1
|
Ekman N, Grossman AB, Dworakowska D. What We Know about and What Is New in Primary Aldosteronism. Int J Mol Sci 2024; 25:900. [PMID: 38255973 PMCID: PMC10815558 DOI: 10.3390/ijms25020900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Primary aldosteronism (PA), a significant and curable cause of secondary hypertension, is seen in 5-10% of hypertensive patients, with its prevalence contingent upon the severity of the hypertension. The principal aetiologies of PA include bilateral idiopathic hypertrophy (BIH) and aldosterone-producing adenomas (APAs), while the less frequent causes include unilateral hyperplasia, familial hyperaldosteronism (FH) types I-IV, aldosterone-producing carcinoma, and ectopic aldosterone synthesis. This condition, characterised by excessive aldosterone secretion, leads to augmented sodium and water reabsorption alongside potassium loss, culminating in distinct clinical hallmarks: elevated aldosterone levels, suppressed renin levels, and hypertension. Notably, hypokalaemia is present in only 28% of patients with PA and is not a primary indicator. The association of PA with an escalated cardiovascular risk profile, independent of blood pressure levels, is notable. Patients with PA exhibit a heightened incidence of cardiovascular events compared to counterparts with essential hypertension, matched for age, sex, and blood pressure levels. Despite its prevalence, PA remains frequently undiagnosed, underscoring the imperative for enhanced screening protocols. The diagnostic process for PA entails a tripartite assessment: the aldosterone/renin ratio (ARR) as the initial screening tool, followed by confirmatory and subtyping tests. A positive ARR necessitates confirmatory testing to rule out false positives. Subtyping, achieved through computed tomography and adrenal vein sampling, aims to distinguish between unilateral and bilateral PA forms, guiding targeted therapeutic strategies. New radionuclide imaging may facilitate and accelerate such subtyping and localisation. For unilateral adrenal adenoma or hyperplasia, surgical intervention is optimal, whereas bilateral idiopathic hyperplasia warrants treatment with mineralocorticoid antagonists (MRAs). This review amalgamates established and emerging insights into the management of primary aldosteronism.
Collapse
Affiliation(s)
- Natalia Ekman
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Ashley B. Grossman
- Centre for Endocrinology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 4NS, UK;
| | - Dorota Dworakowska
- Department of Hypertension & Diabetology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| |
Collapse
|
2
|
Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
Collapse
Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| |
Collapse
|
3
|
Robotic Versus Laparoscopic Adrenalectomy: The European Experience. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
|
4
|
Zdrojewska M, Mech-Siebieszuk E, Świątkowska-Stodulska R, Regent B, Kunc M, Zdrojewski Ł, Sworczak K. Adrenal Tumors in Young Adults: Case Reports and Literature Review. Medicina (B Aires) 2022; 58:medicina58060746. [PMID: 35744009 PMCID: PMC9230179 DOI: 10.3390/medicina58060746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
The current high detection rate of adrenal tumors (4–10% of general population) is attributable to a widespread use of variety of imaging studies, especially a computed tomography. Most of them represent clinically silent and biologically indolent incidentalomas, but some adrenal tumors may pose a significant clinical challenge. Thus, in every patient with an adrenal tumor, a decision on further management is made after careful hormonal and radiological evaluation. All hormonally active tumors and those with radiological features suggesting malignancy are qualified for surgery. Approximately 80% of adrenal tumors are adrenocortical adenomas, hypertrophy, or nodular adrenocortical hyperplasia. Other histopathological diagnoses include pheochromocytoma, adrenocortical carcinoma, metastases, mesenchymal tumors, lymphomas, cysts, and ganglioneuromas. Adrenal tumors are more commonly diagnosed and better studied in elderly patients. In younger patients, under 40 years old, focal adrenal lesions are relatively rare, and histological distribution of diagnoses differs from that in elderly individuals. Younger patients are more likely to display endocrine symptoms, which raise the suspicion of an adrenal mass. In the current study, we present a case series of seven adrenal tumors occurring in young patients. The cases presented below, along with the literature review, demonstrate that the diagnosis and treatment of adrenal tumors are crucial due to endocrinopathy-derived complications and a potential risk of malignancy.
Collapse
Affiliation(s)
- Małgorzata Zdrojewska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland; (E.M.-S.); (R.Ś.-S.); (K.S.)
- Correspondence:
| | - Emilia Mech-Siebieszuk
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland; (E.M.-S.); (R.Ś.-S.); (K.S.)
| | - Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland; (E.M.-S.); (R.Ś.-S.); (K.S.)
| | - Bartosz Regent
- Department of Radiology, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland;
| | - Michał Kunc
- Department of Pathology, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland;
| | - Łukasz Zdrojewski
- Department of Nephrology, Transplantology and Internal Medicine, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland;
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdansk, 80-214 Gdansk, Poland; (E.M.-S.); (R.Ś.-S.); (K.S.)
| |
Collapse
|
5
|
Hartmann I, Hruska F, Vaclavik J, Kocianova E, Frysak Z, Nesvadbova M, Tudos Z, Ctvrtlik F, Benesova K. Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism. Endocrine 2022; 76:142-150. [PMID: 35147923 DOI: 10.1007/s12020-022-02988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/19/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA). METHODS A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis. RESULTS This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4. CONCLUSION A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.
Collapse
Affiliation(s)
- Igor Hartmann
- Department of Urology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Frantisek Hruska
- Department of Urology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic.
| | - Jan Vaclavik
- Department of Internal Medicine and Cardiology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
- Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Eva Kocianova
- Department of Internal Medicine I-Cardiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Zdenek Frysak
- Department of Internal Medicine III, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Marika Nesvadbova
- Department of Urology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Zbynek Tudos
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Filip Ctvrtlik
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Klara Benesova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| |
Collapse
|
6
|
Flammia RS, Anceschi U, Tufano A, Bologna E, Proietti F, Bove AM, Misuraca L, Mastroianni R, Tirone G, Carrara A, Luciani L, Cai T, Leonardo C, Simone G. Minimally Invasive Partial vs. Total Adrenalectomy for the Treatment of Unilateral Primary Aldosteronism: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11051263. [PMID: 35268355 PMCID: PMC8911420 DOI: 10.3390/jcm11051263] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/04/2022] [Accepted: 02/22/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND This systematic review and metanalysis was conducted to assess differences between perioperative and functional outcomes in patients undergoing minimally-invasive partial (mi-PA) and total adrenalectomy (mi-TA) for unilateral primary aldosteronism (uPHA). MATERIAL AND METHODS Multiple scientific databases (PUBMED, Web of Science, and Cochrane Library) were searched up to November 2021 for surgical series comparing mi-PA vs. mi-TA for uPHA according to the PRISMA statement. Primary outcomes of interest were perioperative and functional outcomes. RESULTS Overall, a total of 802 patients from six eligible studies were identified, with mi-PA and mi-TA performed in 40.4% (n = 324) and 59.6% (n = 478) of cases, respectively. No differences were recorded between the two groups according to number of transfusions, EBL and Clavien-Dindo complications ≥2. Similarly, no differences in clinical success, persistence of postoperative hypokalemia and improvement in HTN were reported between mi-PA and mi-TA. CONCLUSIONS In a uPHA setting, mi-PA and mi-TA provide comparable perioperative and functional outcomes despite the use of mi-PA remains limited to patients with small adenoma size, or hereditary/bilateral disease. Due to limited use of standardized reporting criteria in most of current series, the quest for a superiority of mi-PA over mi-TA in the treatment of uPHA still remains open.
Collapse
Affiliation(s)
- Rocco Simone Flammia
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy;
- Correspondence: ; Tel.: +39-33-9583-6431 or +39-379-175-0925
| | - Antonio Tufano
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Eugenio Bologna
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Flavia Proietti
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Alfredo Maria Bove
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Leonardo Misuraca
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Riccardo Mastroianni
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Giuseppe Tirone
- Department of General Surgery, Santa Chiara Regional Hospital, Azienda Sanitaria per i Servizi Sanitari (APSS), Largo Medaglie d’Oro 9, 38122 Trento, Italy;
| | - Alessandro Carrara
- Department of General Surgery, Santa Maria del Carmine Hospital, Azienda Sanitaria per i Servizi Sanitari (APSS), Corso Verona 4, 38068 Rovereto, Italy;
| | - Lorenzo Luciani
- Department of Urology, Santa Chiara Regional Hospital, Azienda Sanitaria per i Servizi Sanitari (APSS), Largo Medaglie d’Oro 9, 38122 Trento, Italy; (L.L.); (T.C.)
| | - Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Azienda Sanitaria per i Servizi Sanitari (APSS), Largo Medaglie d’Oro 9, 38122 Trento, Italy; (L.L.); (T.C.)
| | - Costantino Leonardo
- Urology Unit, Department of Maternal-Child and Urological Sciences, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.S.F.); (A.T.); (E.B.); (F.P.); (A.M.B.); (L.M.); (R.M.); (C.L.)
| | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy;
| |
Collapse
|
7
|
Alesina PF, Knyazeva P, Hinrichs J, Walz MK. Tailored Approach in Adrenal Surgery: Retroperitoneoscopic Partial Adrenalectomy. Front Endocrinol (Lausanne) 2022; 13:855326. [PMID: 35418944 PMCID: PMC8995530 DOI: 10.3389/fendo.2022.855326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
The interest on partial adrenalectomy has steadily increased over the past twenty years. Adrenal pathologies are mostly benign, making an organ-preserving procedure attractive for many patients. The introduction of minimally invasive techniques played probably an important role in this process because they transformed a complex surgical procedure, related to the difficult access to the retroperitoneal space, into a simple operation improving the accessibility to this organ. In this review we summarize the role of partial retroperitoneoscopic adrenalectomy over the years and the current indications and technique.
Collapse
Affiliation(s)
- Pier Francesco Alesina
- Clinic for Endocrine Surgery, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
- *Correspondence: Pier Francesco Alesina, ; orcid.org/0000-0002-8508-9934
| | - Polina Knyazeva
- Department of Surgery and Centre of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Essen, Germany
| | - Jakob Hinrichs
- Department of Surgery and Centre of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Essen, Germany
| | - Martin K. Walz
- Department of Surgery and Centre of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Essen, Germany
| |
Collapse
|
8
|
Velema MS, Canu L, Dekkers T, Hermus ARMM, Timmers HJLM, Schultze Kool LJ, Groenewoud HJMM, Jacobs C, Deinum J. Volumetric evaluation of CT images of adrenal glands in primary aldosteronism. J Endocrinol Invest 2021; 44:2359-2366. [PMID: 33666874 DOI: 10.1007/s40618-021-01540-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate whether adrenal volumetry provides better agreement with adrenal vein sampling (AVS) than conventional CT for subtyping PA. Furthermore, we evaluated whether the size of this contralateral adrenal was a prognostic factor for clinical outcome after unilateral adrenalectomy. METHODS We retrospectively analyzed volumes of both adrenal glands of the 180 CT-scans (88/180 with unilateral and 92/180 with bilateral disease) of the patients with PA included in the SPARTACUS trial of which 85 also had undergone an AVS. In addition, we examined CT-scans of 20 healthy individuals to compare adrenal volumes with published normal values. RESULTS Adrenal volume was higher for the left than the right adrenal (mean and SD: 6.49 ± 2.77 ml versus 5.25 ± 1.87 ml for the right adrenal; p < 0.001). Concordance between volumetry and AVS in subtyping was 58.8%, versus 51.8% between conventional CT results and AVS (p = NS). The volumes of the contralateral adrenals in the patients with unilateral disease (right 4.78 ± 1.37 ml; left 6.00 ± 2.73 ml) were higher than those of healthy controls reported in the literature (right 3.62 ± 1.23 ml p < 0.001; left 4.84 ± 1.67 ml p = 0.02). In a multivariable analysis the contralateral volume was not associated with biochemical or clinical success, nor with the defined daily doses of antihypertensive agents at 1 year follow-up. CONCLUSIONS Volumetry of the adrenal glands is not superior to current assessment of adrenal size by CT for subtyping patients with PA. Furthermore, in patients with unilateral disease the size of the contralateral adrenal is enlarged but its size is not associated with outcome.
Collapse
Affiliation(s)
- M S Velema
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - L Canu
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - T Dekkers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A R M M Hermus
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L J Schultze Kool
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H J M M Groenewoud
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Jacobs
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
9
|
Li KP, Duan X, Yang XS, Huang J, Wu T. Partial versus total adrenalectomy for the treatment of unilateral aldosterone-producing adenoma: a systematic review and meta-analysis. Updates Surg 2021; 73:2301-2313. [PMID: 34148213 DOI: 10.1007/s13304-021-01116-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/11/2021] [Indexed: 12/14/2022]
Abstract
Adrenalectomy is the first line of treatment in unilateral aldosterone-producing adenoma. Whether adrenalectomy should be performed using a cortex-sparing technique (partial adrenalectomy) or total adrenalectomy remains debatable. Therefore, this meta-analysis aims to evaluate the safety and effectiveness of partial adrenalectomy (PA) to total adrenalectomy (TA) by comparing perioperative and functional outcomes. A systematic search was performed across Pubmed, Embase, Web of Science, Cochrane Library database for RCTs and non-RCTs comparing PA and TA on unilateral aldosterone-producing adenoma. The main outcomes analyzed were the perioperative and postoperative effectiveness. In addition, weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals of continuous and dichotomous variables are presented. Two RCTs and 5 non-RCTs trials, including 834 patients were identified and included in the meta-analysis. PA was associated with statistically significant shorter hospital stay (WMD - 0.51 days, 95% CI - 0.87, - 0.14; p = 0.007), shorter operative time (WMD - 15.54 min, 95% CI - 25.12, - 5.97; p = 0.001) and lower overall complications (OR 0.52, 95% CI 0.32, 0.85; p = 0.009) compared to TA. There was no statistical significance in postoperative effectiveness, including postoperative blood pressure, potassium, hypokalemia, ARR and renin between TA and PA. PA seems to have advantages over TA. The surgical outcomes were comparable in TA and PA. The hospital stay, operative time and overall complications may be reduced. When technically feasible, PA might be considered as a better treatment for unilateral aldosterone-producing adenoma.
Collapse
Affiliation(s)
- Kun-Peng Li
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xi Duan
- Department of Dermatology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue-Song Yang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Huang
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Tao Wu
- Department of Urology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
| |
Collapse
|
10
|
Wachtel H, Fraker DL. Therapeutic Outcomes with Surgical and Medical Management of Primary Aldosteronism. Curr Cardiol Rep 2021; 23:89. [PMID: 34081226 DOI: 10.1007/s11886-021-01516-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is the most common cause of secondary hypertension and is significantly under-diagnosed. Delays in diagnosis and treatment can lead to cardiovascular morbidity and mortality. The goal of this study is to review the management of PA, with a focus on medical and surgical treatment outcomes. RECENT FINDINGS PA causes cardiovascular dysfunction in excess of degree of hypertension. Adrenalectomy demonstrates a therapeutic advantage over mineralocorticoid antagonist (MRA) therapy, after controlling for degree of hypertension and subtype of PA. Higher rates of atrial fibrillation, heart failure, stroke, and incidence of chronic kidney disease are observed in subjects treated with MRAs than in subjects treated with adrenalectomy. The therapeutic benefit of surgery may reflect definitive resolution of excess aldosterone. Complete mineralocorticoid blockade may achieve similar benefit to adrenalectomy. Adrenalectomy is the most effective treatment for unilateral PA. Biomarkers for MRA therapy might inform optimal medical therapy of bilateral adrenal hyperplasia.
Collapse
Affiliation(s)
- Heather Wachtel
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
11
|
Meloche-Dumas L, Mercier F, Lacroix A. Role of unilateral adrenalectomy in bilateral adrenal hyperplasias with Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101486. [PMID: 33637447 DOI: 10.1016/j.beem.2021.101486] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Primary bilateral adrenocortical hyperplasias are rare forms of pituitary ACTH-independent Cushing's syndrome (CS). They are divided between primary bilateral macronodular adrenal hyperplasia (PBMAH) and micronodular adrenal hyperplasia (MiBAH), which is subdivided in primary pigmented nodular adrenocortical disease (PPNAD) and isolated micronodular adrenocortical disease (i-MAD). One of the most debated aspects surrounding these entities is their most appropriate therapy. Although bilateral adrenalectomy (BA) has previously been the most utilized therapy for patients with overt CS, recent studies have indicated that unilateral adrenalectomy (UA) can be effective in patients with PBMAH and some with MiBAH with fewer long-term side effects. Medical therapies can also be used for bridging to surgery or rarely in the long-term for these patients. We review the various degrees of CS resulting from PBMAH and MiBAH, with a special focus on their respective therapies including UA, taking into account the recent pathophysiological and genetics findings.
Collapse
Affiliation(s)
- Léamarie Meloche-Dumas
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - Frédéric Mercier
- Surgical Oncology Service, Department of Surgery, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| | - André Lacroix
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de L'Université de Montréal (CHUM), Université de Montréal, Montréal, Canada.
| |
Collapse
|
12
|
Huang WC, Chen YY, Lin YH, Chueh JS. Composite Cardiovascular Outcomes in Patients With Primary Aldosteronism Undergoing Medical Versus Surgical Treatment: A Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:644260. [PMID: 34079522 PMCID: PMC8165438 DOI: 10.3389/fendo.2021.644260] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/12/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Superior outcomes after surgical treatment over medical treatment for primary aldosteronism (PA) has been reported in small-scale clinical studies, but no solid conclusion has been drawn as results of large randomized trials are lacking. METHODS We performed a search of PubMed, MEDLINE, Embase and Cochrane Library for randomized or observational studies that investigated cardiovascular outcomes in patients with PA undergoing medical versus surgical treatment. Meta-analyses of both composite and individual outcomes were conducted. Risks of bias of the included studies were assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) checklist. Trial sequential analysis (TSA) was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive. RESULTS A total of 12 studies, including a total of 6148 PA patients, were included in the meta-analysis. The results of meta-analyses demonstrated lower incidence of composite cardiovascular outcomes among PA patients who underwent surgical treatment over medical treatment (odds ratio (OR): 0.49). Surgical treatment also led to less incidence of persistence of hypertension (OR of non-cure hypertension: 0.31). Fewer major cardiovascular events and mortality events were observed (OR: 0.60) after surgical treatment. TSA result showed that the required information size was 2151 and the cumulative Z curve crossed the futility boundary and reached the required information size. CONCLUSION Superior performance of surgical treatment over medical treatment is confirmed with meta-analyses in terms of lower incidences of composite cardiovascular outcomes and non-cure of hypertension. Hence, adrenalectomy could now be concluded as the treatment of choice for lateralized PA.
Collapse
Affiliation(s)
- Wei-Chieh Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Ying-Ying Chen
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jeff S. Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, United States
- *Correspondence: Jeff S. Chueh,
| |
Collapse
|
13
|
Billmann F, Billeter A, Thomusch O, Keck T, El Shishtawi S, Langan EA, Strobel O, Müller-Stich BP. Minimally invasive partial versus total adrenalectomy for unilateral primary hyperaldosteronism-a retrospective, multicenter matched-pair analysis using the new international consensus on outcome measures. Surgery 2020; 169:1361-1370. [PMID: 33077201 DOI: 10.1016/j.surg.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/22/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary hyperaldosteronism is a recognized risk factor for myocardial infarction, stroke, and atrial fibrillation. Minimally invasive adrenalectomy is the first-line treatment for localized primary hyperaldosteronism. Whether minimally invasive adrenalectomy should be performed using a cortex-sparing technique (partial minimally invasive adrenalectomy) or not (total minimally invasive adrenalectomy) remains a subject of debate. The aim of our study was to evaluate the clinical and biochemical efficacy of both procedures and to examine the morbidity associated with partial minimally invasive adrenalectomy versus total minimally invasive adrenalectomy in a multicenter study. METHODS Using a retrospective study design, we determined the efficacy, morbidity, and mortality of partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy. The Primary Aldosteronism Surgical Outcome Study classification was used to explore clinical and biochemical success. Matched-pair analysis was used in order to address possible bias. RESULTS We evaluated 234 matched patients with unilateral primary hyperaldosteronism: 78 (33.3%) underwent partial minimally invasive adrenalectomy, and 156 (66.7%) were treated with total minimally invasive adrenalectomy. Complete clinical success was achieved in 40.6%, and partial clinical success in an additional 52.6% of patients in the entire cohort. Complete biochemical success was seen in 94.0% of patients. Success rates and the incidence of perioperative complications were comparable between groups. Both postoperative hypocortisolism (11.5% vs 25.0% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy, respectively; P < .001) and postoperative hypoglycemia (2.6% vs 7.1% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy; P = .039) occurred more frequently after total minimally invasive adrenalectomy. CONCLUSION Our study provides evidence that patients with unilateral primary hyperaldosteronism are good surgical candidates for partial minimally invasive adrenalectomy. Not only is the surgical outcome comparable to that of total minimally invasive adrenalectomy, but also postsurgical morbidity, particularly in terms of hypocortisolism and hypoglycemia, may be reduced.
Collapse
Affiliation(s)
- Franck Billmann
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Adrian Billeter
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Oliver Thomusch
- Department of Surgery, University Hospital of Freiburg im Breisgau, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | | | - Ewan A Langan
- Department of Dermatology, University Hospital Schleswig Holstein, Campus Lübeck, Germany; Department of Dermatological Science, University of Manchester, United Kingdom
| | - Oliver Strobel
- Department of Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | | |
Collapse
|
14
|
Arora A, Jha C, Singh P. Letter to the Editor: Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy? World J Surg 2020; 44:1683-1684. [PMID: 31900566 DOI: 10.1007/s00268-019-05338-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Abhishek Arora
- All India Institute of Medical Sciences - Patna, General Surgery, Patna, India
| | - Chandan Jha
- All India Institute of Medical Sciences - Patna, General Surgery, Patna, India.
| | - Prashant Singh
- All India Institute of Medical Sciences - Patna, General Surgery, Patna, India
| |
Collapse
|
15
|
Rossi GP, Bisogni V, Bacca AV, Belfiore A, Cesari M, Concistrè A, Del Pinto R, Fabris B, Fallo F, Fava C, Ferri C, Giacchetti G, Grassi G, Letizia C, Maccario M, Mallamaci F, Maiolino G, Manfellotto D, Minuz P, Monticone S, Morganti A, Muiesan ML, Mulatero P, Negro A, Parati G, Pengo MF, Petramala L, Pizzolo F, Rizzoni D, Rossitto G, Veglio F, Seccia TM. The 2020 Italian Society of Arterial Hypertension (SIIA) practical guidelines for the management of primary aldosteronism. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2020; 5:100029. [PMID: 33447758 PMCID: PMC7803025 DOI: 10.1016/j.ijchy.2020.100029] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
Background and aim Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism. Methods To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered. Results Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review. Conclusions After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.
Collapse
Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- Corresponding author. DIMED –Clinica dell’Ipertensione Arteriosa, University Hospital, via Giustiniani, 2; 35126, Padova, Italy.
| | - Valeria Bisogni
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | | | - Anna Belfiore
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Antonio Concistrè
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Rita Del Pinto
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | - Bruno Fabris
- Department of Medical Sciences, Università degli Studi di Trieste, Cattinara Teaching Hospital, Trieste, Italy
| | - Francesco Fallo
- Department of Medicine, DIMED, Internal Medicine 3, University of Padua, Italy
| | - Cristiano Fava
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Claudio Ferri
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | | | | | - Claudio Letizia
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Mauro Maccario
- Endocrinology, Diabetology, and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Giuseppe Maiolino
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Dario Manfellotto
- UO Medicina Interna, Ospedale Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Pietro Minuz
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Silvia Monticone
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Ospedale Policlinico, Università Milano, Milan, Italy
| | - Maria Lorenza Muiesan
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Paolo Mulatero
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Aurelio Negro
- Department of Medicine, Center for Hypertension, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Martino F. Pengo
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi Petramala
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Francesca Pizzolo
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Giacomo Rossitto
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Franco Veglio
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Teresa Maria Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| |
Collapse
|
16
|
Abstract
Primary hyperaldosteronism (PA) is one of the most common causes of hypertension that is amenable to surgical cure. Once a patient has a biochemical diagnosis of PA, workup should proceed with tumor lateralization to determine whether the patient has unilateral or bilateral disease. Tumor lateralization can be done with noninvasive imaging such as a CT or MRI. However, in older patients or in patients with non-lateralizing imaging, arteriovenous sampling (AVS) should be considered. If the patient has confirmed unilateral disease, options for surgical intervention include laparoscopic or, less commonly, open. Laparoscopic adrenalectomy for PA has been shown to be a safe and effective procedure that is associated with less morbidity compared to open adrenalectomy. Patients can either undergo a laparoscopic transabdominal adrenalectomy via a lateral (most common) or anterior approach or a retroperitoneoscopic adrenalectomy via a posterior approach. The majority of patients have complete biochemical success, defined as normalization of plasma aldosterone, renin and potassium levels and appropriate suppression with stimulation tests. Less than half of patients have complete clinical success, defined as normotensive with no antihypertensive medications. However, the majority of patients who do not have complete clinical success will have some improvement in their blood pressure and/or are able to decrease the number of antihypertensive medications that they require.
Collapse
Affiliation(s)
- Catherine McManus
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
17
|
Abstract
Primary aldosteronism (PA) is a highly prevalent cause of arterial hypertension featuring excess cardiovascular events. A timely diagnosis and treatment of PA cures hyperaldosteronism and can provide resolution or improvement of arterial hypertension, even when the latter is resistant to drug treatment. Accordingly, strategies to screen early and widely the hypertensive patients for PA by means of simplified diagnostic algorithms are justified. Such strategies are particularly beneficial in subgroups of hypertensive patients, who are at the highest cardiovascular risk. Broadening of screening strategies means facing with an increased number of patients where monitoring the disease becomes necessary. Hence, after identification of the surgically and non surgically curable cases of PA and implementation of targeted treatment physicians are faced with the challenges of follow-up, which are scantly discussed in the literature. Hence, the purpose of this paper is to provide some recommendations on how to optimize the monitoring of patients in whom the PA subtype has been diagnosed and treatment, either with unilateral laparoscopic adrenalectomy or medically, has been instituted.
Collapse
Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Livia Lenzini
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Teresa M Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| |
Collapse
|
18
|
Alesina PF, Walz MK. Adrenal Tumors: Are Gender Aspects Relevant? Visc Med 2020; 36:15-19. [PMID: 32110652 DOI: 10.1159/000505788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
The distribution of malignant tumors is strongly related to gender due to sex-related organ and tissue differentiation. Neoplasias of the adrenal glands are relatively common and typically benign. Mainly based on our recently published contributions, we analyzed the influence of gender on type of tumors, complexity of surgery, and long-term outcome. Cortisol-secreting adrenal tumors are more often diagnosed in female patients, while the incidence of Conn's syndrome and pheochromocytoma is similar between male and female patients. Adrenalectomy is more difficult in male patients because of longer operating time and higher blood loss. The probability of cure in male patients with Conn's syndrome is significantly lower. Gender does not influence long-term results in adrenal hypercortisolism and pheochromocytomas.
Collapse
Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
19
|
Schneider H, Williams TA, Heinrich DA, Lechner B, Reincke M. Primary aldosteronism long-term outcome: Medical versus surgical therapy. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.coemr.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Shariq OA, Mehta K, Thompson GB, Lyden ML, Farley DR, Bancos I, Dy BM, Young WF, McKenzie TJ. Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy? World J Surg 2019; 43:2469-2476. [PMID: 31214831 DOI: 10.1007/s00268-019-05059-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Patients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes. METHODS A retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups. RESULTS Of 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left-sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24-h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype. CONCLUSIONS Clinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal-sparing approaches.
Collapse
Affiliation(s)
- Omair A Shariq
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
| | - Kabir Mehta
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| |
Collapse
|
21
|
Malignancy Risk and Hormonal Activity of Adrenal Incidentalomas in a Large Cohort of Patients from a Single Tertiary Reference Center. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16101872. [PMID: 31137898 PMCID: PMC6571894 DOI: 10.3390/ijerph16101872] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/17/2022]
Abstract
Background: A rise in adrenal incidentalomas (AIs) detection has been observed recently. Even though AIs are detected in asymptomatic patients, thorough assessment may reveal hormonal and metabolic abnormalities or malignant character. Methods: Medical records of 2005 patients (1301 women, 704 men) with 2498 tumors aged 61 ± 11.3 (18–93) years, who had been hospitalized due to AI diagnosis, were reviewed. Patients underwent clinical examination, adrenal CT and hormonal assessment. In patients subjected to adrenalectomy, histopathological character of AI was confirmed. Results: AIs most frequently occurred in patients in their 7th decade of life. Hypertension was present in 76.6%, glucose metabolism disorders in 41.3%, and hypercholesterolemia in 60.1% of patients. Lipid-rich adenomas (83.2%) and hormonally inactive tumors (83.1%) predominated. Autonomous cortisol secretion was present or suspected in 6.6%, pheochromocytoma in 4.7%, hyperandrogenism in 3.1%, and primary hyperaldosteronism in 2.4% of patients. The risk of malignancy increased in patients with tumors >6 cm was 37.7%. The logistic regression analysis revealed that the strongest predictor of hormonal activity of AIs was lipid-poor picture on CT scan (OR 7.072; CI 5.118–9.771), while the most important factor increasing the risk of malignancy was lipid-poor adenoma or non-adenoma on CT scan (OR 4.843; CI 1.697–13.819). Final histopathology was available for 214 tumors; 106 adrenocortical adenomas, 46 pheochromocytomas, and 18 adrenocortical carcinomas were diagnosed. Conclusion: Most AIs are hormonally inactive adenomas. The most frequent hormonal manifestation of AI is subclinical hypercortisolemia. Presence of AI is often accompanied by features of metabolic syndrome. The tumor density on CT scan picture may be predictive of both hormonal activity and the risk of malignancy. Tumors of all sizes may exhibit hormonal activity, while the risk of malignancy significantly increases with the size above 6 cm.
Collapse
|
22
|
Kim K, Kim JK, Lee CR, Kang SW, Lee J, Jeong JJ, Nam KH, Chung WY. Surgical outcomes of laparoscopic adrenalectomy for primary hyperaldosteronism: 20 years of experience in a single institution. Ann Surg Treat Res 2019; 96:223-229. [PMID: 31073512 PMCID: PMC6483932 DOI: 10.4174/astr.2019.96.5.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/28/2018] [Accepted: 01/29/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Recently, posterior retroperitoneoscopic adrenalectomy (PRA) has been reported to have some advantages over laparoscopic transperitoneal adrenalectomy (LTA). The objectives of this study were to report our experience over 12 years with laparoscopic adrenalectomy for primary hyperaldosteronism (PHA) and to examine surgical outcomes of PRA compared with LTA in patients with PHA. Methods The medical records of 527 patients who underwent minimally invasive adrenalectomy, including LTA or PRA, from January 2006 until May 2017 were reviewed at Severance Hospital (Seoul, Korea). Clinicopathologic characteristics and surgical outcomes of 146 patients with PHA who underwent LTA (19 patients) or PRA (127 patients) were analyzed retrospectively by complete chart review. Results The overall rates of biochemical and clinical cure were 91.1% and 93.1%, respectively. The mean operation time of the PRA group was significantly shorter than that of the LTA group (72.3 ± 24.1 minutes vs. 115.7 ± 69.7 minutes, P = 0.015). The length of hospital stay in the PRA group was significantly shorter than in the LTA group (3.5 ± 1.3 days vs. 4.2 ± 1.6 days, P = 0.029), and the first meal after surgery came earlier in the PRA group (0.3 ± 0.5 days vs. 0.6 ± 0.5 days, P = 0.049). The number of pain-killers used was also significantly smaller in the PRA group (2.3 ± 2.1 vs. 4.3 ± 2.3, P < 0.001). Conclusion PRA offers an alternative or likely superior method for treatment of small adrenal diseases such as PHA, with improved surgical outcomes.
Collapse
Affiliation(s)
- Kwangsoon Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Wook Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jandee Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Hyun Nam
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Youn Chung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
23
|
Lorenz K, Langer P, Niederle B, Alesina P, Holzer K, Nies C, Musholt T, Goretzki PE, Rayes N, Quinkler M, Waldmann J, Simon D, Trupka A, Ladurner R, Hallfeldt K, Zielke A, Saeger D, Pöppel T, Kukuk G, Hötker A, Schabram P, Schopf S, Dotzenrath C, Riss P, Steinmüller T, Kopp I, Vorländer C, Walz MK, Bartsch DK. Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2019; 404:385-401. [PMID: 30937523 DOI: 10.1007/s00423-019-01768-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.
Collapse
Affiliation(s)
- K Lorenz
- Universitätsklinikum Halle, Halle/Saale, Germany.
| | | | - B Niederle
- Ordination Siebenbrunnenstrasse, Wien, Austria
| | - P Alesina
- Kliniken Essen-Mitte, Essen, Germany
| | - K Holzer
- Universitätsklinikum Marburg, Marburg, Germany
| | - Ch Nies
- Marienhospital Osnabrück, Osnabrück, Germany
| | - Th Musholt
- Universitatsklinikum Mainz, Mainz, Germany
| | - P E Goretzki
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - N Rayes
- Universitätsklinikum Leipzig, Leipzig, Germany
| | - M Quinkler
- Endokrinologiepraxis Berlin, Berlin, Germany
| | - J Waldmann
- MIVENDO Klinik Hamburg, Hamburg, Germany
| | - D Simon
- Evangelisches Krankenhaus BETHESDA Duisburg, Duisburg, Germany
| | - A Trupka
- Klinikum Starnberg, Klinikum Starnberg, Germany
| | - R Ladurner
- Ludwig-Maximilians-Universität München, München, Germany
| | - K Hallfeldt
- Ludwig-Maximilians-Universität München, München, Germany
| | - A Zielke
- Diakonie-Klinikum Stuttgart, Stuttgart, Germany
| | - D Saeger
- Universitätsklinikum Hamburg, Hamburg, Germany
| | - Th Pöppel
- Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - G Kukuk
- Universitätsklinikum Bonn, Bonn, Germany
| | - A Hötker
- Universitätsklinikum Zürich, Zürich, Switzerland
| | - P Schabram
- RAE Ratacjzak und Partner, Sindelfingen, Germany
| | - S Schopf
- Krankenhaus Agatharied, Hausham, Germany
| | - C Dotzenrath
- HELIOS Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - P Riss
- Medizinische Universität Wien, Wien, Austria
| | - Th Steinmüller
- Deutsches Rotes Kreuz Krankenhaus Berlin, Berlin, Germany
| | - I Kopp
- AWMF, Frankfurt am Main, Germany
| | - C Vorländer
- Bürgerhospital Frankfurt, Frankfurt am Main, Germany
| | - M K Walz
- Kliniken Essen-Mitte, Essen, Germany
| | - D K Bartsch
- Universitätsklinikum Marburg, Marburg, Germany
| |
Collapse
|
24
|
Hellman P, Björklund P, Åkerström T. Aldosterone-Producing Adenomas. VITAMINS AND HORMONES 2019; 109:407-431. [PMID: 30678866 DOI: 10.1016/bs.vh.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aldosterone-producing adenomas (APA) are more common than initially anticipated. APA cause primary aldosteronism (PA), which affect 3-10% of the hypertensive population. Research during recent years has led to an increased knowledge of the background dysregulation of the increased aldosterone release, where mutation in the gene encoding the potassium channel GIRK4-KCNJ5-is the most common. Moreover, the discovery of aldosterone-producing cell clusters in apparently normal adenomas has also led to increased understanding of the development of PA, and presumably also APA. A continuum ranging from low-renin hypertension to APA and overt PA is reasoned, and the secondary effects of aldosterone on especially the cardiovascular system have also become more evident. Diagnostics of PA and APA is important in order to reduce cardiovascular morbidity and mortality, but the diagnostic methods are somewhat unspecific and insensitive, indicating the need for novel methods.
Collapse
Affiliation(s)
- Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Peyman Björklund
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tobias Åkerström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
25
|
La chirurgie d’épargne surrénalienne : du cortex à la médulla. ANNALES D'ENDOCRINOLOGIE 2018; 78 Suppl 1:S11-S20. [PMID: 29157485 DOI: 10.1016/s0003-4266(17)30921-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The 2017 Endocrine Society annual meeting included several communications and debates on the conservative adrenal surgery in bilateral hereditary pheochromocytomas (BHP), bilateral adrenal macronodular hyperplasia (BAMH) and primary hyperaldosteronism (PHA). The general principle is to preserve a part of the adrenal cortex to prevent the occurrence of a definitive adrenal insufficiency. In BHP, cortical sparing surgery allows more than 50% of patients to maintain normal corticotropic function at 10 years with a low recurrence rate (~ 10%). Since the adrenal medulla cannot be removed entirely, recurrence seems inevitable and long-term follow-up is essential. Individual risk of malignancy must be taken into account. In BAMH responsible for Cushing syndrome, unilateral adrenalectomy induces a normalization of urinary free cortisol in 92 to 100% of cases and even corticotropic insufficiency in 40 to 100% of cases. This is most often transient. Late recurrences of Cushing's syndrome may occur in 13 to 60% of cases. Prolonged patient monitoring is therefore essential. In PAH with lateralized aldosterone production, minimally invasive partial adrenal surgery, which consists of removing only the adrenal adenoma visualized at TDM, allows an improvement blood pressure in about 94% of patients. However, failure or recurrence may occur. Its place therefore remains marginal in the treatment of the lateralized PAHs.
Collapse
|
26
|
Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach. Surg Endosc 2018; 32:3732-3737. [PMID: 29855711 DOI: 10.1007/s00464-018-6262-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation. METHODS Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips. RESULTS Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86 min (range 40-135). There were no perioperative or postoperative complications. CONCLUSIONS Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.
Collapse
|
27
|
Ko J, Jeong J, Lee S, Son H, Kweon OK, Kim WH. Feasibility of single-port retroperitoneoscopic adrenalectomy in dogs. Vet Surg 2018; 47:O75-O83. [PMID: 29697143 PMCID: PMC6032942 DOI: 10.1111/vsu.12789] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 01/22/2018] [Accepted: 03/02/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the feasibility of single-port retroperitoneoscopic adrenalectomy (SPRA) in dogs. STUDY DESIGN A pilot experimental study. ANIMALS Eight healthy beagle dogs. METHODS SPRA was performed on the left and right sides (4 dogs each). Resection of the adrenal gland was performed through a SILS port using a retroperitoneal approach. Operative time was defined from skin incision to the completion of skin suture. Postoperative pain was evaluated by using 3 pain scores. Integrity of the adrenal gland capsule was evaluated by histologic assessment. RESULTS Mean time taken to complete the SPRA was 44.1 minutes (range, 37-51) and was significantly longer on the right side than on the left side (P < .05). There were no complications intraoperatively or during 14 days of postoperative monitoring. The adrenal gland capsule was found to be injured in 3 of the 8 dogs by histologic assessment. CONCLUSION This is the first report of SPRA in the veterinary literature. With this technique it is possible to perform adrenalectomy with some risk of capsule penetration and with excellent visibility. CLINICAL SIGNIFICANCE This study suggests that SPRA is feasible and can be used to resect small adrenal tumors with minimal complications.
Collapse
Affiliation(s)
- Jonghyeok Ko
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Junemoe Jeong
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | | | - Hyunglak Son
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Oh-Kyeong Kweon
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| | - Wan Hee Kim
- Department of Veterinary Clinical Science, College of Veterinary Medicine and Research, Institute for Veterinary Science, Seoul National University, Seoul, Republic of Korea
| |
Collapse
|
28
|
Pollaers K, Lisewski D. How to do lateral retroperitoneoscopic resection of intra-abdominal paraganglioma. ANZ J Surg 2018; 88:792-793. [PMID: 29534344 DOI: 10.1111/ans.14450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/23/2017] [Accepted: 01/14/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Katherine Pollaers
- Endocrine Surgical Service, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Dean Lisewski
- Endocrine Surgical Service, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| |
Collapse
|
29
|
Huang KH, Yu CC, Hu YH, Chang CC, Chan CK, Liao SC, Tsai YC, Jeff Chueh SC, Wu VC, Lin YH. Targeted treatment of primary aldosteronism - The consensus of Taiwan Society of Aldosteronism. J Formos Med Assoc 2018; 118:72-82. [PMID: 29506889 DOI: 10.1016/j.jfma.2018.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/25/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/PURPOSE Even with the increasing recognition of primary aldosteronism (PA) as a cause of refractory hypertension and an issue of public health, the consensus of its optimal surgical or medical treatment in Taiwan has not been reached. Our objective was to develop a clinical practice guideline that is feasible for real-world management of PA patients in Taiwan. METHODS The Taiwan Society of Aldosteronism (TSA) Task Force recognized the above-mentioned issues and reached this Taiwan PA consensus at its inaugural meeting, in order to provide updated information of internationally acceptable standards, and also to incorporate our local disease characteristics and constraints into PA management. RESULTS In patients with lateralized PA, including aldosterone producing adenoma (APA), laparoscopic adrenalectomy is the 'gold standard' of treatment. Mini-laparoscopic and laparoendoscopic single-site approaches are feasible only in highly experienced surgeons. Patients with bilateral adrenal hyperplasia or those not suitable for surgery should be treated by mineralocorticoid receptor antagonists. The outcome data of PA patient management from the literature, especially from PA patients in Taiwan, are reviewed. Mental health screening is helpful in early detection and management of psychopathology among PA patients. CONCLUSION We hope this consensus will provide a guideline to help medical professionals to manage PA patients in Taiwan to achieve a better quality of care.
Collapse
Affiliation(s)
- Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Chin Yu
- Division of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan
| | - Ya-Hui Hu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Taiwan
| | - Chin-Chen Chang
- Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chieh-Kai Chan
- Department of Internal Medicine, National Taiwan University Hospital, Hsin Chu Branch, Hsinchu County, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Cheng Liao
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chou Tsai
- Division of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan; Department of Urology, Tzu Chi University, Hualien, Taiwan.
| | - Shih-Chieh Jeff Chueh
- Glickman Urological and Kidney Institute, and Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Vin-Cent Wu
- Division of Nephrology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | | |
Collapse
|
30
|
Duh QY, Suh I. It's Complicated: How Often are Patients with Primary Aldosteronism Cured After Adrenalectomy? World J Surg 2017; 42:464-465. [PMID: 29159604 DOI: 10.1007/s00268-017-4380-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Quan-Yang Duh
- Section of Endocrine Surgery, University of California, San Francisco (UCSF), San Francisco, CA, USA.
| | - Insoo Suh
- Section of Endocrine Surgery, University of California, San Francisco (UCSF), San Francisco, CA, USA
| |
Collapse
|
31
|
Zhou Y, Zhang M, Ke S, Liu L. Hypertension outcomes of adrenalectomy in patients with primary aldosteronism: a systematic review and meta-analysis. BMC Endocr Disord 2017; 17:61. [PMID: 28974210 PMCID: PMC5627399 DOI: 10.1186/s12902-017-0209-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 09/12/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The hypertension cure rate of unilateral adrenalectomy in primary aldosteronism (PA) patients varies widely in existing studies. METHODS We conducted an observational meta-analysis to summarize the pooled hypertension cure rate of unilateral adrenalectomy in PA patients. Comprehensive electronic searches of PubMed, Embase, Cochrane, China National Knowledge Internet (CNKI), WanFang, SinoMed and Chongqing VIP databases were performed from initial state to May 20, 2016. We manually selected eligible studies from references in accordance with the inclusion criteria. The pooled hypertension cure rate of unilateral adrenalectomy in PA patients was calculated using the DerSimonian-Laird method to produce a random-effects model. RESULTS Forty-three studies comprising approximately 4000 PA patients were included. The pooled hypertension cure rate was 50.6% (95% CI: 42.9-58.2%) for unilateral adrenalectomy in PA. Subgroup analyses showed that the hypertension cure rate was 61.3% (95% CI: 49.4-73.3%) in Chinese studies and 43.7% (95% CI: 38.0-49.4%) for other countries. Furthermore, the hypertension cure rate at 6-month follow-up was 53.3% (95% CI: 36.0-70.5%) and 49.6% (95% CI: 40.9-58.3%) for follow-up exceeding 6 months. The pooled hypertension cure rate was 50.9% (95% CI: 40.5-61.3%) from 2001 to 2010 and 50.2% (95% CI: 39.0-61.5%) from 2011 to 2016. CONCLUSIONS The hypertension cure rate for unilateral adrenalectomy in PA is not optimal. Large clinical trials are required to verify the utility of potential preoperative predictors in developing a novel and effective prediction model.
Collapse
Affiliation(s)
- Yu Zhou
- Department of Endocrinology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001 China
| | - Meilian Zhang
- Department of Ultrasonography, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001 China
| | - Sujie Ke
- Department of Endocrinology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001 China
| | - Libin Liu
- Department of Endocrinology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001 China
| |
Collapse
|
32
|
Scholl UI, Abriola L, Zhang C, Reimer EN, Plummer M, Kazmierczak BI, Zhang J, Hoyer D, Merkel JS, Wang W, Lifton RP. Macrolides selectively inhibit mutant KCNJ5 potassium channels that cause aldosterone-producing adenoma. J Clin Invest 2017; 127:2739-2750. [PMID: 28604387 PMCID: PMC5490757 DOI: 10.1172/jci91733] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/20/2017] [Indexed: 11/17/2022] Open
Abstract
Aldosterone-producing adenomas (APAs) are benign tumors of the adrenal gland that constitutively produce the salt-retaining steroid hormone aldosterone and cause millions of cases of severe hypertension worldwide. Either of 2 somatic mutations in the potassium channel KCNJ5 (G151R and L168R, hereafter referred to as KCNJ5MUT) in adrenocortical cells account for half of APAs worldwide. These mutations alter channel selectivity to allow abnormal Na+ conductance, resulting in membrane depolarization, calcium influx, aldosterone production, and cell proliferation. Because APA diagnosis requires a difficult invasive procedure, patients often remain undiagnosed and inadequately treated. Inhibitors of KCNJ5MUT could allow noninvasive diagnosis and therapy of APAs carrying KCNJ5 mutations. Here, we developed a high-throughput screen for rescue of KCNJ5MUT-induced lethality and identified a series of macrolide antibiotics, including roxithromycin, that potently inhibit KCNJ5MUT, but not KCNJ5WT. Electrophysiology demonstrated direct KCNJ5MUT inhibition. In human aldosterone-producing adrenocortical cancer cell lines, roxithromycin inhibited KCNJ5MUT-induced induction of CYP11B2 (encoding aldosterone synthase) expression and aldosterone production. Further exploration of macrolides showed that KCNJ5MUT was similarly selectively inhibited by idremcinal, a macrolide motilin receptor agonist, and by synthesized macrolide derivatives lacking antibiotic or motilide activity. Macrolide-derived selective KCNJ5MUT inhibitors thus have the potential to advance the diagnosis and treatment of APAs harboring KCNJ5MUT.
Collapse
Affiliation(s)
- Ute I Scholl
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Nephrology, Medical School, Heinrich Heine University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Laura Abriola
- Yale Center for Molecular Discovery, Yale University, West Haven, Connecticut, USA
| | - Chengbiao Zhang
- Department of Pharmacology, New York Medical College, Valhalla, New York, USA
| | - Esther N Reimer
- Department of Nephrology, Medical School, Heinrich Heine University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mark Plummer
- Yale Center for Molecular Discovery, Yale University, West Haven, Connecticut, USA
| | - Barbara I Kazmierczak
- Department of Medicine (Infectious Diseases), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Junhui Zhang
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Denton Hoyer
- Yale Center for Molecular Discovery, Yale University, West Haven, Connecticut, USA
| | - Jane S Merkel
- Yale Center for Molecular Discovery, Yale University, West Haven, Connecticut, USA
| | - Wenhui Wang
- Department of Pharmacology, New York Medical College, Valhalla, New York, USA
| | - Richard P Lifton
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
33
|
Christakis I, Livesey JA, Sadler GP, Mihai R. Laparoscopic Adrenalectomy for Conn's Syndrome is Beneficial to Patients and is Cost Effective in England. J INVEST SURG 2017; 31:300-306. [DOI: 10.1080/08941939.2017.1323055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ioannis Christakis
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - John A. Livesey
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Gregory P. Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| |
Collapse
|
34
|
Posterior retroperitoneoscopic adrenal surgery for clinical and subclinical Cushing’s syndrome in patients with bilateral adrenal disease. Langenbecks Arch Surg 2017; 402:775-785. [DOI: 10.1007/s00423-017-1569-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/13/2017] [Indexed: 12/26/2022]
|
35
|
Liu SYW, Chu CCM, Tsui TKC, Wong SKH, Kong APS, Chiu PWY, Chow FCC, Ng EKW. Aldosterone-producing Adenoma in Primary Aldosteronism: CT-guided Radiofrequency Ablation—Long-term Results and Recurrence Rate. Radiology 2016; 281:625-634. [DOI: 10.1148/radiol.2016152277] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
36
|
Comparison of Modified Retroperitoneal Adrenalectomy With the Gold Standard for Benign Adrenal Tumors. Surg Laparosc Endosc Percutan Tech 2016; 26:86-9. [PMID: 26766311 DOI: 10.1097/sle.0000000000000235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To compare our modified retroperitoneoscopic adrenalectomy with the standard procedure. METHODS A total of 68 patients underwent modified retroperitoneoscopic adrenalectomy. Simultaneously, another 23 patients were treated using the standard procedure. The demographic data and perioperative outcomes of the patients were obtained for statistical analysis. RESULTS No significant differences in age, evaluated blood loss, oral intake, and hospital stay were observed. The mean operation time in the modified group was shorter than that in the standard group (58.3±16.4 vs. 79.5±23.6 min, P<0.05). The median total length of incision was shorter in the modified group than in the standard group (4.5±0.8 vs. 6.4±1.1 cm, P<0.05). The modified group also showed significantly better pain control (3 vs. 6 diclofenac sodium use, P<0.05) and cosmetic outcome (score, 9.1±1.8 vs. 8.2±2.1, P<0.05) than the standard group. CONCLUSIONS Our modified retroperitoneoscopic adrenalectomy is a safe and alternative procedure for adrenal tumors. This procedure offers superior cosmetic outcome, better pain control, and shorter operation time compared with the standard retroperitoneal adrenalectomy.
Collapse
|
37
|
Benham JL, Eldoma M, Khokhar B, Roberts DJ, Rabi DM, Kline GA. Proportion of Patients With Hypertension Resolution Following Adrenalectomy for Primary Aldosteronism: A Systematic Review and Meta-Analysis. J Clin Hypertens (Greenwich) 2016; 18:1205-1212. [DOI: 10.1111/jch.12916] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/14/2016] [Accepted: 06/22/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jamie L. Benham
- Department of Medicine; University of Calgary; Calgary AB Canada
| | - Maysoon Eldoma
- Department of Medicine; University of Calgary; Calgary AB Canada
| | - Bushra Khokhar
- Department of Community Health Sciences; University of Calgary; Calgary AB Canada
| | - Derek J. Roberts
- Department of Surgery and Community Health Sciences; University of Calgary; Calgary AB Canada
| | - Doreen M. Rabi
- Department of Medicine, Community Health and Cardiac Sciences; University of Calgary; Calgary AB Canada
| | - Gregory A. Kline
- Department of Medicine; University of Calgary; Calgary AB Canada
| |
Collapse
|
38
|
Laparoendoscopic single-site adrenalectomy in patients with primary hyperaldosteronism: A prospective study with long-term follow up. Asian J Surg 2015; 40:221-226. [PMID: 26626099 DOI: 10.1016/j.asjsur.2015.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 08/19/2015] [Accepted: 09/14/2015] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Laparoendoscopic single-site (LESS) adrenalectomy is a promising minimally invasive technique, however, the current evidence has not confirmed its long-term effectiveness in primary aldosteronism (PA). We conducted a study to analyze the long-term efficacy of LESS adrenalectomy in patients with PA. METHODS A total of 49 patients who had been clinically confirmed with PA who had an indication for unilateral adrenalectomy were included in this study. Perioperative data were obtained for all patients. Blood pressure and the levels of serum aldosterone, renin, and potassium were checked periodically. The median follow-up was 16.5 months. RESULTS No intra- or early post-operative complication occurred. All LESS adrenalectomies were completed successfully, except one with laparoscopic conversion. Hypokalemia was resolved in all cases and no patient required potassium supplements after surgery. Post-operative cure of hypertension was achieved in 63% of our patients. Overall, 84% of our PA patients had clinical improvement in blood pressure control after surgery. CONCLUSIONS Our long-term experience revealed that LESS adrenalectomy is a safe and effective approach, which demonstrated comparable long-term cure and improvement of hypertension to a conventional laparoscopic series in treating PA.
Collapse
|
39
|
Scholl UI, Healy JM, Thiel A, Fonseca AL, Brown TC, Kunstman JW, Horne MJ, Dietrich D, Riemer J, Kücükköylü S, Reimer EN, Reis AC, Goh G, Kristiansen G, Mahajan A, Korah R, Lifton RP, Prasad ML, Carling T. Novel somatic mutations in primary hyperaldosteronism are related to the clinical, radiological and pathological phenotype. Clin Endocrinol (Oxf) 2015; 83:779-89. [PMID: 26252618 PMCID: PMC4995792 DOI: 10.1111/cen.12873] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/18/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
UNLABELLED Aldosterone-producing adenomas (APAs) and bilateral adrenal hyperplasia are important causes of secondary hypertension. Somatic mutations in KCNJ5, CACNA1D, ATP1A1, ATP2B3 and CTNNB1 have been described in APAs. OBJECTIVE To characterize clinical-pathological features in APAs and unilateral adrenal hyperplasia, and correlate them with genotypes. DESIGN Retrospective study. SUBJECTS AND MEASUREMENTS Clinical and pathological characteristics of 90 APAs and seven diffusely or focally hyperplastic adrenal glands were reviewed, and samples were examined for mutations in known disease genes by Sanger or exome sequencing. RESULTS Mutation frequencies were as follows: KCNJ5, 37·1%; CACNA1D, 10·3%; ATP1A1, 8·2%; ATP2B3, 3·1%; and CTNNB1, 2·1%. Previously unidentified mutations included I157K, F154C and two insertions (I150_G151insM and I144_E145insAI) in KCNJ5, all close to the selectivity filter, V426G_V427Q_A428_L433del in ATP2B3 and A39Efs*3 in CTNNB1. Mutations in KCNJ5 were associated with female and other mutations with male gender (P = 0·007). On computed tomography, KCNJ5-mutant tumours displayed significantly greater diameter (P = 0·023), calculated area (P = 0·002) and lower precontrast Hounsfield units (P = 0·0002) vs tumours with mutations in other genes. Accordingly, KCNJ5-mutant tumours were predominantly comprised of lipid-rich fasciculata-like clear cells, whereas other tumours were heterogeneous (P = 5 × 10(-6) vs non-KCNJ5 mutant and P = 0·0003 vs wild-type tumours, respectively). CACNA1D mutations were present in two samples with hyperplasia without adenoma. CONCLUSIONS KCNJ5-mutant tumours appear to be associated with fasciculata-like clear cell predominant histology and tend to be larger with a characteristic imaging phenotype. Novel somatic KCNJ5 variants likely cause adenomas by loss of potassium selectivity, similar to previously described mutations.
Collapse
Affiliation(s)
- Ute I. Scholl
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - James M. Healy
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| | - Anne Thiel
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Annabelle L. Fonseca
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| | - Taylor C. Brown
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| | - John W. Kunstman
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew J. Horne
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Dimo Dietrich
- Institute of Pathology, University of Bonn, Bonn, Germany
| | - Jasmin Riemer
- Institute of Pathology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Seher Kücükköylü
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Esther N. Reimer
- Department of Nephrology, Medical School, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Anna-Carinna Reis
- Institute of Pathology, University Hospital of Essen, University of Duisburg-Essen, Germany
| | - Gerald Goh
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA
| | | | - Amit Mahajan
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Reju Korah
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| | - Richard P. Lifton
- Department of Genetics and Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA
| | - Manju L. Prasad
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Tobias Carling
- Department of Surgery and Yale Endocrine Neoplasia Laboratory, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
40
|
Burrello J, Monticone S, Tetti M, Rossato D, Versace K, Castellano I, Williams TA, Veglio F, Mulatero P. Subtype Diagnosis of Primary Aldosteronism: Approach to Different Clinical Scenarios. Horm Metab Res 2015; 47:959-66. [PMID: 26575304 DOI: 10.1055/s-0035-1565089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Identification and management of patients with primary aldosteronism are of utmost importance because it is a frequent cause of endocrine hypertension, and affected patients display an increase of cardio- and cerebro-vascular events, compared to essential hypertensives. Distinction of primary aldosteronism subtypes is of particular relevance to allocate the patients to the appropriate treatment, represented by mineralocorticoid receptor antagonists for bilateral forms and unilateral adrenalectomy for patients with unilateral aldosterone secretion. Subtype differentiation of confirmed hyperaldosteronism comprises adrenal CT scanning and adrenal venous sampling. In this review, we will discuss different clinical scenarios where execution, interpretation of adrenal vein sampling and subsequent patient management might be challenging, providing the clinician with useful information to help the interpretation of controversial procedures.
Collapse
Affiliation(s)
- J Burrello
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - S Monticone
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - M Tetti
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - D Rossato
- Division of Radiology, University of Torino, Torino, Italy
| | - K Versace
- Division of Radiology, University of Torino, Torino, Italy
| | - I Castellano
- Division of Pathology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - T A Williams
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - F Veglio
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| | - P Mulatero
- Division of Internal Medicine and Hypertension, University of Torino, Torino, Italy
| |
Collapse
|
41
|
Pirvu A, Naem N, Baguet JP, Thony F, Chabre O, Chaffanjon P. Is adrenal venous sampling mandatory before surgical decision in case of primary hyperaldosteronism? World J Surg 2015; 38:1749-54. [PMID: 24481990 DOI: 10.1007/s00268-014-2461-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary hyperaldosteronism (PHA) is a cause of secondary arterial hypertension potentially curable by laparoscopic unilateral adrenalectomy. We describe the follow-up of these patients according to their medical or surgical treatment. METHODS We report a retrospective single-center study of 91 patients with PHA from 1998 to 2012. Treatment was guided by computed tomography (CT) scans. Preoperative adrenal vein sampling (AVS) was performed when the CT scan did not show single solitary unilateral nodules on the adrenal glands. During the follow-up, we considered hypertension to be cured in patients with normal blood pressure without antihypertensive medication (AM), and improvement was defined by a decrease in AM. RESULTS A total of 28 patients received only AM. Of the 62 patients who underwent a unilateral adrenalectomy, 46 (74 %) had an adrenal adenoma, 14 (22 %) a hyperplasia, and the adrenal gland was normal in two cases. Hypertension was cured in 24 cases (38 %), and 28 patients (45 %) showed improvement with a reduction in AM. Predictive factors for a cure were gender, age, number of preoperative AMs, preoperative arterial systolic blood pressure, and plasma renin activity. All patients who presented with hypokalemia were cured postoperatively. We performed 38 AVS and nine of these patients were operated on based on the AVS findings, with an improvement of 100 % of arterial blood pressure after surgery. CONCLUSION Laparoscopic unilateral adrenalectomy for PHA cured or improved hypertension in 84 % of patients. Preoperative AVS is mandatory for surgical decision making if the CT scan shows bilateral or no lesions associated with PHA.
Collapse
Affiliation(s)
- Augustin Pirvu
- Department of Thoracic, Vascular and Endocrine Surgery, University Hospital Grenoble, Grenoble, France,
| | | | | | | | | | | |
Collapse
|
42
|
Nagaraja V, Eslick GD, Edirimanne S. Recurrence and functional outcomes of partial adrenalectomy: A systematic review and meta-analysis. Int J Surg 2015; 16:7-13. [DOI: 10.1016/j.ijsu.2015.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 12/27/2014] [Accepted: 01/19/2015] [Indexed: 12/15/2022]
|
43
|
Iacobone M, Citton M, Viel G, Rossi GP, Nitti D. Approach to the surgical management of primary aldosteronism. Gland Surg 2015; 4:69-81. [PMID: 25713782 DOI: 10.3978/j.issn.2227-684x.2015.01.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/15/2015] [Indexed: 11/14/2022]
Abstract
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal involvement [aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH)], and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques [computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy] may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
Collapse
Affiliation(s)
- Maurizio Iacobone
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Marilisa Citton
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Giovanni Viel
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| | - Donato Nitti
- 1 Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, 2 Internal Medicine 4, Department of Medicine-DIMED, University of Padua, Padova, Italy
| |
Collapse
|
44
|
Muth A, Ragnarsson O, Johannsson G, Wängberg B. Systematic review of surgery and outcomes in patients with primary aldosteronism. Br J Surg 2015; 102:307-17. [PMID: 25605481 DOI: 10.1002/bjs.9744] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common cause of secondary hypertension. The main aims of this paper were to review outcome after surgical versus medical treatment of PA and partial versus total adrenalectomy in patients with PA. METHODS Relevant medical literature from PubMed, the Cochrane Library and Embase OvidSP from 1985 to June 2014 was reviewed. RESULTS Of 2036 records, 43 articles were included in the final analysis. Twenty-one addressed surgical versus medical treatment of PA, four considered partial versus total adrenalectomy for unilateral PA, and 18 series reported on surgical outcomes. Owing to the heterogeneity of protocols and reported outcomes, only a qualitative analysis was performed. In six studies, surgical and medical treatment had comparable outcomes concerning blood pressure, whereas six showed better outcome after surgery. No differences were seen in cardiovascular complications, but surgery was associated with the use of fewer antihypertensive medications after surgery, improved quality of life, and (possibly) lower all-cause mortality compared with medical treatment. Randomized studies indicate a role for partial adrenalectomy in PA, but the high rate of multiple adenomas or adenoma combined with hyperplasia in localized disease is disconcerting. Surgery for unilateral dominant PA normalized BP in a mean of 42 (range 20-72) per cent and the biochemical profile in 96-100 per cent of patients. The mean complication rate in 1056 patients was 4·7 per cent. CONCLUSION Recommendations for treatment of PA are hampered by the lack of randomized trials, but support surgical resection of unilateral disease. Partial adrenalectomy may be an option in selected patients.
Collapse
Affiliation(s)
- A Muth
- Section for Endocrine Surgery and Abdominal Sarcoma, Department of Surgery, Institute of Clinical Sciences, Gothenburg, Sweden
| | | | | | | |
Collapse
|
45
|
Hartmann I, Grepl M, Vidlar A, Smakal O, Vaclavik J, Frysak Z, Dolezel M, Student V. Outcomes of adrenalectomy in patients with primary hyperaldosteronism - a single centre experience. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:583-90. [DOI: 10.5507/bp.2014.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 11/11/2014] [Indexed: 12/31/2022] Open
|
46
|
Lu CC, Wu VC, Wu KD, Liu KL, Lin WC, Cheng MF, Tzen KY, Yen RF. Prognostic value of semiquantification NP-59 SPECT/CT in primary aldosteronism patients after adrenalectomy. Eur J Nucl Med Mol Imaging 2014; 41:1375-84. [PMID: 24525587 DOI: 10.1007/s00259-014-2692-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 01/02/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Primary aldosteronism (PA), characterized by an excessive production of aldosterone, affects 5-13 % of patients with hypertension. Accurate strategies are needed for the timely diagnosis of PA to allow curability and prevention of excessive cardiovascular events and related damage. This study aimed to evaluate the usefulness of semiquantification of (131)I-6β-iodomethyl-norcholesterol (NP-59) single photon emission computed tomography (SPECT)/CT in differentiating aldosterone-producing adenoma (APA) from idiopathic adrenal hyperplasia (IAH) and in predicting clinical outcomes after adrenalectomy. METHODS We retrospectively reviewed 49 PA patients who had undergone adrenalectomy after NP-59 SPECT/CT within 1 year. A conventional visual scale (VS) and two semiquantitative parameters generated from SPECT/CT, adrenal to liver ratio (ALR) and lesion to contralateral ratio of bilateral adrenal glands (CON), with cutoff values calculated by receiver-operating characteristic (ROC) analysis, were compared with pathology results and postsurgical outcomes to determine the accuracy. RESULTS An ALR cutoff of 1.84 and a CON cutoff of 1.15 showed an ability to distinguish adenoma from hyperplasia similar to VS (p = 0.2592 and 0.1908, respectively). An ALR cutoff of 2.28 and a CON cutoff of 1.11 yielded the highest sensitivity and specificity to predict postsurgical outcomes, and an ALR of 2.28 had an ability superior to VS (p = 0.0215), while a CON of 1.11 did not (p = 0.1015). Patients with either ALR or CON greater than the cutoff had a high probability of positive postsurgical outcomes (n = 36/38), while patients with both ALR and CON less than the cutoff had a low probability of positive postsurgical outcomes (n = 2/11). CONCLUSION Semiquantification of NP-59 scintigraphy has an ability similar to VS in differentiating APA from IAH, but an excellent ability to predict postsurgical outcomes of adrenalectomy. An ALR or CON greater than the cutoff strongly suggests benefits from adrenalectomy, and both ALR and CON less than the cutoff implies a reduced chance of improvement in postsurgical outcome.
Collapse
Affiliation(s)
- Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, 7 Chung-Shan South Road, Taipei, Taiwan, 100,
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Predictors of successful outcome after adrenalectomy for primary aldosteronism. Int Surg 2014; 97:104-11. [PMID: 23102075 DOI: 10.9738/cc140.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The underlying cause of resistant hypertension after adrenalectomy for primary hyperaldosteronism remains controversial. The objective of this study was to identify preoperative factors predictive of resistant hypertension in patients after undergoing retroperitoneoscopic adrenalectomy. Between 2003 and 2009, 124 patients with unilateral aldosterone-producing adenoma or unilateral adrenal hyperplasia underwent retroperitoneoscopic adrenalectomy at our institution. Clinical and biochemical data were reviewed retrospectively at baseline and after a median follow-up time of 59.2 ± 37.2 months. Adrenalectomy cured hypertension in 68 patients (54.8%) and 43 (34.8%) had persistent hypertension that was much easier to control after surgery, whereas 13 patients (10.4%) had continued hypertension and poor blood pressure control. Multivariate regression analysis revealed that the main determinants of postoperative cure were duration of hypertension less than 5 years [odds ratio (OR): 6.515, 95% confidence interval (CI) 2.278-10.293), number of antihypertensive medications ≤2 (OR: 2.939, 95% CI 1.254-5.235), preoperative response to spironolactone (OR: 3.405, 95% CI 1.681-6.985), the TT genotype of the CYP11B2 gene (344 C/T) (OR: 2.765, 95% CI 1.221-4.986), and the presence of adenoma rather than hyperplasia (OR: 5.274, 95% CI 2.150-8.141). The main determinants of surgical cure or control of hypertension in patients with primary hyperaldosteronism were duration of hypertension, number of antihypertensive medications, preoperative response to spironolactone, the presence of adenoma, and CYP11B2 (344 C/T) genotype. Consideration of these factors may help in the evaluation of patients for surgery and for the identification of patients with continued postoperative hypertension that may require more long-term monitoring and treatment.
Collapse
|
48
|
Stefanidis D, Goldfarb M, Kercher KW, Hope WW, Richardson W, Fanelli RD. SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc 2013; 27:3960-80. [PMID: 24018761 DOI: 10.1007/s00464-013-3169-z] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 08/02/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, CMC Surgical Specialty Center, Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC, 28204, USA,
| | | | | | | | | | | | | |
Collapse
|
49
|
Outcome after surgery for primary hyperaldosteronism may depend on KCNJ5 tumor mutation status: a population-based study from Western Norway. Langenbecks Arch Surg 2013; 398:869-74. [PMID: 23778974 DOI: 10.1007/s00423-013-1093-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is a frequent cause (about 10 %) of hypertension. Some cases of PA were recently found to be caused by mutations in the potassium channel KCNJ5. Our objective was to determine the mutation status of KCNJ5 and seven additional candidate genes for tumorigenesis: YY1, FZD4, ARHGAP9, ZFP37, KDM5C, LRP1B, and PDE9A and, furthermore, the surgical outcome of PA patients who underwent surgery in Western Norway. METHODS Twenty-eight consecutive patients with aldosterone-producing adrenal tumors (20 patients with single adenoma, 8 patients with unilateral multiple adenomas or hyperplasia) who underwent surgery were included in this study. All patients were operated on by uncomplicated laparoscopic total adrenalectomy. Genomic DNA was isolated from tumor and non-tumor adrenocortical tissue, and DNA sequencing revealed the mutation status. RESULTS Ten out of 28 (36 %) patients with PA displayed tumor mutations in KCNJ5 (p. G151R and L168R) while none were found in the corresponding non-tumor samples. No mutations were found in the other seven candidate genes screened. The presence of KCNJ5 mutations was associated with lower blood pressure and a higher chance for cure by surgery when compared to patients harboring the KCNJ5 wild type. CONCLUSIONS KCNJ5 mutations are associated with a better surgical outcome. Preoperative identification of the mutation status might have impact on surgical strategy (total vs. subtotal adrenalectomy).
Collapse
|
50
|
Weisbrod AB, Webb RC, Mathur A, Barak S, Abraham SB, Nilubol N, Quezado M, Stratakis CA, Kebebew E. Adrenal histologic findings show no difference in clinical presentation and outcome in primary hyperaldosteronism. Ann Surg Oncol 2013; 20:753-8. [PMID: 23090573 PMCID: PMC3556341 DOI: 10.1245/s10434-012-2670-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary hyperaldosteronism is most commonly due to a solitary cortical adenoma. Thus, some surgeons have suggested a subtotal adrenalectomy is a reasonable approach when a mass can be identified. On the other hand, adrenal vein sampling (AVS) is being used more frequently to distinguish patients with unilateral disease for adrenalectomy, even if a discrete mass is not identified on axial imaging. In these cases, surgical pathology may reveal a cortical adenoma, a cortical adenoma with hyperplasia, or cortical hyperplasia. The goal of this study was to compare the presentation and outcome among patients undergoing adrenalectomy and found to have different histologic features. METHODS We performed a retrospective analysis of 136 patients with primary hyperaldosteronism. A total of 95 patients had an adrenalectomy for unilateral disease. The preoperative clinical and laboratory, and postoperative outcome of the three aforementioned histologic groups were compared. RESULTS A total of 95 patients underwent an adrenalectomy. We found no significant difference in age, gender, body mass index, duration of hypertension, number of antihypertensive medications, serum aldosterone level, serum renin level, or adrenal vein sampling ratios among the three histologic categories. We also found no significant difference among the three categories in postoperative cure rate. CONCLUSION The rate of unilateral hyperplasia in patients with primary hyperaldosteronism (16%) is likely higher than previously reported, which may be due to the increasing use of AVS. The clinical presentation and outcome of patients regardless of the histologic findings are similar. Our data also suggests that subtotal adrenalectomy would not be appropriate in patients with primary hyperaldosteronism.
Collapse
Affiliation(s)
- Allison B Weisbrod
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|