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Swearingen AJ, Kahramangil B, Monteiro R, Krishnamurthy V, Jin J, Shin J, Siperstein A, Berber E. Analysis of postoperative biochemical values and clinical outcomes after adrenalectomy for primary aldosteronism. Surgery 2017; 163:807-810. [PMID: 29249599 DOI: 10.1016/j.surg.2017.10.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/21/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Primary aldosteronism causes hypertension and hypokalemia and is often surgically treatable. Diagnosis includes elevated plasma aldosterone, suppressed plasma renin activity, and elevated aldosterone renin ratio. Adrenalectomy improves hypertension and hypokalemia. Postoperative plasma aldosterone and plasma renin activity may be useful in documenting cure or failure. METHOD A retrospective analysis of patients who underwent adrenalectomy for primary aldosteronism from 2010 to 2016 was performed, analyzing preoperative and postoperative plasma aldosterone, plasma renin activity, hypertension, and hypokalemia. The utility of postoperative testing was assessed. Clinical cure was defined as improved hypertension control and resolution of potassium loss. Biochemical cure was defined as aldosterone renin ratio reduction to <23.6. RESULTS Forty-four patients were included; 20 had plasma aldosterone and plasma renin activity checked on postoperative day 1. In the study, 40/44 (91%) were clinically cured. All clinical failures had of biochemical failure at follow-up. Postoperative day 1aldosterone renin ratio <23.6 had PPV of 95% for clinical cure. Cured patients had mean plasma aldosterone drop of 33.1 ng/dL on postoperative day 1; noncured patient experienced 3.9 ng/dL increase. A cutoff of plasma aldosterone decrease of 10 ng/dL had high positive predictive value for clinical cure. CONCLUSION Changes in plasma aldosterone and plasma renin activity after adrenalectomy correlate with improved hypertension and hypokalemia. The biochemical impact of adrenalectomy manifests as early as postoperative day 1. We propose a plasma aldosterone decrease of 10 ng/dL as a criterion to predict clinical cure.
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Nilubol N, Soldin SJ, Patel D, Rwenji M, Gu J, Masika LS, Chang R, Stratakis CA, Kebebew E. 11-Deoxycortisol may be superior to cortisol in confirming a successful adrenal vein catheterization without cosyntropin: a pilot study. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2017; 4:75-83. [PMID: 28758009 DOI: 10.2217/ije-2016-0020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/07/2017] [Indexed: 01/28/2023] Open
Abstract
AIM We aimed to compare the performance of nine adrenal steroids in confirming the correct catheter position during adrenal venous sampling (AVS) without cosyntropin in patients with primary hyperaldosteronism. MATERIALS & METHODS A successful adrenal vein catheterization without cosyntropin was defined as the ratio of steroids from adrenal to peripheral veins being >3:1. AVS samples from four patients with primary hyperaldosteronism were analyzed. RESULTS Compared with the mean ratio of cortisol without cosyntropin, the ratios of 11-deoxycortisol (p = 0.008), dehydroepiandrosterone (p = 0.01) and androstenedione (p = 0.008) were significantly higher. None of the ratios (n = 8) of cortisol from adrenal to peripheral veins exceeded 3:1, while all ratios of 11-deoxycortisol (p < 0.001) were >3. CONCLUSION Cosyntropin infusion during AVS may not be necessary if 11-deoxycortisol is used to confirm catheter position.
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Affiliation(s)
- Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA.,Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA
| | - Steven J Soldin
- Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA.,Department of Medicine, Division of Endocrinology & Metabolism, Georgetown University, WA 20007, USA.,Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA.,Department of Medicine, Division of Endocrinology & Metabolism, Georgetown University, WA 20007, USA
| | - Dhaval Patel
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA.,Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA
| | - Muthoni Rwenji
- Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA.,Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA
| | - Jianghong Gu
- Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA.,Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA
| | - Likhona S Masika
- Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA.,Department of Laboratory Medicine, National Institutes of Health, MD 20892, USA
| | - Richard Chang
- Endocrine & Venous Services Section, Interventional Radiology Section, Radiology & Imaging Sciences, National Institutes of Health, MD 20892, USA.,Endocrine & Venous Services Section, Interventional Radiology Section, Radiology & Imaging Sciences, National Institutes of Health, MD 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, MD 20892, USA.,Section on Endocrinology & Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, MD 20892, USA
| | - Electron Kebebew
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA.,Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, MD 20892, USA
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Di Martino M, García Sanz I, Muñoz de Nova JL, Marín Campos C, Martínez Martín M, Domínguez Gadea L. NP-59 test for preoperative localization of primary hyperaldosteronism. Langenbecks Arch Surg 2017; 402:303-308. [PMID: 28224279 DOI: 10.1007/s00423-017-1561-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/31/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Adrenal venous sampling is generally considered the gold standard to identify unilateral hormone production in cases of primary hyperaldosteronism. The aim of this study is to evaluate whether the iodine-131-6-β-iodomethyl-19-norcholesterol (NP-59) test may represent an alternative in selected cases. METHODS Patients submitted to laparoscopic adrenalectomy for suspected primary hyperaldosteronism (n = 27) were retrospectively reviewed. When nuclear medicine tests were preoperatively performed, their results were compared with the histopathologic findings and clinical improvement. RESULTS Nuclear medicine tests were realized in 13 patients. In 11 (84.6%), a planar anterior and posterior NP-59 scintigraphy was performed and a SPECT/TC in two (15.4%). Scintigraphy indicated a preoperative lateralization in 12 out of 13 patients (92.3%). When the value of NP-59 tests was based on pathologic results, it showed a sensitivity of 90.9% and a positive predictive value of 83.3%. When the nuclear medicine test's performance was based on postoperative blood pressure control, both sensitivity and positive predictive value were 91.6%. CONCLUSIONS Nuclear medicine tests represent a useful tool in the preoperative localisation of primary hyperaldosteronism with a high sensitivity and positive predictive value. In patients with contraindications to adrenal venous sampling like contrast allergies, or when it is inconclusive, scintigraphy can represent a useful and non-invasive alternative.
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Rodríguez Maya B, Rodríguez Goncer I, Diego Hernández C. [Hypokalemia, a key clinical data for diagnosing primary hyperaldosteronism]. HIPERTENSION Y RIESGO VASCULAR 2016; 33:69-73. [PMID: 26869044 DOI: 10.1016/j.hipert.2015.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Abstract
We report a case of a 37 year-old man with a long history of hypertension under treatment, who was admitted at our institution with intense fatigue and weakness of lower limbs. The laboratory results at Emergency Department showed severe hypokalemia. A study of secondary hypertension was carried out. With the initial suspicion of primary hyperaldosteronism, complete blood test was done including plasma renine activity, which was completely suppressed, and plasma aldosterone concentration, which resulted normal. Likewise, an abdomen CT was performed and revealed a left adrenal mass consistent of suprarrenal adenoma. Therefore, a salt loading suppression test was done with subsequent measure of plasmatic renine activity, which was still suppressed, plasma aldosterone concentration, that persisted normal, and a 24-h urinary aldosterone excretion rate, which was clearly high, supporting the suspected diagnosis. After the adrenalectomy, the patient remained asymptomatic with normal blood pressure without treatment and with normal serum potassium levels.
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Affiliation(s)
- B Rodríguez Maya
- Servicio de Medicina Interna, Hospital Universitario de Móstoles, Móstoles, Madrid, España.
| | - I Rodríguez Goncer
- Servicio de Medicina Interna, Hospital Universitario de Móstoles, Móstoles, Madrid, España
| | - C Diego Hernández
- Servicio de Anatomía Patológica, Hospital Universitario de Móstoles, Móstoles, Madrid, España
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Guerios SD, Souza CHDM, Bacon NJ. Adrenocortical tumor in a cat secreting more than one type of corticosteroid. JFMS Open Rep 2015; 1:2055116915617970. [PMID: 28491398 PMCID: PMC5362000 DOI: 10.1177/2055116915617970] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 11/16/2022] Open
Abstract
CASE SUMMARY A 14-year-old, spayed female domestic shorthair cat was evaluated because of a right adrenal mass. The referring veterinarian had started treatment for hypokalemia and systemic arterial hypertension. During the initial evaluation the cat was alert and responsive, and serum potassium concentration was within the reference range. Serum concentrations of aldosterone and progesterone were increased. Atrophy of the contralateral adrenal and an exaggerated response of cortisol to stimulation with adrenocorticotropic hormone suggested hypersecretion of cortisol. Unilateral adrenalectomy was performed and recovery was uneventful. Histologic examination of the mass revealed an adrenocortical tumor. After surgery, clinical signs of hypercortisolism, hyperaldosteronism and hyperprogesteronism were no longer observed, and neither potassium supplementation nor antihypertensive treatment were needed. RELEVANCE AND NOVEL INFORMATION In cases with an adrenocortical tumor, clinicians should investigate whether the tumor hypersecretes glucocorticoids, mineralocorticoids, sex steroids or combinations of these. Hypersecretion of more than one adrenal hormone may occur in a cat with an adrenocortical tumor.
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Affiliation(s)
| | | | - Nicholas J Bacon
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, FL, USA
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Lo AJ, Holt DE, Brown DC, Schlicksup MD, Orsher RJ, Agnello KA. Treatment of aldosterone-secreting adrenocortical tumors in cats by unilateral adrenalectomy: 10 cases (2002-2012). J Vet Intern Med 2013; 28:137-43. [PMID: 24372771 PMCID: PMC4895543 DOI: 10.1111/jvim.12186] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/25/2013] [Accepted: 08/06/2013] [Indexed: 11/28/2022] Open
Abstract
Background Primary hyperaldosteronism (PHA) in cats occurs as a consequence of excessive hormone production by an adrenocortical tumor. Median survival time, association between tumor type and prognosis, and the likelihood that cats require continued medical therapy after surgery have not been systematically evaluated. Objectives To determine the median survival time of cats with PHA treated by unilateral adrenalectomy. To examine if tumor type, anesthesia time, or tumor location (left or right side) affect survival and if affected cats require continued postoperative treatment for persistent hypertension or hypokalemia. Animals Ten client‐owned cats. Methods Retrospective study. Cats were diagnosed with PHA based on clinical signs, increased plasma aldosterone concentration, and advanced imaging. Cats underwent unilateral adrenalectomy. Survival time (days alive after surgery) was determined for each cat. Factors affecting median survival time were investigated, including histopathology, anesthesia time, and location (side) of the tumor. Results Eight of 10 cats survived to discharge from the hospital post adrenalectomy. Overall median survival was 1,297 days (range 2–1,582 days). The only significant factor affecting median survival time was anesthesia time >4 hours. Tumor type and location (side) did not significantly affect median survival time. No cats required continued medical treatment for PHA. Conclusions and Clinical Importance Although PHA in cats is still considered an uncommon condition, it should be considered in middle to older aged cats with hypokalemic polymyopathy and systemic hypertension. Surgical correction by unilateral adrenalectomy is a viable approach to definitive treatment of PHA with no need for continued medical management.
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Affiliation(s)
- A J Lo
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
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Abstract
An adrenal incidentaloma (AI) is a puzzle for clinician. In the era of widespread use of CT and MRI, it is becoming an increasingly frequent diagnosis. A detailed list of investigations is ordered to diagnose pathology responsible for AI. Most likely etiology of AI is pathology of AI is benign non-functional adenoma. But looking to the need of specific preoperative preparation for functional adrenal adenoma and importance of early diagnosis in adrenal carcinoma, a complete workup is essential. CT scan of adrenals with contrast gives maximum information about nature of lesion. In general, a lesion more than 6cm or a functioning AI or tumor signal intensity of more than 10HU on unenhanced image, significant enhancement on contrast and deenhancement in signal intensity of less than 50% is suggestive of carcinoma and must be removed. Those AI which are left for observation, also needs regular testing and if found functional on subsequent follow-up or if their size enlarge, they must be removed.
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Affiliation(s)
- Sunil M. Jain
- Department of Endocrinology and Diabetology, TOTALL Diabetes Hormone Institute, Indore, Madhya Pradesh, India
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Agha A, Hornung M, Iesalnieks I, Schreyer A, Jung EM, Haneya A, Schlitt HJ. Predictors of malignancy in primary aldosteronism. Langenbecks Arch Surg 2013; 399:93-8. [PMID: 24048685 DOI: 10.1007/s00423-013-1121-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 09/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Primary aldosteronism (PA, also Conn syndrome) is a benign disease in majority of cases. However, malignant transformation has been described. Present study reports on three cases of aldosterone producing adrenocortical carcinoma (APAC) in comparison to patients with benign PA. PATIENTS AND METHODS Data of patients undergoing adrenalectomy for benign PA were compared to patients with APAC. Retrospective chart analysis was performed. All patients received spironolactone for 6-8 weeks preoperatively. RESULTS Seventy-four patients underwent adrenalectomy for PA between 1994 and 2011. Three of them revealed an APAC. Patients with APAC presented with a significantly lower serum potassium level (1.7 mmol/l vs. 3.4 mmol/l, p = 0.001) and significant larger tumors (5.2 vs. 1.8 cm, p = 0.002). In addition, aldosterone/renin (A/R) ratio 675 in patients with APAC as compared to 74 in patients with benign PA (p = 0.0001). Sixty-eight of 71 patients with benign PA underwent minimal invasive surgery, whereas all three patients with APAC were operated conventionally. All patients with APAC developed disease recurrence 6-18 months postoperatively. CONCLUSION Tumor size >4 cm and a very high A/R ratio seems to predictors of malignancy in patients with PA. If these criteria are present, open adrenalectomy should be performed instead of endoscopic procedure.
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Affiliation(s)
- Ayman Agha
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Abstract
PURPOSE OF REVIEW Adrenal incidentalomas are common in this era of ubiquitous imaging. There is a lack of consensus on the mode and extent of evaluation, and follow-up of adrenal incidentalomas. RECENT FINDINGS There is increasing evidence of morbidity associated with subclinical hormone excess from functioning adrenal masses. Improved radiological techniques and interpretation have helped identify lipid-rich adenomas more accurately and tailor the evaluation of adrenal incidentalomas. SUMMARY A practical outline in the investigation and follow-up of adrenal incidentalomas incorporating the recent evidence is presented.
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Affiliation(s)
- Subramanian Kannan
- Endocrinology Diabetes and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
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Abbas A, Idriz S, Railton NJ, McGill N, Nasruddin AB, Sandeman DD, Breen DJ. Image-guided ablation of Conn's adenomas in the management of primary hyperaldosteronism. Clin Radiol 2012; 68:279-83. [PMID: 23218647 DOI: 10.1016/j.crad.2012.06.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/25/2012] [Accepted: 06/01/2012] [Indexed: 11/18/2022]
Affiliation(s)
- A Abbas
- Department of Radiology, University Hospital Southampton, Southampton, UK
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Åkerström T, Crona J, Delgado Verdugo A, Starker LF, Cupisti K, Willenberg HS, Knoefel WT, Saeger W, Feller A, Ip J, Soon P, Anlauf M, Alesina PF, Schmid KW, Decaussin M, Levillain P, Wängberg B, Peix JL, Robinson B, Zedenius J, Bäckdahl M, Caramuta S, Iwen KA, Botling J, Stålberg P, Kraimps JL, Dralle H, Hellman P, Sidhu S, Westin G, Lehnert H, Walz MK, Åkerström G, Carling T, Choi M, Lifton RP, Björklund P. Comprehensive re-sequencing of adrenal aldosterone producing lesions reveal three somatic mutations near the KCNJ5 potassium channel selectivity filter. PLoS One 2012; 7:e41926. [PMID: 22848660 PMCID: PMC3407065 DOI: 10.1371/journal.pone.0041926] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 06/29/2012] [Indexed: 11/19/2022] Open
Abstract
Background Aldosterone producing lesions are a common cause of hypertension, but genetic alterations for tumorigenesis have been unclear. Recently, either of two recurrent somatic missense mutations (G151R or L168R) was found in the potassium channel KCNJ5 gene in aldosterone producing adenomas. These mutations alter the channel selectivity filter and result in Na+ conductance and cell depolarization, stimulating aldosterone production and cell proliferation. Because a similar mutation occurs in a Mendelian form of primary aldosteronism, these mutations appear to be sufficient for cell proliferation and aldosterone production. The prevalence and spectrum of KCNJ5 mutations in different entities of adrenocortical lesions remain to be defined. Materials and Methods The coding region and flanking intronic segments of KCNJ5 were subjected to Sanger DNA sequencing in 351 aldosterone producing lesions, from patients with primary aldosteronism and 130 other adrenocortical lesions. The specimens had been collected from 10 different worldwide referral centers. Results G151R or L168R somatic mutations were identified in 47% of aldosterone producing adenomas, each with similar frequency. A previously unreported somatic mutation near the selectivity filter, E145Q, was observed twice. Somatic G151R or L168R mutations were also found in 40% of aldosterone producing adenomas associated with marked hyperplasia, but not in specimens with merely unilateral hyperplasia. Mutations were absent in 130 non-aldosterone secreting lesions. KCNJ5 mutations were overrepresented in aldosterone producing adenomas from female compared to male patients (63 vs. 24%). Males with KCNJ5 mutations were significantly younger than those without (45 vs. 54, respectively; p<0.005) and their APAs with KCNJ5 mutations were larger than those without (27.1 mm vs. 17.1 mm; p<0.005). Discussion Either of two somatic KCNJ5 mutations are highly prevalent and specific for aldosterone producing lesions. These findings provide new insight into the pathogenesis of primary aldosteronism.
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Affiliation(s)
- Tobias Åkerström
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Joakim Crona
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Alberto Delgado Verdugo
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Lee F. Starker
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Kenko Cupisti
- Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Holger S. Willenberg
- Department of Endocrinology, Diabetes and Rheumatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T. Knoefel
- Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Alfred Feller
- Department of Pathology, University Hospital Lübeck, Lübeck, Germany
| | - Julian Ip
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Patsy Soon
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
- Department of Surgery, Bankstown Hospital, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Martin Anlauf
- Institute of Pathology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Pier F. Alesina
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Universität Duisburg-Essen, Essen, Germany
| | - Kurt W. Schmid
- Institut für Pathologie und Neuropathologie Universitätsklinikum, Universität Duisburg-Essen, Essen, Germany
| | - Myriam Decaussin
- Department of Pathology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Pierre Levillain
- Pathology Department, Centre Hospitalier Poitiers, Poitiers, France
| | - Bo Wängberg
- Sahlgrenska akademin, Göteborg University, Göteborg, Sweden
| | - Jean-Louis Peix
- Department of Endocrine Surgery, Centre Hospitalier Lyon Sud, Lyon, France
| | - Bruce Robinson
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Jan Zedenius
- Department of Molecular Medicine and Surgery, Endocrine Surgery Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Bäckdahl
- Department of Molecular Medicine and Surgery, Endocrine Surgery Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefano Caramuta
- Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - K. Alexander Iwen
- Medizinischen Klinik Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Johan Botling
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Henning Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Per Hellman
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Stan Sidhu
- University of Sydney, Endocrine Surgical Unit and Cancer Genetics, Hormones and Cancer Group , Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, Australia
| | - Gunnar Westin
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hendrik Lehnert
- Medizinischen Klinik Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Martin K. Walz
- Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Universität Duisburg-Essen, Essen, Germany
| | - Göran Åkerström
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Tobias Carling
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Murim Choi
- Department of Genetics, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Richard P. Lifton
- Department of Genetics, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Peyman Björklund
- Department of Surgical Sciences, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- * E-mail:
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Abstract
Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).
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Affiliation(s)
- A Germain
- Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital d'adultes, CHU de Nancy-Brabois, université Henri-Poincaré-Nancy-1, 11, allée du Morvan, 54511 Vandœuvre-lès-Nancy, France
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Mathur A, Kemp CD, Dutta U, Baid S, Ayala A, Chang RE, Steinberg SM, Papademetriou V, Lange E, Libutti SK, Pingpank JF, Alexander HR, Phan GQ, Hughes M, Linehan WM, Pinto PA, Stratakis CA, Kebebew E. Consequences of adrenal venous sampling in primary hyperaldosteronism and predictors of unilateral adrenal disease. J Am Coll Surg 2010; 211:384-90. [PMID: 20800196 PMCID: PMC2930893 DOI: 10.1016/j.jamcollsurg.2010.05.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 05/04/2010] [Accepted: 05/11/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with primary hyperaldosteronism, distinguishing between unilateral and bilateral adrenal hypersecretion is critical in assessing treatment options. Adrenal venous sampling (AVS) has been advocated by some to be the gold standard for localization of the responsible lesion, but there remains a lack of consensus for the criteria and the standardization of technique. STUDY DESIGN We performed a retrospective study of 114 patients with a biochemical diagnosis of primary hyperaldosteronism who all underwent CT scan and AVS before and after corticotropin (ACTH) stimulation. Univariate and multivariate analyses were performed to determine what factors were associated with AVS lateralization, and which AVS values were the most accurate criteria for lateralization. RESULTS Eighty-five patients underwent surgery at our institution for unilateral hyperaldosteronism. Of the 57 patients who demonstrated unilateral abnormalities on CT, AVS localized to the contralateral side in 5 patients and revealed bilateral hyperplasia in 6 patients. Of the 52 patients who showed bilateral disease on CT scan, 43 lateralized with AVS. The most accurate criterion on AVS for lateralization was the post-ACTH stimulation value. Factors associated with AVS lateralization included a low renin value, high plasma aldosterone-to plasma-renin ratio, and adrenal mass > or = 3 cm on CT scan. CONCLUSIONS Because 50% of patients would have been inappropriately managed based on CT scan findings, patients with biochemical evidence of primary hyperaldosteronism and considering adrenalectomy should have AVS. The most accurate measurement for AVS lateralization was the post-ACTH stimulation value. Although several factors predict successful AVS lateralization, none are accurate enough to perform AVS selectively.
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Affiliation(s)
- Aarti Mathur
- Endocrine Oncology Section, Surgery Branch, National Cancer Institute, MD, USA
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