Is confirmation of an adrenal adenoma in patients with primary aldosteronism sufficient for indication of adrenalectomy?

Česká verzia

Authors: M. Ballon ¹; J. Ceral ¹; M. Solař ¹; A. Krajina ²; J. Raupach ²; L. Ungermann ²
Authors place of work: I. interní klinika Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Jan Vojáček, DrSc. ¹; Radiologická klinika Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Pavel Eliáš, CSc. ²
Published in the journal: Vnitř Lék 2009; 55(6): 555-559
Category: Original Contributions

Summary

Background:
Primary aldosteronism is one of the most common forms of secondary arterial hypertension. Adrenalectomy is effective in patients with proven unilateral hypersecretion of aldosterone whereas pharmacotherapy is indicated in bilateral forms of the disease. We can meet the opinion that in patients with confirmed primary aldosteronism and finding of suprarenal adenoma ≥ 1 cm on computed tomography (CT) scanning, adrenalectomy can be recommended without further investigation. On the other hand we can perform adrenal venous sampling (AVS) to prove unilateral overproduction of aldosterone.

Objectives:
To evaluate whether AVS is necessary in all patients with unilateral adenoma ≥ 1 cm.

Methods:
We analyzed data from patients with proven primary aldosteronism, CT finding of adenoma ≥ 1 cm along with normal morphology of contralateral adrenal gland, and successfully performed AVS. Results: Out of 107 patients with proven primary aldosteronism, indicated for AVS, we included 30 patients with CT finding of suprarenal adenoma ≥ 1 cm along with normal morphology of contralateral adrenal gland and successful AVS. Unilateral overproduction of aldosterone was found only in 17 cases (56.7%), the results in remaining 13 patients (43.3%) did not confirm activity of adenoma.

Conclusion:
Our results support necessity of performing AVS in all patients with primary aldosteronism in whom surgical treatment is considered, CT confirmation of an adenoma is insufficient in this indication.

Key words:
primary aldosteronism – adenoma of adrenal gland – adrenal venous sampling – computed tomography

Zdroje

1. Widimský J jr, Cífková R, Špinar J et al. Doporučení diagnostických a léčebných postupů u arteriální hypertenze – verze 2007. Doporučení České společnosti pro hypertenzi. Vnitř Lék 2008; 54: 101–118.

2. Funder JW, Carey RM, Fardella C et al. Case Detection, Diagnosis, and Treatment of Patients with Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008; 93: 3266–3281.

3. Kaplan NM. Primary Aldosteronism. In: Kaplan NM (ed). Kaplan’s Clinical Hypertension. Philadelphia: Lippincott Williams & Wilkins 2006: 410–433.

4. Tan YY, Ogilvie JB, Triponez F et al. Selective use of adrenal venous sampling in the lateralization of aldosterone-producing adenomas. World J Surg 2006; 30: 879–885.

5. Zarnegar R, Bloom AI, Lee J et al. Is adrenal venous sampling necessary in all patients with hyperaldosteronism before adrenalectomy? J Vasc Interv Radiol 2008; 19: 66–71.

6. Young WF, Stanson AW, Thompson GB et al. Role for adrenal venous sampling in primary aldosteronism. Surgery 2004; 136: 1227–1235.

7. Tokárčiková A. Primárny aldosteronismus. Vnitř Lék 2007; 53: 1000–1002.

8. Mazza A, Zamboni S, Armigliato M et al. Endocrine arterial hypertension: diagnostic approach in clinical practice. Minerva Endocrinol 2008; 33: 127–146.

9. Harper R, Ferrett CG, McKnight JA et al. Accuracy of CT scanning and adrenal vein sampling in the pre‑operative localization of aldosterone-secreting adrenal adenomas. QJM 1999; 92: 643–650.

10. Magill SB, Raff H, Shaker JL et al. Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism. J Clin Endocrinol Metab 2001; 86: 1066–1071.

11. Mulatero P, Bertello C, Rossato D et al. Roles of clinical criteria, computed tomography scan, and adrenal vein sampling in differential diagnosis of primary aldosteronism subtypes. J Clin Endocrinol Metab 2008; 93: 1366–1371.

12. Young WF jr, Stanson AW, Grant CS et al. Primary aldosteronism: Adrenal venous sampling. Surgery 1996; 120: 913–920.

13. Widimský J jr, Zelinka T. Endokrinní hypertenze. In: Widimský J et al (eds). Hypertenze. Praha: Triton 2004: 518–540.

14. Mulatero P, Stowasser M, Loh KC et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab 2004; 89: 1045–1050.

15. Nwariaku FE, Miller BS, Auchus R et al. Primary Hyperaldosteronism: effect of adrenal vein sampling on surgical outcome. Arch Surg 2006; 141: 497–503.

16. Widimský J jr. Incidentalomy nadledvin/zvětšení nadledvin: stručný přehled. In: Widimský J jr et al (eds). Arteriální hypertenze – současné klinické trendy. Praha: Triton 2008: 41–46.

17. Stowasser M, Gordon RD. Primary aldosteronism. Best Pract Res Clin Endocrinol Metab 2003; 17: 591–605.

18. Gross MD, Shapiro B, Freitas JE. Limited significance of asymmetric adrenal visualization on dexamethasone-supression scintigraphy. J Nucl Med 1985; 26: 43–48.

19. Horký K, Gregorová I, Šilinková-Málková E et al. Diferenciální diagnostika primárního a pseudoprimárního hyperaldosteronismu. Čas Lék čes 1976; 115: 200–206.

20. Horký K, Gregorová I, Tomsová Z et al. Význam současného stanovení aldosteronu, 18-hydroxy-11-deoxykortikosteronu a kortizolu v nadledvinových žilách u arteriální hypertenze s potlačeným reninem. Sborník lékařský 1977; 79: 1–10.

21. Siragy HM, Vieweg WV, Pincus S et al. Increased disorderliness and amplified basal and pulsatile aldosterone secretion in patients with primary aldosteronism. J Clin Endocrinol Metab 1995; 80: 28–33.

22. Doppman JL, Gill JR jr. Hyperaldosteronism: sampling the adrenal veins. Radiology 1996; 198: 309–312.

23. Rossi GP, Pitter G, Bernante P et al. Adrenal vein sampling for primary aldosteronism: the assessment of selectivity and lateralization of aldosterone excess baseline and after adrenocorticotropic hormone (ACTH) stimulation. J Hypertens 2008; 26: 989–997.

24. Stowasser M, Gordon RD, Gunasekera TG et al. High rate of detection of primary aldosteronism, including surgically treatable forms, after non‑selective screening of hypertensive patients. J Hypertens 2003; 21: 2149–2157.