels <400 nmol/L and 60% <500 nmol/L (11).
There were limitations to our meta-analyses. Only a minority of studies performed CYP21A2 gene analysis of
300
1400
A
C
1200
250
Basal 17OHP value (nmol/L)
r = 0.356
Basal 17OHP value (nmol/L)
1000
P = 0.015
200
800
150
600
r = 0.743
100
P <0.001
400
200
50
0
0
1600
300
B
D
Stimulated 17OHP value (nmol/L)
1400
Stimulated 17OHP value (nmol/L)
250
1200
r = 0.248
1000
P = 0.100
200
800
150
600
100
r = 0.593
400
P <0.001
200
50
0
0
20
40
60
80
100
120
140
160
0
0
20
40
60
80
100
120
140
160
Largest diameter of adrenal incidentaloma (mm)
Largest diameter of adrenal incidentaloma (mm)
| Table 4 Meta-Analysis of Individual Cases Presented as an AI Subsequently Diagnosed with CAH Due to 21-Hydroxylase Deficiency Divided into Subgroupsª | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Age (yr) | Sex | Ethnicity | Offspring (n) | AI sizeb (mm) | Bilat AIs | 17OHP values (nmol/L)c | Cortisol values (nmol/L)d | CYP21A2 mildest mutation | Dx | Treatment | |
| All CAH cases n = 74 | 57.5±11.8 | 55% (n = 33) F 45% (n = 27) M (n = 5 46XX) (n = 14 sex not reported) | Caucasian 66% (n = 49) Asian 12% (n = 9) Middle Eastern 19% (n = 14) Hispanic 3% (n = 2) | 1 (0-3) | 31.5 (10-150) | 35% (n = 26) | 24.8 (B) (1-1,311) 61 (S) (30-1,520) | 278 (B) (95-687) 428 (S) (128-832) | Genetic test not done in 73% (n = 54) | SVCAH 19% (n = 14) NCAH 81% (n = 60) | GC 55% (n = 11) No GC 45% (n = 9) Adrenalectomy 50% (n = 10) |
| CAH cases genetically confirmed n = 17 | 57.9 ±16.2 | 44% (n =7) F 56% (n = 9) M (n = 1 46XX) | Caucasians 59% (n = 10) Asians 29% (n = 5) Middle Eastern 6% (n=1) Hispanic 6% (n= 1) | 0.5 (0-3) | 43.0 (10-150) | 53% (n = 9) | 212 (B) (7.5-1,076) 190 (S) (32-1,329) | 231 (B) (95-687) 339 (S) (128-792) | I2splice n = 4 I172N n =4 P30L n = 1 V281L n = 4 P453S n = 2 Unclear n = 1 HLA data n= 1 | SVCAH 47% (n = 8) NCAH 53% (n = 9) | GC 60% (n = 6) No GC 40% (n = 4) Adrenalectomy 50% (n = 5) |
| CAH not genetically confirmed N=3 | 57.0 ±9.0 | 33% (n=1) F 67% (n = 2) M | Caucasian 67% (n = 2) Middle Eastern 33% (n= 1) | 3 (1-3) | 15.0 (12-20) | 100% (n = 3) | 6.9 (B) (3.4-14) 46 (S) (31-57) | 467 (B) (238-538) 824 (S) (499-832) | No mutation detected 100% (n=3) | NCAH 100% (n = 3) | No GC 100% (n = 3) Adrenalectomy 0% (n = 3) |
| P valuee | .882 | 1.000 | 1.000 | .164 | .044 | .242 | .017 (B) .024 (S) | .319 (B) .036 (S) | <. 001 | .242 | .192 (GC) .231 (sx) |
Abbreviations: B = basal; CAH = congenital adrenal hyperplasia; dx = diagnosis; GC = glucocorticoid; NCAH = nonclassic CAH; 17OHP = 17-hydroxyprogesterone; S = ACTH stimulated; sx = surgery yr = years.
a Results presented as mean + SD, median (range) or percentage (n).
b Only the largest diameter of the largest AI noted.
c Stimulated levels given at 60 min.
d Stimulated levels given at 30 min if measured at that time, otherwise at 60 min.
e Comparing those CAH cases genetically confirmed with those where no mutation could be found in spite of CYP21A2 mutation analysis. Conversion 17OHP: nmol/L = 3.18 x ng/mL. The diagnosis was assumed to be CAH if 17OHP was ≥30 nmol/L. Conversion cortisol: nmol/L = 25.59 mg/dL
all consecutive AI patients with controls from the same geographical area. Selection bias may have driven those tested for 17OHP levels, especially when performed on unstimulated samples, leading to overestimation of CAH prevalence. Conversely, some cases of mild CAH may be missed without ACTH-stimulated 17OHP levels. A lack of reporting of detailed clinical features of the identified CAH cases limited clinical analyses.
CONCLUSION
In conclusion, AI patients were not substantially enriched in the prevalence of heterozygous CYP21A2 mutations, but a small increase in the prevalence of genetically verified CAH was seen. Elevated basal and stimulated 17OHP levels were seen more frequently than CYP21A2 mutations, suggesting low specificity of
17OHP for CAH diagnosis in the setting of AI, especially for 17OHP levels <60 nmol/L. Bilateral AIs do not reli- ably predict CAH, but if present with hyperandrogenism, testing may be justified. No cases of adrenal crisis precip- itated by adrenalectomy were recorded. Hence, the results do not support routine screening for CYP21A2 mutations in adults with AIs.
ACKNOWLEDGMENT
This study was supported by the Magnus Bergvall Foundation, the Swedish Endocrine Society, Karolinska Institutet, and the Stockholm County Council.
DISCLOSURE
The authors have no multiplicity of interest to disclose.
| Supplemental Table | |||
|---|---|---|---|
| Section/topic | # | Checklist item | Reported in section |
| TITLE | |||
| Title | 1 | Identify the report as a systematic review, meta-analysis, or both. | Title page |
| ABSTRACT | |||
| Structured summary | 2 | Provide a structured summary including, as applicable: background; objec- tives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. | First page |
| INTRODUCTION | |||
| Rationale | 3 | Describe the rationale for the review in the context of what is already known. | Introduction |
| Objectives | 4 | Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PI- COS). | Introduction |
| METHODS | |||
| Protocol and registra- tion | 5 | Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registra- tion number. | Search strategy and selection criteria |
| Eligibility criteria | 6 | Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale. | Search strategy and selection criteria |
| Information sources | 7 | Describe all information sources (e.g., databases with dates of coverage, con- tact with study authors to identify additional studies) in the search and date last searched. | Search strategy and selection criteria |
| Search | 8 | Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. | Search strategy and selection criteria |
| Study selection | 9 | State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). | Search strategy and selection criteria |
| Data collection pro- cess | 10 | Describe method of data extraction from reports (e.g., piloted forms, indepen- dently, in duplicate) and any processes for obtaining and confirming data from investigators. | Search strategy and selection criteria |
| Data items | 11 | List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. | Search strategy and selection criteria |
| Risk of bias in indi- vidual studies | 12 | Describe methods used for assessing risk of bias of individual studies (includ- ing specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. | Search strategy and selection criteria |
| Supplemental Table Continued | |||
| Summary measures | 13 | State the principal summary measures (e.g., risk ratio, difference in means). | Search strategy and selection criteria Statistical analysis |
| Synthesis of results | 14 | Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis. | Statistical analysis |
| Risk of bias across studies | 15 | Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies). | Search strategy and selection criteria |
| Additional analyses | 16 | Describe methods of additional analyses (e.g., sensitivity or subgroup analy- ses, meta-regression), if done, indicating which were pre-specified. | Search strategy and selection criteria |
| RESULTS | |||
| Study selection | 17 | Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram. | Figure 1 |
| Study characteristics | 18 | For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations. | Tables 1 and 3 |
| Risk of bias within studies | 19 | Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). | Table 2 |
| Results of individual studies | 20 | For all outcomes considered (benefits or harms), present, for each study: (1) simple summary data for each intervention group and (2) effect estimates and confidence intervals, ideally with a forest plot. | Tables 1 and 4 |
| Synthesis of results | 21 | Present results of each meta-analysis done, including confidence intervals and measures of consistency. | Tables 1 and 4 |
| Risk of bias across studies | 22 | Present results of any assessment of risk of bias across studies (see item 15). | Table 2 |
| Additional analysis | 23 | Give results of additional analyses, if done (e.g., sensitivity or subgroup anal- yses, meta-regression; see item 16). | Table 1 |
| DISCUSSION | |||
| Summary of evidence | 24 | Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers). | Paragraphs 1-7 |
| Limitations | 25 | Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias). | Paragraph 8 |
| Conclusions | 26 | Provide a general interpretation of the results in the context of other evidence, and implications for future research. | Paragraph 9 |
| FUNDING | |||
| Funding | 27 | Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review. | Acknowledgment |
| From: (21) Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS Med. 2009;6:e1000097. doi:10.1371/journal.pmed 1000097 | |||
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