Journal of Endocrinological Investigation

, Volume 42, Issue 12, pp 1435–1442 | Cite as

Saliva versus serum cortisol to identify subclinical hypercortisolism in adrenal incidentalomas: simplicity versus accuracy

  • M. Vieira-Correa
  • R. B. Giorgi
  • K. C. Oliveira
  • L. F. Hayashi
  • F. A. Costa-Barbosa
  • C. E. KaterEmail author
Original Article



Subclinical hypercortisolism (SCH) leads to metabolic derangements and increased cardiovascular risk. Cortisol autonomy is defined by the overnight 1 mg dexamethasone suppression test (DST). Saliva cortisol is an easier, stress-free, and cost-effective alternative to serum cortisol. We compared 23 h and post-1 mg DST saliva with serum cortisol to identify SCH in adrenal incidentalomas (AI).


We analyzed 359 DST obtained retrospectively from 226 AI subjects (173F/53 M; 19–83 years) for saliva and serum cortisol. We used three post-DST serum cortisol cutoffs to uncover SCH: 1.8, 2.5, and 5.0 μg/dL. We determined post-DST and 23 h saliva cortisol cutoffs by ROC curve analysis and calculated their sensitivities (S) and specificities (E).


The sensitive 1.8 μg/dL cutoff defined 137 SCH and 180 non-functioning adenomas (NFA): post-DST and 23 h saliva cortisol S/E were: 75.2%/74.4% and 59.5%/65.9%, respectively. Using the specific 5.0 μg/dL cortisol cutoff (22 SCH/295 NFA), post-DST and 23 h saliva cortisol S/E were 86.4%/83.4% and 66.7%/80.4%, respectively. Using the intermediate 2.5 μg/dL cutoff (89 SCH/228 NFA), post-DST and 23 h saliva cortisol S/E were 80.9%/68.9% and 65.5%/62.8%, respectively.


Saliva cortisol showed acceptable performance only with the 5.0 μg/dL cortisol cutoff, as in overt Cushing’s syndrome. Lower cutoffs (1.8 and 2.5 μg/dL) that identify larger samples of patients with poor metabolic outcomes are less accurate for screening. These results may be attributed to pre-analytical factors and inherent patient conditions. Thus, saliva cortisol cannot replace serum cortisol to identify SCH among patients with AI for screening DST.


Saliva cortisol Dexamethasone suppression Adrenal incidentaloma Subclinical hypercortisolism 



Marcelo Vieira-Correa received a fellowship grant from CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), Brazil.


This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the ethical committee of the Federal University of Sao Paulo.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Italian Society of Endocrinology (SIE) 2019

Authors and Affiliations

  • M. Vieira-Correa
    • 1
  • R. B. Giorgi
    • 1
  • K. C. Oliveira
    • 1
  • L. F. Hayashi
    • 1
  • F. A. Costa-Barbosa
    • 1
  • C. E. Kater
    • 1
    Email author
  1. 1.From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of MedicineFederal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo)São PauloBrazil

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