Precise Mapping of Intra-Adrenal Aldosterone Activities Provides a Novel Surgical Strategy for Primary Aldosteronism

Abstract

Segmental selective adrenal venous sampling (sAVS) elucidates an intraadrenal aldosterone activity map (IAMap), which allows us to design a novel surgical treatment strategy for patients with primary aldosteronism. We evaluated the usefulness of sAVS by analyzing 278 patients with whom we had prospectively used IAMap using the criteria of sAVS for surgical indication between 2009 and 2015. We evaluated its diagnostic accuracy using pathological and postsurgical biochemical and clinical outcomes. One hundred twenty and 158 patients were diagnosed with unilateral and bilateral disease, respectively, through sAVS. The concordance of lateralization diagnosis with computed tomography imaging was 66.6%. Among the unilateral patients, we performed partial adrenalectomy in 68 patients whose IAMap showed focal aldosterone hypersecretion from computed tomography-detectable tumor in the affected adrenal gland. All of them achieved complete biochemical success 1 year after surgery. Furthermore, 25 of 158 bilateral disease patients underwent surgical resection because they were preoperatively diagnosed as bilateral aldosterone-producing adenomas by IAMap. These cases showed complete or partial biochemical success (28.0% and 72.0%, respectively); 36.0% showed complete clinical success. Pathological studies demonstrated that all 145 resected specimens possessed aldosterone-producing adenoma or multiple nodules (132 and 13 cases, respectively), and none showed diffuse hyperplasia. IAMap accurately diagnosed both bilateral and unilateral aldosterone-producing adenomas and diffuse hyperplasia before surgery. sAVS allows a novel surgical strategy for selected PA patients with favorable outcomes.

KCNJ5 Mutation Contributes to Complete Clinical Success in Aldosterone-Producing Adenoma: A Study From a Single Center

“…Our results implied that partial adrenalectomy had a prognosis similar to that of unilateral adrenalectomy. A recent study also proposed a new surgical strategy based on segmental selective adrenal venous sampling 30 . Although KCNJ5 somatic mutations can only be identified in tissues after surgery up till now, with the development of AVS measurement technology, such as cell-free DNA techniques using in samples from AVS, could facilitate the identification of KCNJ5 mutations before surgery and allow for partial adrenalectomy in the future.…”

Cortisol Co-Secretion and Clinical Usefulness of ACTH Stimulation Test in Primary Aldosteronism: A Systematic Review and Biases in Epidemiological Studies

“…These limitations have made the clinical usefulness of the ACTH stimulation test inconclusive. For example, we previously demonstrated that the predictive performance of the ACTH stimulation test for subtype diagnosis of PA could vary by the definition of lateralization during AVS with ACTH stimulation ( 51 ); i.e., whether evaluating the ratio of aldosterone to cortisol at adrenal central veins ( 21 ) or evaluating the absolute value of aldosterone at adrenal tributary veins ( 56 ). Compared with the subtype diagnosis of PA, the evidence about the definite diagnosis of PA has been very limited and has not been consistent ( 49 – 51 ).…”

MANAGEMENT OF ENDOCRINE DISEASE: The role of surgical adrenalectomy in primary aldosteronism

“…This demonstration, that contralateral aldosterone suppression during adrenal venous sampling is a rare finding in lateralizing cases, provides support for the hypothesis that truly unilateral disease in primary aldosteronism may be rare, and may potentially support the hypothesis that aldosterone-producing cell clusters are a prevalent cause of bilateral primary aldosteronism pathogenesis (81). Recent techniques employing segmental selective adrenal venous sampling to precisely map the location of aldosterone production within the adrenal gland have shown promise for the use of partial adrenalectomy, rather than complete adrenalectomy (82). This procedure has been shown to induce a high rate of partial, or complete, biochemical and clinical success for both unilateral and bilateral disease; however, it is not broadly available and has not been widely replicated yet.…”