Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

Abstract

ORIGINAL ARTICLE PURPOSE We aimed to assess the value of adrenal venous sampling (AVS) for diagnosing primary aldosteronism (PA) subtypes in patients with a unilateral nodule detected on adrenal computed tomography (CT) and scheduled for adrenalectomy. MATERIALS AND METHODSThis retrospective study included 80 consecutive patients with PA undergoing CT and AVS. Different lateralization indices were assessed, and a cutoff established using receiver operating characteristic curve analysis. The value of CT alone versus CT with AVS for differentiating PA subtypes was compared. The adrenalectomy outcome was assessed, and predictors of cure were determined using univariate analysis. RESULTS AVS was successful in 68 patients. A cortisol-corrected aldosterone affected-to-unaffected ratio cutoff of 2.0 and affected-to-inferior vena cava ratio cutoff of 1.4 were the best lateralization indices, with accuracies of 82.5% and 80.4%, respectively. CT and AVS diagnosed 38 patients with aldosterone-producing adenomas, five patients with unilateral adrenal hyperplasia, and 25 patients with bilateral adrenal hyperplasia. Of the 52 patients with a nodule detected on CT, subsequent AVS diagnosed bilateral adrenal hyperplasia in 14 patients (27%). Compared to the results of combining CT with AVS, the accuracy of CT alone for diagnosing aldosterone-producing adenomas was 71.1% (P < 0.001). The cure rate for hypertension after adrenalectomy was 39.2%, with improvement in 53.5% of patients. On univariate analysis, predictors of persistent hypertension were male gender and preoperative systolic blood pressure. CONCLUSIONTo avoid inappropriate surgery, AVS is necessary for diagnosing unilateral nodules with aldosterone hypersecretion detected by CT. P rimary aldosteronism (PA) is the most common form of secondary hypertension, with a prevalence of 5%-11% (1-3). PA is due primarily to the hypersecretion of aldosterone by an aldosterone-producing adenoma (APA) or unilateral (primary) adrenal hyperplasia (UAH), which constitute 30%-40% of cases; the remainder are presumed to be secondary to idiopathic bilateral adrenal hyperplasia (BAH) (1, 4, 5). APA and UAH are two forms of unilateral aldosterone hypersecretion, and both are curable with adrenalectomy. BAH induces bilateral aldosterone hypersecretion, and anti-aldosterone drugs are used in its medical management (5-7).The plasma aldosterone-to-renin ratio is used to screen for PA in patients at high risk for PA (8). Recent guidelines recommend using computed tomography (CT) of the adrenal gland to categorize the subtype after confirming PA. However, CT cannot reliably visualize a microadenoma or distinguish between an incidentaloma or BAH and APA. It has been suggested that adrenal venous sampling (AVS) be performed to determine the subtype of PA and to differentiate between unilateral and bilateral production of aldosterone preoperatively (9). AVS to measure the adrenal vein aldosterone and cortisol is the gold standard for lateralizing aldosterone secretion (10). Lateralization is define...

Reversing the established order: Should adrenal venous sampling precede cross‐sectional imaging in the evaluation of primary aldosteronism?

“…The overall positive predictive value of imaging for correctly identifying a unilaterally secreting adrenal gland was only 54%, with a negative predictive value of 49%. These findings are consistent with other reports in the literature .…”

Influence of autonomous cortisol secretion in patients with primary aldosteronism: subtype analysis and postoperative outcome

“…PA can be generally subtyped into unilateral disease (including primarily aldosterone-producing adenomas (APAs), and unilateral adrenal hyperplasia in rare cases) and bilateral disease (mainly bilateral hyperplasia) ( 5 , 6 ). Adrenal venous sampling (AVS) has been regarded as the standard for differentiating between the two disease subtypes ( 3 , 7 , 8 , 9 ), in contrast to cross-sectional imaging studies (computed tomography (CT) or magnetic resonance imaging (MRI)).…”