Abstract Background Management of Mild Autonomous Cortisol Secretion (MACS) remains controversial, with conservative monitoring often preferred for uncomplicated cases. This study aimed to compare the long-term metabolic and radiological outcomes of adrenalectomy versus conservative management to evaluate the safety of surveillance. Methods Seventy MACS patients were retrospectively analysed. Patients were stratified into the Surgical Group, treated with laparoscopic/retroperitoneoscopic adrenalectomy, and the Medical Group managed conservatively. Primary endpoints included hypertension control, diabetes parameters, and BMI; secondary endpoints included tumour progression, Dexamethasone Suppression Test (DST) trends, and changes in bone mineral density (BMD). Results In the Surgical Group (n=26); median follow-up:14 months,95% CI: 18.03–37.57), the median number of anti-hypertensive medications decreased significantly from 1 to 0 (p=0.001). Lumbar T-scores improved from -2.15 to -1.15 (p=0.009), and LDL levels decreased (p=0.004). Post-operative ACTH elevation (p0.001) confirmed axis recovery. Median steroid withdrawal time was 3 months, showing a positive correlation with pre-op DST levels (p=0.029). Conversely, the Medical Group (n=44; median follow-up: 41 months, 95% CI: 44.18–72.45) exhibited progression: 11.4% showed tumour enlargement, 20.5% had hormonal worsening (increased DST), and 34.1% required increased anti-hypertensive medication, with 9.1% developing de novo hypertension. Conclusion Adrenalectomy significantly reduces hypertensive burden, improves bone density, and reverses metabolic risks in MACS. In contrast, conservative management is associated with evident radiological and metabolic progression. Our findings suggest the “watch-and-wait” strategy is not benign; early surgical intervention should be considered a superior alternative to prevent disease progression in eligible patients.
Tunali et al. (2026) studied this question.