Summary: In CHIRACIC, adults with unilateral adrenal incidentaloma, mild autonomous cortisol secretion, and hypertension were more likely to achieve normotension on home blood pressure monitoring with reduced antihypertensive treatment after adrenalectomy than with conservative management at 13 months, 46% versus 15% (adjusted risk difference 34 percentage points, 95% CI 11 to 58; P=0.0038).
PICO Summary
| Element | Detail |
|---|---|
| Population | 52 adults with unilateral adrenal incidentaloma, mild autonomous cortisol secretion, and confirmed hypertension after a standardized antihypertensive run-in at 17 university hospitals in France, Italy, and Germany; multicentre open-label superiority RCT. |
| Intervention | Minimally invasive adrenalectomy with protocolized follow-up and antihypertensive de-escalation attempts (n=26 intention-to-treat; 23 underwent surgery and completed follow-up). |
| Comparison | Conservative management after the same standardized run-in and follow-up framework (n=26 intention-to-treat; 25 completed follow-up). |
| Outcome | Normotension on home blood pressure monitoring with reduced antihypertensive treatment at study completion occurred in 46% versus 15%; adjusted risk difference 34 percentage points (95% CI 11 to 58; P=0.0038). Patients still requiring antihypertensives were 43% versus 96% (P<0.0001). |
Adrenalectomy in MACS Hypertension (CHIRACIC)
Open-label superiority RCT - unilateral adrenal incidentaloma - 13 months
Adrenalectomy more often achieved normotension with lower treatment burden than conservative management in carefully selected unilateral MACS-associated hypertension.
Expert Commentary
CHIRACIC matters because it tested a question endocrinologists and hypertension specialists face in clinic: when a unilateral adrenal incidentaloma is causing mild autonomous cortisol secretion, does adrenalectomy meaningfully reduce blood-pressure treatment burden after standardized medical optimization? In this small but carefully run randomized trial, the answer was yes. After 13 months, 46% of surgical patients were normotensive on home readings with less antihypertensive treatment versus 15% with conservative management, and over half of operated patients were off antihypertensives entirely. That is clinically relevant because the comparator was not therapeutic neglect; both groups underwent a run-in phase with stepped-care blood-pressure standardization before randomization. The main limitation is scale. Only 52 participants were randomized, the trial was open label, and outcomes depended partly on treatment de-escalation decisions, although those decisions were protocolized. Serious adverse events were similar overall, but surgery still caused procedure-related events in three patients.
Can I use this with my patients?
Yes, if the patient truly has a unilateral adrenal incidentaloma with confirmed mild autonomous cortisol secretion, persistent hypertension despite careful evaluation, and access to experienced adrenal surgery plus postoperative endocrine follow-up. This trial supports selective referral, not automatic adrenalectomy for every incidentaloma with borderline cortisol autonomy.
References
Tabarin A, Espiard S, Deutschbein T, et al. Surgery for the treatment of arterial hypertension in patients with unilateral adrenal incidentalomas and mild autonomous cortisol secretion (CHIRACIC): a multicentre, open-label, superiority randomised controlled trial. Lancet Diabetes Endocrinol. 2025;13(7):580-590. doi:10.1016/S2213-8587(25)00062-2. PMID: 40373786.