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Context: Several studies have reported increased risk of fragility fractures in patients with mild autonomous cortisol secretion (MACS), discordant to the degree of bone density deterioration., Objective: To evaluate the effect of MACS on bone metabolism in patients with adrenal adenomas., Design: Cross-sectional study with prospective enrollment, 2014-2019., Setting: Referral center., Patients: 213 patients with adrenal adenomas: 22 Cushing syndrome (CS), 92 MACS and 99 nonfunctioning adrenal tumors (NFAT)., Main Outcome Measures: Osteocalcin, procollagen I intact N-terminal (PINP), C-terminal telopeptide (CTX), sclerostin., Results: Patients with CS demonstrated lower markers of bone formation compared with patients with MACS and NFAT (CS vs MACS vs NFAT: mean osteocalcin 14.8 vs 20.1 vs 21.3 ng/mL [P < 0.0001]; mean PINP 34.8 vs 48.7 vs 48.5 µg/L [P = 0.003]). Severity of cortisol excess was inversely associated with sclerostin (CS vs MACS vs NFAT: mean sclerostin 419 vs 538 vs 624 ng/L, [P < 0.0001]). In a multivariable model of age, sex, body mass index, cortisol, and bone turnover markers, sclerostin was a significant predictor of low bone mass in patients with MACS (OR 0.63 [CI 95%, 0.40-0.98] for each 100 ng/L of sclerostin increase).After adrenalectomy, osteocalcin, CTX, and sclerostin increased by a mean difference of 6.3 ng/mL, 0.12 ng/mL, and 171 pg/mL (P = 0.02 for all), respectively., Conclusions: Lower sclerostin level in patients with MACS reflects a reduction in osteocyte function or number associated with exposure to chronic cortisol excess. Increase in bone turnover markers after adrenalectomy suggests restoration of favorable bone metabolism., (© Endocrine Society 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To determine the indications for prediagnostic testing, subsequent diagnoses found, and follow-up practices in patients who were incidentally diagnosed with monoclonal gammopathy of undetermined significance (MGUS)., Patients and Methods: From our prospective MGUS database, we identified 329 patients residing in southeastern Minnesota who were diagnosed from January 1, 2011, through December 31, 2014, and followed up at Mayo Clinic., Results: Most test orders came from nonhematologists (n=310, 94.2%). The top 5 indications were neuropathy (n=65, 19.8%), renal disease (n=45, 13.7%), anemia (n=42, 12.8%), bone disorder or connective tissue pain (n=42, 12.8%), and cutaneous disease (n=19, 5.8%). Hypercalcemia was an infrequent indication (n=9, 2.7%). The final diagnosis for all neuropathy evaluations was sensory/motor neuropathy-not otherwise specified, with 18.7% having IgM MGUS. Chronic kidney disease-not otherwise specified, iron deficiency, and osteoporosis/osteopenia were the most common subsequent diagnoses for test indications of renal disease, anemia, and bone disorder or connective tissue pain, respectively. Most patients (n=213, 64.7%) had 1 or more follow-up visit during the study period. A minority were followed by hematologists (43.5%, n=143). Patients with low-risk MGUS comprised 45.0% (n=148) of the cohort. Male patients and younger patients were more likely to be followed up than their counterparts (P<.01). About one-third (n=27, 32.1%) of patients 80 years or older (n=84) continued to have regular follow-up visits. Hematologists were more likely to follow patients with MGUS more closely than nonhematologists (P<.001). However, the intensity of follow-up was not based on MGUS risk., Conclusion: Monoclonal protein testing is commonly performed for signs and symptoms not typically associated with lymphoplasmacytic malignancies. There is a significant variation in MGUS follow-up between hematologists and nonhematologists (P<.001) that is not based on risk factors or clinical practice guidelines., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)