Adrenocorticotrophic hormone stimulation in adrenal vein sampling / 中华内分泌代谢杂志

Objective:To explore the value of adrenocorticotrophic hormone (ACTH) stimulation in adrenal vein sampling (AVS) with its effect on the sampling success rate and lateralization determination.Methods:The clinical data of 54 patients with primary aldosteronism (PA) who underwent AVS in Nanjing Drum Tower Hospital from July 2018 to June 2020 were collected retrospectively. Blood samples from bilateral adrenal veins were collected simultaneously at baseline and after ACTH stimulation. The selectivity index (SI), lateralization index (LI), and relative aldosterone secretion index (RASI) were examined.Results:The concentration of serum cortisol level in left and right adrenal vein and peripheral vein increased significantly after ACTH stimulation ( P<0.001). SI of left adrenal vein increased from 18.00 (2.29, 20.29) to 34.76 (12.10, 46.86) , and the SI of right adrenal vein increased from 26.61(5.24, 31.85) to 28.40 (27.65, 56.05, P<0.001). The bilateral vein sampling success rate increased from 80%(43/54) to 93%(50/54). LI decreased from 2.85(1.78, 6.20) at baseline to 2.45(1.40, 6.10) after ACTH stimulation without significant difference( P>0.05). Eleven patients who identified unilateral secretion at baseline demonstrated bilateral after ACTH stimulation, and the RASI of these patients decreased from 0.50 (0.38, 1.25 ) to 0.37 (0.22, 0.84, P=0.019). Conclusion:ACTH stimulation significantly increased SI and the AVS success rate in patients with PA: ACTH stimulation decreased the relative aldosterone secretion in the dominant side of some patients with aldosterone producing adenoma, thus reduced the proportion of identified unilateral PA.

Gold standard for primary aldosteronism subtype diagnosis: adrenal vein sampling / 中华内分泌外科杂志

Adrenal vein sampling (AVS),as the gold standard of subtype diagnosis for primary aldosteronism,can directly detect the hormone concentration in adrenal vein by adrenal vein cannulation.Adrenal tumor can be categorized into no function adenoma,adrenal carcinoma,aldosterone producing adenoma (APA),cortisol producing adenoma (CPA) and pheochromocytoma.Traditionally,peripheral blood hormone testing and image examination were performed to make functional diagnosis of adrenal tumor,which exhibits low specificity and sensitivity.On the contrary,AVS can help make a distinct lateralization diagnosis according the aldosterone concentration of each gland,even in the condition of bilateral adrenal tumor and early stage tumor,which is difficult to make functional lateralization diagnosis by traditional methods.AVS can be categorized into simultaneous sampiing and sequencing sampling,according to the order of sampling.According to using adrenocorticotropic hormone (ACTH) or not,AVS can be categorized into no stimulus sampling and post-stimulus sampling.

Application of low-dose CT scanning technique in right adrenal vein imaging / 中华放射医学与防护杂志

Objective To investgate the application value of low-dose CT scanning in right adrenal vein imaging.Methods A total of 124 patients were enrolled in the study who were suspected as primary aldosteronism and requiring a contrast enhanced CT examination on adrenal glands.Four patients were excluded according to the exclusion criteria,so that the rest 120 patients were divided equally into three groups.Group A was a control group with conventional radiation dose using tube voltage of 120 kV and automatic mA.It was divided into A1,A2 and A3 groups according to arterial phase,portal venous phase and parenchymal phase.Group B was a experimental group with conventional tube voltage of 120 kV and automatic mA,which was divided into B1,B2 and n3 groups according to arterial phase,late arterial phase and portal venous phase.Group C was a low-dose experimental group with a tube voltage of 100 kV and a tube current of 150 mA only in the second phase,the remaining scanning parameters and method were the same as that of group B.The subjective scores of the images of groups A,B and C were statistically analyzed,and the CT values of the right adrenal vein(RAV),the right adrenal gland(RAG),and the fat of anterior abdominal wall at different scan phases were measured.The dose length products (DLP) were recorded and the signal-to-noise ratios (SNR),contrast-to-noise ratios (CNR),effective doses (E) of the three groups were calculated and compared.Results The subjective scores of the two observers were consistent (Kappa value =0.63);the subjective scores of the B2 images were statistically significant (H =7.18,P＜0.05).Difference of subjective scores between B2 and A2was statistically significant (t=-18.03,P＜0.05).The CT values of RAV,SNR,and CNR of the B2 group were higher than those of the A2 group (t=36.99,6.92,9.02,P＜0.05).The radiation dose comparison showed that the effective dose (E) was 45.52％ lower in the low-dose group than the conventional dose group with the statistically significant difference(t =12.19,P＜0.05).Conclusions Using MDCT scanning technique with lower tube voltage and lower tube current of 100 kV-150 mA,the detection rate of right adrenal vein can reach 95％ in the late arterial phase,and the effective dose can be reduced about 45.52％ on the basis of ensuring image quality.

To compare the role on determining the functional location of primary hyperaldosteronism by multi-slice spiral CT and by adrenal vein sampling / 中华泌尿外科杂志

Objective To compare the role on determining the functional location of primary hyperaldosteronism (PHA)by multi-slice spiral CT (MSCT)and by adrenal vein sampling (AVS),and to discuss the reasonable method to use MSCT and AVS in localization diagnosis of PHA.Methods Clinical data of 78 patients with PHA were analyzed retrospectively.These patients were diagnosed in our department from June 2014 to June 2018.There were 27 male and 51 female patients.With mean age of (47.5 ± 11.2) years old.The mean systolic blood pressure was (190 ± 24)mmHg and mean diastolic blood pressure was (111 ± 16) mmHg.The mean history of hypertension was (6.0 ± 6.0) years.The mean serum potassium was (2.4 ± 0.6) mmol/L.The mean plasma aldosterone concentration (PAC) was (415.7 ± 235.4) pg/ml.The mean plasma renin activity (PRA) was (3.2 ± 5.7) ng/(ml · h).The mean aldosterone/renin ratio (ARR) was 409.0 ± 434.9.All PHA patients underwent MSCT and AVS,the accuracy on determining the functional location of PHA by MSCT and by AVS were evaluated based on the pathological results and clinical outcomes.The influence of adrenal size and character on the accuracy of determining the functional location of PHA by MSCT were analyzed.Results The rate of accuracy of determining the location of PHA by AVS was higher than that by MSCT[100.0％ (78/78) vs.71.8％ (56/78),P ＜ 0.05].When MSCT indicated:adrenal hyperplasia,adrenal tumor volume less than 1 cm,1 cm ＜ adrenal tumor volume ≤ 2 cm,adrenal tumor volume ＞ 2 cm,the rate of accuracy in localization diagnosis with MSCT was 50.0％ (4/8),81.0％ (17/21),92.9％ (26/28),100.0％ (9/9) respectively.Its trend has statistical significance (P ＜ 0.05).The diagnostic accuracy rate of MSCT for aldosterone adenoma was 79.6％ (43/54),while that of adrenal hyperplasia was 58.3 ％ (7/12).There was no statistical significance between two diagnostic accuracy rate of MSCT(P ＞ 0.05).Conclusions AVS is the gold standard for localization diagnosis.When MSCT indicates that there is no obvious abnormality in the adrenal gland,adrenal hyperplasia,small tumor (≤ 2 cm),and bilateral adrenal lesions,AVS should be examined at the same time,which can be considered as the gold standard for localization diagnosis.For isolated adrenal tumor (＞ 2 cm) in PHA,the accuracy of localization diagnosis in MSCT is very high and the AVS is unnecessary.

Adrenocorticotropic Hormone-Independent Cushing Syndrome with Bilateral Cortisol-Secreting Adenomas

A 48-year-old woman was incidentally found to have bilateral adrenal masses, 2.8 cm in diameter on the right, and 2.3 cm and 1.7 cm in diameter on the left, by abdominal computed tomography. The patient had a medical history of hypertension, which was not being controlled by carvedilol, at a dose of 25 mg daily. She presented with signs and symptoms that suggested Cushing Syndrome. We diagnosed adrenocorticotropic hormone (ACTH)-independent Cushing Syndrome based on the results of basal and dynamic hormone tests. Adrenal vein sampling (AVS) was performed to localize a functioning adrenal cortical mass. AVS results were consistent with hypersecretion of cortisol from both adrenal glands, with a cortisol lateralization ratio of 1.1. Upon bilateral laparoscopic adrenalectomy, bilateral ACTH-independent adrenal adenomas were found. The patient's signs and symptoms of Cushing Syndrome improved after surgery just as the blood pressure was normalized. After surgery, the patient was started on glucocorticoid and mineralocorticoid replacement therapy.

Identification of the etiology of primary aldosteronism with adrenal vein sampling in patients with equivocal imaging findings / 中华内分泌代谢杂志

A group of 19 referred hypertensive patients were diagnosed to have primary aldosteronism(PA) with inconclusive computed tomography scan results.Adrenal vein sarmpling (AVS) was performed in all patients.AVS was successful in 16 cases but failed in 3 cases.According to the results of AVS and postoperative pathology,8 cases were diagnosed as aldosterone-producing adenoma (APA) and unilateral adrenal hyperplasia (UAH),and the other 8 cases were diagnosed as idiopathic hyperaldosteronism (IHA).In conclusion,AVS is one of the most crucial methods in typing diagnosis of PA.

Renin-responsive Adrenal Adenoma with a Suspicious Abberant Adrenal Vein / 대한내분비학회지

A renin- or angiotensin-II responsive aldosterone producing tumor is a rare cause of primary hyperaldosteronism. This tumor can be identified by tests that show that the aldosterone producing adrenal tumor is not fully autonomous. In other words partially it is responsible for the stimulation of aldosterone secretion that results aldosterone levels in an increase in serum in response to the upright posture and spironolactone treatment. Furthermore, the urinary 18-hydroxycortisol level is within the normal range. Because of different responses to surgical removal, the differential diagnosis of the causes of primary aldosteronism can't be overemphasized even for rare causes of primary aldosteronism such as unilateral nodular hyperplasia or a renin-responsible aldosterone producing tumor. We should consider renin or angiotensin-II responsive adrenal adenoma in the differential diagnosis of primary aldosteronism when biochemical data shows atypical results. Here we present the first case in Korea of a renin-responsive aldosterone producing adrenal adenoma which was fully accessible and was successfully treated by surgical removal. Also, sampling for aldosterone secretion just above the insertion site in the left renal vein before surgery showed a suspiciously abberant left adrenal vein drainage into the IVC, This was very helpful information during adrenal vein ligation in laparoscopic adrenalectomy.

A Case of Adrenalectomy after Preterm Delivery in Cushing's Syndrome of Third Trimester Pregnant Woman / 대한내분비학회지

A renin- or angiotensin-II responsive aldosterone producing tumor is a rare cause of primary hyperaldosteronism. This tumor can be identified by tests that show that the aldosterone producing adrenal tumor is not fully autonomous. In other words partially it is responsible for the stimulation of aldosterone secretion that results aldosterone levels in an increase in serum in response to the upright posture and spironolactone treatment. Furthermore, the urinary 18-hydroxycortisol level is within the normal range. Because of different responses to surgical removal, the differential diagnosis of the causes of primary aldosteronism can't be overemphasized even for rare causes of primary aldosteronism such as unilateral nodular hyperplasia or a renin-responsible aldosterone producing tumor. We should consider renin or angiotensin-II responsive adrenal adenoma in the differential diagnosis of primary aldosteronism when biochemical data shows atypical results. Here we present the first case in Korea of a renin-responsive aldosterone producing adrenal adenoma which was fully accessible and was successfully treated by surgical removal. Also, sampling for aldosterone secretion just above the insertion site in the left renal vein before surgery showed a suspiciously abberant left adrenal vein drainage into the IVC, This was very helpful information during adrenal vein ligation in laparoscopic adrenalectomy.