[Hyperaldosteronism sensitive to dexamethasone with adrenal adenoma. Clinical, biological and genetic study]

OBJECTIVES

Dexamethasone-sensitive hyperaldosteronism is associated with early onset hypertension and primary hyperaldosteronism. Diagnosis is difficult but can be improved by genetic testing for the mutant gene.

METHODS

We collected the clinical, biological and genetic elements observed in a family with dexamethasone-sensible hyperaldosteronism. Complete data were obtained in 5 adult subjects with the disease. Degree of hypertension varied, more so in the second generations as did hypokaliaemia and hyperaldosteronism. In affected patients, there was a 10 to 50 fold increase in urinary 18-OH components and 18 oxocortisol.

RESULTS

Single dose (1.5 mg) dexamethasone led to a greater than 80% drop in aldosterone levels in the blood and urine, confirming the abnormal effect of ACTH on mineralocorticoid secretion. At the dose of 1 mg/d for 10 weeks, dexamethasone lowered mean 24-H ambulatory arterial pressure (11.8/9.6 mmHg) and corrected for the hypokaliaemia (+0.54 mmol/l) and the hyperaldosteronism (mean decrease -36% and -75% in blood and urine respectively). An adrenal tumour was identified in hyperplasic glands in two subjects and a micronodular formation was identified in two others. The specific molecular diagnosis of the disease was done with Southern blotting. Among the 18 families in 3 generations, 8 carried a 11 beta OHase-aldosterone synthetase chimeric gene. This mutation cosegregates with hormonal abnormalities and confirms the autosomal dominant inheritance of the disease.

CONCLUSION

The simplicity and rapidity of genetic testing allows early diagnosis of this disease among families with early onset hypertension and associated hyperaldosteronism with or without adrenal hyperplasia and/or a tumoral formation.

[The value of fine needle puncture in adrenal gland tumors]

The value of fine needle biopsy (FNB) in adrenal masses was investigated in 33 patients presenting with such masses. Representative material was obtained 18 times from 19 patients with a history of tumour. 4 of them were diagnosed to be genuinely benign and 14 to be genuinely malignant. Further representative material was obtained 13 times from 14 patients with incidental findings of adrenal masses. The material gained by puncturing was classified correctly as benign in 9 cases, and twice it was considered benign although the tumours later proved malignant. In one case a clinically not suspected malignant lesion was detected by FNB, while in another case a malignant lesion was suspected by FNB, whereas a benign tumour was proven by means of surgery. The share of malignant diagnoses corresponded with the size of tumour, ascertained by the application of ultrasound or CT. The rate of malignant adrenal masses, which were found incidentally, increased from 7 cm onwards; however, the rate of malignant adrenal masses obtained from patients with a history of tumour increased distinctively already from 4 cm onwards. From 11 patients out of 33, adrenal tissue was obtained and classified as benign lesion (adenoma), although, by means of FNB and the conditions for reasons of method, a well differentiated carcinoma cannot be excluded.

CONCLUSION

FNB is indicated for non-functioning tumours examined in patients with a history of tumour, furthermore, for incidental findings of the size between 4-6 cm. A diagnostic approach to adrenal masses is suggested.

Scintigraphy of incidentally discovered bilateral adrenal masses

The purpose of this study was to determine the patterns of iodine-131 6 beta-iodomethylnorcholesterol (NP-59) imaging and the correlation with computed tomography (CT)-guided adrenal biopsy and follow-up in patients with bilateral adrenal masses. To this end we investigated a consecutive sample of 29 euadrenal patients with bilateral adrenal masses discovered on CT for reasons other than suspected adrenal disease. Adrenal scintigraphy was performed using 1 mCi of NP-59 injected intravenously, with gamma camera imaging 5-7 days later. In 13 of the 29 patients bilateral adrenal masses were the result of metastatic involvement from lung carcinoma (5), lymphoma (3), adrenocarcinoma of the colon (3), squamous cell carcinoma of the larynx (1), and anaplastic carcinoma of unknown primary (1). Among these cases the NP-59 scan demonstrated either bilaterally absent tracer accumulation (in eight, all with bilateral metastases proven by CT-guided biopsy or progression on follow-up CT) or marked asymmetry of adrenocortical NP-59 uptake (in five). Biopsy of the adrenal demonstrating the least NP-59 uptake documented malignant involvement of that gland in five of five patients. In two patients an adenoma was found simultaneously in one adrenal with a contralateral malignant adrenal mass. In each of these cases, the adenoma demonstrated the greatest NP-59 uptake. In 16 patients diagnosis of adenoma was made on the basis of (a) CT-guided adrenal biopsy of the gland with the greatest NP-59 uptake of the pair (n = 4), or (b) adrenalectomy (n = 2), or (c) absence of change in the size of the adrenal mass on follow-up CT scanning performed 6 months to 3 years later (n = 10).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous computed tomography-guided ethanol injection in aldosterone-producing adrenocortical adenoma

The feasibility, safety and effectiveness of percutaneous computed tomography-guided ethanol injection (PEI-CT) was investigated in a patient affected by aldosterone-producing adenoma (APA). A 42-year-old male patient with typical features of hyperaldosteronism presented a solitary left adrenal adenoma measuring 2 cm, with a normal contralateral gland, evidenced by both CT scan and adrenal [75Se-19]-nor-cholesterol scintigraphy. After normalization of potassium plasma levels, 4 ml of sterile 95% ethanol with 0.5 ml of 80% iothalamate sodium was injected. The procedure was completed in about 30 min. No severe pain or local complication was noted. Five hours after PEI, a fourfold and a twofold increase in aldosterone and cortisol plasma levels were observed, respectively. After 11 days on a normal sodium and potassium diet, normal potassium plasma levels and reduced aldosterone plasma levels were present, with reappearance of an aldosterone postural response. Plasma renin activity and aldosterone plasma levels normalized 1 month later, with reappearance also of a plasma renin activity postural response and maintenance of normal potassium plasma levels even on a high sodium and normal potassium diet. The patient has remained hypertensive, although lower antihypertensive drug dosages have been employed. After 17 months, normal biochemical, hormonal and morphological findings were still present. Thus, we suggest PEI-CT as a further alternative approach to surgery in the management of carefully selected patients with APA.

Combined Conn's and Cushing's syndrome: an unusual presentation of adrenal adenoma

In most aldosterone-producing adenomas (APA) dedifferentiation occurs with formation of transitional cells, bearing characteristics of both glomerulosa and fasciculata cells. These cells are able to produce cortisol, and their aldosterone production follows the circadian rhythm of ACTH. Usually, no clinical signs of cortisol excess develop, since the cortisol production remains under ACTH feedback control. Only a few cases have been described with autonomous cortisol secretion, not suppressible by low dose dexamethasone. We present a patient with an APA, synthesizing enough cortisol to cause the typical clinical expression of Cushing's syndrome. Possible etiopathological mechanisms are discussed.

Interference by spironolactone on adrenocortical scintigraphy and other pitfalls in the location of adrenal abnormalities in primary aldosteronism

A case of primary aldosteronism is presented in which the CT scan was initially misleading, adrenocortical scintigraphy was rendered inaccurate by pharmacological interference of spironolactone, and selective adrenal venous sampling of aldosterone was technically difficult. When dexamethasone suppression adrenocortical scintigraphy was performed with attention to technical detail and exclusion of interference by spironolactone, the causative lesion was scintigraphically demonstrated. This finding was confirmed by the results of venous sampling and the correctly located tumor removed.

CT and MR distinction of adenomas and nonadenomas of the adrenal gland

OBJECTIVE

Because the distinction between adenomas and nonadenomas of the adrenal gland is essential, we investigated which of the following parameters--size, CT attenuation values, MRI signal intensity ratios on T1- and T2-weighted sequences, calculated T2 relaxation times, or T2 relaxation time ratios--provides better discrimination.

MATERIALS AND METHODS

We compared these parameters in 44 adrenal masses of 37 patients by means of the Student t test and receiver operating characteristics (ROC) analyses.

RESULTS

Only size, CT attenuation values, and signal intensity ratios on T2-weighted MR images of adenomas showed a significant difference from those of nonadenomas. With use of ROC analysis, CT demonstrated a significantly larger area under the curve compared to size and T2 signal intensity ratios, indicating superior performance.

CONCLUSION

We found attenuation values on non-contrast-enhanced CT to be the best method in discriminating adrenal adenomas from nonadenomas. Adrenal masses with CT attenuation values below 15 HU warrant no further investigations.

[A case of adrenal adenoma with radiologic "cystic" appearance associated with hypophyseal adenoma]

Expansive lesions of the adrenal glands without signs of hormonal hypersecretion are usually discovered "incidentally", and are therefore called "incidentalomas". Since the silent adrenal masses constitute a heterogeneous group of lesions, the most important issue raised by the identification of these masses is their possible malignant potential. Therefore, the age and sex of the patients, the size of the mass, its imaging characteristic and its histologic features are the most important factors in the assessment of nonfunctioning adrenal masses. We report here the case of a women, aged 43 years mild hypertension, harbouring a great adrenal mass of 8 cm diameter, with cystic appearance at CT scan and ultrasonography, it did not show any uptake after 75Se-Seleniumcholesterol or 131I-Metaiodobenzyl-guanidine. The patient was also affected by mild hyperprolactinemia caused a small pituitary adenoma. After selective venography, she underwent the surgical removal of the left adrenal gland with its mass, which showed a hystological picture of adrenal adenoma. The postoperative course was clinically normal. The interest of this case resides: in the dimensions of the adrenal tumor (the presence of adenomas greater than 6 cm diameter is extremely rare); in the radiographic findings, showing a cystic appearance, probably related to a fluid component, in the association of adrenal and pituitary adenoma, as a possible variant of multiple endocrine neoplasia (MEN) of type I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound of incidental tumors of the adrenal gland and endocrine hypertension]

We report on a retrospective analysis of 1,500 hypertensive patients who underwent a sonographic examination of the abdomen. 8 'incidentalomas' of the adrenal gland (0.6%) were thereby found. Endocrinological analysis showed that only 1 of the incidentalomas was active (pheochromocytoma). The other tumors had no endocrine activity. On the other side, 7 patients without any sonographic abnormality had hyperaldosteronism, 1 patient suffered from an adrenomedullary hyperplasia. Those patients had been thought to have endocrine hypertension from clinical suspicion. We conclude that a thorough sonographic examination of the adrenal area is an important part of the diagnostic workup in hypertensive patients, although most of the incidentally discovered tumors are endocrinologically inactive. Adrenocortical and adrenomedullary hyperplasias and adrenocortical adenomas are detected clinically while they are still not visible by ultrasound.

The role of adrenocortical scintigraphy in the evaluation of unilateral incidentally discovered adrenal and juxtaadrenal masses

We reviewed the findings of adrenocortical scintigraphy with 131I-6-beta-iodomethyl-19-norcholesterol (NCL-6-131I) of 39 patients to clarify its role in the evaluation of unilateral adrenal or juxtaadrenal masses incidentally discovered by CT, ultrasonography or plain radiography. Twenty-seven benign adrenal masses showed various scintigraphic findings (hot nodule: 12 silent adenomas, warm nodule: one solid mass, normal appearance: one cyst and 2 solid masses, diffuse decrease: each one; solid mass, myelolipoma, ganglioneuroma and calcified adrenal and partial or complete defect: each one; solid mass, myelolipoma and ganglioneuroma and 2 cysts and 2 pheochromocytomas); while a partial or complete defect was shown in a nonfunctioning carcinoma and 3 metastases and a complete defect or inhomogeneous uptake without opposite adrenal visualization was shown in 2 patients with cortisol-producing carcinoma. Therefore a hot nodule and an inhomogeneous uptake or complete defect with nonvisualization of the opposite adrenal are specific to a benign tumor and a cortisol-producing carcinoma, respectively. The impaired tumor uptake of NCL-6-131I is a nonspecific finding. The scintigraphic findings of juxtaadrenal masses were normal in 4 and deviated adrenals in 2. Thus adrenocortical scintigraphy can identify silent adenomas and cortisol-producing carcinomas among the adrenal masses and may help to differentiate juxtaadrenal from adrenal masses.