Use Of Adrenal Venous Sampling Research Articles

Adrenal venous sampling in patients with ACTH-independent hypercortisolism

PurposeTo study the usefulness of adrenal venous sampling (AVS) in distinguishing unilateral from bilateral cortisol production in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions, or morphologically normal adrenal glands.MethodsA retrospective analysis of ten consecutive patients with ACTH-independent hypercortisolism who underwent AVS at our institution between 2009 and 2017. Unilateral dominant cortisol production was defined as a side-to-side cortisol/aldosterone lateralization ratio >2.ResultsFour of ten patients had overt Cushing’s syndrome. Of these, two had bilateral adrenal lesions on computed tomography and two had normal adrenal glands. One of the two patients with bilateral adrenal lesions had, based on the AVS, a unilateral dominant cortisol production. Following unilateral adrenalectomy the patient developed adrenal insufficiency. The other three patients were considered to have bilateral cortisol production and underwent bilateral adrenalectomy. Six patients had a mild autonomous cortisol secretion and bilateral adrenal lesions. Based on AVS, one patient was considered to have unilateral dominant cortisol production, underwent unilateral adrenalectomy and developed transient adrenal insufficiency postoperatively.ConclusionsAVS may contribute to appropriate treatment in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions. In our series, AVS was helpful in the decision-making of two out of ten patients, avoiding chronic treatment with steroidogenesis inhibitors, or inappropriate bilateral adrenalectomy.

Adrenal Venous Sampling for Assessment of Autonomous Cortisol Secretion.

Autonomous cortisol secretion (ACS) can be unilateral or bilateral irrespective of the presence of an adrenal tumor. A reliable method to distinguish between unilateral and bilateral ACS is lacking. Evaluate the use of adrenal venous sampling (AVS) to distinguish between unilateral and bilateral ACS. This was a prospective study of AVS in patients with adrenal tumors who received a diagnosis of ACS or adrenal Cushing syndrome (CS). Unilateral secretion was defined as >2.3-fold difference in cortisol levels between the two adrenal veins. Metanephrine levels were used to ascertain correct catheter position. Results were correlated with findings on CT and iodine-131-cholesterol scintigraphy. Thirty-nine patients underwent AVS; there were no complications. The procedure was inconclusive in six patients and repeated with success in one, giving a success rate of 85%, and leaving 34 procedures for evaluation (adrenal CS, n = 2; ACS, n = 32). Of 14 patients with bilateral tumors, 10 had bilateral and 4 had unilateral overproduction. Of 20 patients with unilateral tumors, 11 had lateralization to the side of the tumor and the remaining had bilateral secretion. Cholesterol scintigraphy findings were concordant with those of AVS in 13 of 18 cases (72%) and discordant in 5 (28%). Laterality of ACS does not always correspond to findings on CT images. AVS is a safe and valuable tool for differentiation between unilateral and bilateral cortisol secretion and should be considered when operative treatment of ACS is a possibility.

Adrenal venous sampling in a patient with adrenal Cushing syndrome

The primary bilateral macronodular adrenal hyperplasia or the independent adrenocorticotropic hormone bilateral nodular adrenal hyperplasia is a rare cause hypercortisolism, its diagnosis is challenging and there is no clear way to decide the best therapeutic approach. Adrenal venous sampling is commonly used to distinguish the source of hormonal production in patients with primary hyperaldosteronism. It could be a useful tool in this context because it might provide information to guide the treatment. We report the case of a patient with ACTH independent Cushing syndrome in whom the use of adrenal venous sampling with some modifications radically modified the treatment and allowed the diagnosis of a macronodular adrenal hyperplasia.

An Expert Consensus Statement on Use of Adrenal Vein Sampling for the Subtyping of Primary Aldosteronism

Adrenal venous sampling is recommended by current guidelines to identify surgically curable causes of hyperaldosteronism but remains markedly underused. Key factors contributing to the poor use of adrenal venous sampling include the prevailing perceptions that it is a technically challenging procedure, difficult to interpret, and can be complicated by adrenal vein rupture. In addition, the lack of uniformly accepted standards for the performance of adrenal venous sampling contributes to its limited use. Hence, an international panel of experts working at major referral centers was assembled to provide updated advice on how to perform and interpret adrenal venous sampling. To this end, they were asked to use the PICO (Patient or Problem, Intervention, Control or comparison, Outcome) strategy to gather relevant information from the literature and to rely on their own experience. The level of evidence/recommendation was provided according to American Heart Association gradings whenever possible. A consensus was reached on several key issues, including the selection and preparation of the patients for adrenal venous sampling, the procedure for its optimal performance, and the interpretation of its results for diagnostic purposes even in the most challenging cases.

Is there still a place for adrenal venous sampling in the diagnostic localization of pheochromocytoma?

Our objective is to outline the utility of adrenal venous sampling (AVS) with measurements of metanephrine to normetanephrine ratios for diagnostic localization of phaeochromocytoma in a patient with normal plasma levels of catecholamines. A 53-year-old-woman was referred for evaluation of recurrent pheochromocytoma following a right adrenalectomy 14 years earlier. Diagnosis of recurrent disease was established from elevations in plasma metanephrines with normal levels of catecholamines. Magnetic resonance imaging indicated two 1-2 cm masses in the right surgical bed and another 1-1.5 cm mass in the left adrenal. These masses were negative on (123)I-metaiodobenzylguanidine scintigraphy. There was no evidence of a hereditary syndrome. We, therefore, carried out two investigational approaches to identify the tumor masses. Hybrid positron emission tomography/computed tomography with (68)Ga-DOTATOC ((68)Ga-DOTATOC-PET/CT) confirmed the presence of recurrent disease in the right surgical bed and also suggested additional left adrenal involvement. Normal plasma catecholamines precluded the use of adrenal venous sampling (AVS) with catecholamine measurements. Hence, we performed AVS with measurements of plasma metanephrines, which were 4- to 7-fold higher in the left adrenal vein than in central venous plasma. We observed a reversal of the normally high metanephrine to normetanephrine ratio (mean value ± SD 5.28 ± 1.86; range 3.36-8.84, n = 13) to 0.73, establishing the presence of a left adrenal pheochromocytoma. Surgical pathology confirmed bilateral disease. This case highlights a scenario where a combination of (68)Ga-DOTATOC-PET/CT and AVS with measurement of the metanephrine to normetanephrine ratio was crucial for the preoperative assessment of a patient with bilateral pheochromocytoma.

27 SINGLE CENTER OUTCOME OF LAPAROSCOPIC ADRENALECTOMY FOR PATIENTS WITH UNILATERAL ALDOSTERONE EXCESS: LATERALIZING DISEASE BASED ON THE RESULTS OF ADRENAL VENOUS SAMPLING

You have accessJournal of UrologyAdrenal: Surgery/Tumors/Benign and Malignant Disease1 Apr 201127 SINGLE CENTER OUTCOME OF LAPAROSCOPIC ADRENALECTOMY FOR PATIENTS WITH UNILATERAL ALDOSTERONE EXCESS: LATERALIZING DISEASE BASED ON THE RESULTS OF ADRENAL VENOUS SAMPLING Shigeto Ishidoya, Akihiro Ito, Yoshihide Kawasaki, Susumu Miyazato, Yasuhiro Kaiho, Haruo Nakagawa, and Yoichi Arai Shigeto IshidoyaShigeto Ishidoya Sendai, Japan More articles by this author , Akihiro ItoAkihiro Ito Sendai, Japan More articles by this author , Yoshihide KawasakiYoshihide Kawasaki Yuzawa, Japan More articles by this author , Susumu MiyazatoSusumu Miyazato Sendai, Japan More articles by this author , Yasuhiro KaihoYasuhiro Kaiho Sendai, Japan More articles by this author , Haruo NakagawaHaruo Nakagawa Sendai, Japan More articles by this author , and Yoichi AraiYoichi Arai Sendai, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.089AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Endocrine Society published Clinical Practice Guideline of primary aldosteronism (PA) (J Clin Endocrinol Metab 93: 3266, 2008), which recommended that the distinction between unilateral and bilateral adrenal disease should be made by adrenal venous sampling (AVS) when considering surgical treatment. This study assessed the clinical impact of the universal use of adrenal venous sampling (AVS) and to investigate the characteristics of patients with PA undergoing laparoscopic adrenalectomy in a single tertiary center. METHODS After screening examination, confirmatory test, and computed tomography (CT) were completed, all patients with biochemically diagnosed hyperaldosteronism underwent AVS for differentiating unilateral disease from bilateral idiopathic hyperaldosteronism. A total of 174 consecutive patients with unilateral aldosterone excess underwent unilateral laparoscopic adrenalectomy. RESULTS Surgically treated cohort was divided into 3 groups based on CT findings. One hundred and twenty-nine patients were associated with CT-positive macroadenoma (Type 1A: 74.1%), while 42 were associated with CT-negative microadenoma (Type 2A: 24.1%). Only 3 patients had adrenocortical hyperplasia (Type 3: 1.8%). Aldosterone level was normalized in all but 2 patients (98.9%) and the number of antihypertensive agents was significantly reduced within one month after adrenalectomy. One hundred and fifty-five (89.1%) of 174 patients showed resolution or improvement of hypertension. CONCLUSIONS Routine use of AVS could adequately detect lateralization in patients with unilateral aldosterone excess, which led to satisfactory short-term outcomes following surgery. This study showed that nearly one-fourth of patients with the unilateral form were associated with CT-negative aldosterone-producing microadenoma. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e10 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shigeto Ishidoya Sendai, Japan More articles by this author Akihiro Ito Sendai, Japan More articles by this author Yoshihide Kawasaki Yuzawa, Japan More articles by this author Susumu Miyazato Sendai, Japan More articles by this author Yasuhiro Kaiho Sendai, Japan More articles by this author Haruo Nakagawa Sendai, Japan More articles by this author Yoichi Arai Sendai, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single-center Outcome of Laparoscopic Unilateral Adrenalectomy for Patients With Primary Aldosteronism: Lateralizing Disease Using Results of Adrenal Venous Sampling

To assess the clinical effect of the universal use of adrenal venous sampling and to investigate the characteristics of patients with primary aldosteronism undergoing laparoscopic adrenalectomy at a single tertiary care center. After the screening examination, confirmatory test, and computed tomography (CT) scans were completed, all patients with biochemically diagnosed hyperaldosteronism underwent adrenal venous sampling to differentiate unilateral disease from bilateral idiopathic hyperaldosteronism. A total of 174 consecutive patients with unilateral aldosterone excess underwent unilateral laparoscopic adrenalectomy. The surgically treated cohort was divided into 3 groups according to the CT findings. A total of 129 patients (74.1%) had findings associated with CT-positive macroadenoma (type 1A) and 42 (24.1%) with CT-negative microadenoma (type 2A). Only 3 patients (1.8%) had adrenocortical hyperplasia (type 3). The aldosterone level was normalized in all but 2 patients (98.9%), and the number of antihypertensive agents was significantly reduced within 1 month after adrenalectomy. Of the 174 patients, 155 (89.1%) showed resolution or improvement of hypertension. The routine use of adrenal venous sampling could adequately detect lateralization in patients with unilateral aldosterone excess, which led to satisfactory short-term outcomes after surgery. The results of the present study showed that nearly one fourth of patients with the unilateral form had a CT-negative aldosterone-producing microadenoma.

Localization of Aldosterone-Producing Adrenocortical Adenomas: Significance of Adrenal Venous Sampling

Accurate localization of aldosterone-producing adenoma (APA) is essential for the treatment of primary aldosteronism (PA). In order to confirm the clinical usefulness of adrenal venous sampling (AVS), we retrospectively studied 87 cases of PA in whom AVS was conducted. We collected right and left adrenal venous effluents simultaneously before and after adrenocorticotropic hormone (ACTH) stimulation for measurements of aldosterone concentration (A) and cortisol concentration (C). Based on AVS results, we judged 66 cases as having unilateral aldosterone hypersecretion and the remaining 21 cases as having no apparent laterality. Of the above 66 subjects, 61 underwent laparoscopic removal of the adrenal gland through a retroperitoneal approach. The presence of APA was histopathologically confirmed, and blood pressure decreased significantly with normalization of plasma aldosterone concentration (PAC) in all cases. The receiver operator characteristics (ROC) curve analysis between the operated and no-apparent-laterality groups revealed that the ratio of A/C on the higher side to A/C on the lower side (A/C ratio) after ACTH stimulation is a useful index, with a cutoff value of 2.6, a sensitivity of 0.98 and a specificity of 1.0. The ROC curve analysis between the APA side and contralateral side within the operated patients revealed that the cutoff value of A was 1,340 ng/dL, with a sensitivity of 0.92 and a specificity of 1.00. Our results indicate the usefulness of simultaneous AVS and ACTH stimulation for localizing APA.

Selective Use of Adrenal Venous Sampling in the Lateralization of Aldosterone-producing Adenomas

Selective Use of Adrenal Venous Sampling in the Lateralization of Aldosterone-producing Adenomas

Re: “Selective Use of Adrenal Venous Sampling in the Lateralization of Aldosterone‐Producing Adenomas

Re: “Selective Use of Adrenal Venous Sampling in the Lateralization of Aldosterone‐Producing Adenomas

Selective Use of Adrenal Venous Sampling in the Lateralization of Aldosterone‐producing Adenomas

It has been suggested that routine adrenal venous sampling (AVS) is necessary to lateralize an aldosterone-producing adenoma in patients with primary hyperaldosteronism. However, the success rate of AVS is variable, with potential risks. We review our experience at University of California San Francisco (UCSF), where AVS is used only selectively, to determine outcomes with this approach. All patients undergoing adrenalectomy for aldosteronoma at UCSF from January 1995 to October 2004 were included. Outcome after adrenalectomy was determined based on plasma levels of aldosterone and potassium, rates of persistent hypertension, and reduced use of antihypertensive medications. Altogether, 65 patients were included in the study, 52 (80%) of whom had their adrenal tumors lateralized based on computed tomography scans, magnetic resonance imaging, or both. The remaining 13 (20%) patients had doubtful localization of their lesions on imaging. We did not routinely perform AVS in patients with definitive imaging findings. Thus, only 4 (8%) patients with definitive imaging findings underwent AVS, and one was unsuccessful. Of the 13 patients with doubtful lateralization on imaging, 8 underwent AVS. With this practice, biochemical cure rates after adrenalectomy were up to 100%, and hypertension resolved or was improved in 85% of patients. AVS may be performed selectively only when preoperative imaging cannot definitively lateralize the aldosteronoma. This practice in our center has resulted in high cure rates. During the era of improved imaging resolution and experience, mandatory routine AVS is not necessary to achieve high cure rates for aldosteronomas.

Minireview: primary aldosteronism--changing concepts in diagnosis and treatment.

Primary aldosteronism affects 5-13% of patients with hypertension. Patients with hypertension and hypokalemia and most patients with treatment-resistant hypertension should undergo screening for primary aldosteronism with a plasma aldosterone concentration to plasma renin activity ratio. A high plasma aldosterone concentration to plasma renin activity ratio is a positive screening test result, a finding that warrants confirmatory testing. For those patients that want to pursue a surgical cure, the accurate distinction between the subtypes (unilateral vs. bilateral adrenal disease) of primary aldosteronism is a critical step. The subtype evaluation may require one or more tests, the first of which is imaging the adrenal glands with computed tomography, followed by selective use of adrenal venous sampling. Because of the deleterious cardiovascular effects of aldosterone, normalization of circulating aldosterone or aldosterone receptor blockade should be part of the management plan for all patients with primary aldosteronism. Unilateral laparoscopic adrenalectomy is an excellent treatment option for patients with unilateral aldosterone-producing adenoma. Bilateral idiopathic hyperaldosteronism should be treated medically. In addition, aldosterone-producing adenoma patients may be treated medically if the medical treatment includes mineralocorticoid receptor blockade.