Adrenal Vein Sampling to Distinguish Between Unilateral and Bilateral Primary Hyperaldosteronism: To ACTH Stimulate or Not?

Sung, Tae‐Yon; Alobuia, Wilson; Tyagi, Monica; Ghosh, Chandra Kanta; Kebebew, Electron

doi:10.3390/jcm9051447

Cited by 12 publications

(23 citation statements)

References 30 publications

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“…Since incidental nonfunctional adrenal cortical nodules are frequent in the general population and not all radiologically identified adrenal lesions cause aldosterone excess in patients with primary aldosteronism [4][5][6], the appropriate lateralization of the aldosterone excess (versus potential bilateral disease) has been an important clinical task in the management of patients with primary aldosteronism. Several preoperative techniques (e.g., adrenal venous sampling with or without cosyntropin stimulation) are increasingly used to help distinguish the source of aldosterone-excess [7][8][9][10].…”

Section: Morphologic and Genomic Correlates Of Primary Aldosteronismmentioning

confidence: 99%

What Did We Learn from the Molecular Biology of Adrenal Cortical Neoplasia? From Histopathology to Translational Genomics

et al. 2021

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Approximately one-tenth of the general population exhibit adrenal cortical nodules, and the incidence has increased. Afflicted patients display a multifaceted symptomatology-sometimes with rather spectacular features. Given the general infrequency as well as the specific clinical, histological, and molecular considerations characterizing these lesions, adrenal cortical tumors should be investigated by endocrine pathologists in high-volume tertiary centers. Even so, to distinguish specific forms of benign adrenal cortical lesions as well as to pinpoint malignant cases with the highest risk of poor outcome is often challenging using conventional histology alone, and molecular genetics and translational biomarkers are therefore gaining increased attention as a possible discriminator in this context. In general, our understanding of adrenal cortical tumorigenesis has increased tremendously the last decade, not least due to the development of next-generation sequencing techniques. Comprehensive analyses have helped establish the link between benign aldosterone-producing adrenal cortical proliferations and ion channel mutations, as well as mutations in the protein kinase A (PKA) signaling pathway coupled to cortisol-producing adrenal cortical lesions. Moreover, molecular classifications of adrenal cortical tumors have facilitated the distinction of benign from malignant forms, as well as the prognostication of the individual patients with verified adrenal cortical carcinoma, enabling high-resolution diagnostics that is not entirely possible by histology alone. Therefore, combinations of histology, immunohistochemistry, and next-generation multi-omic analyses are all needed in an integrated fashion to properly distinguish malignancy in some cases. Despite significant progress made in the field, current clinical and pathological challenges include the preoperative distinction of non-metastatic low-grade adrenal cortical carcinoma confined to the adrenal gland, adoption of individualized therapeutic algorithms aligned with molecular and histopathologic risk stratification tools, and histological confirmation of functional adrenal cortical disease in the context of multifocal adrenal cortical proliferations. We herein review the histological, genetic, and epigenetic landscapes of benign and malignant adrenal cortical neoplasia from a modern surgical endocrine pathology perspective and highlight key mechanisms of value for diagnostic and prognostic purposes.

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Section: Morphologic and Genomic Correlates Of Primary Aldosteronismmentioning

confidence: 99%

What Did We Learn from the Molecular Biology of Adrenal Cortical Neoplasia? From Histopathology to Translational Genomics

et al. 2021

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“…A third limitation was the protocol used for cosyntropin administration. The administration of cosyntropin is debated because, while it improves AVS, it can also affect the LI in some cases 6,26,27 . Fourth, patients with LI = 3–4 underwent surgery with careful consideration of their characteristics.…”

Section: Discussionmentioning

confidence: 99%

Indices of ACTH‐stimulated adrenal venous sampling as predictors of postsurgical outcomes in primary aldosteronism

Lee

Kim

Yoon

et al. 2021

Clinical Endocrinology

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Objective This study aimed to investigate the impact of indices of adrenal venous sampling (AVS) on postsurgical outcomes in patients with primary aldosteronism (PA). Design and Patients This retrospective study determined biochemical and clinical outcomes based on ACTH‐stimulated AVS parameters (lateralisation index [LI], contralateral ratio [CLR], and ipsilateral ratio [ILR]) in 251 patients with PA at 3 months after surgery. Results Modified complete biochemical success was achieved in 8 of 12 (66.7%) patients with LI = 3–4, 39 of 47 (83.0%) with LI = 4–10, and 155 of 169 (91.7%) with LI ≥ 10 (p = .004 for trend). Modified complete biochemical success was achieved in 29 of 38 (76.3%) patients with CLR ≥ 1 and ILR ≤ 2, 73 of 86 (84.9%) with CLR = 0.25–1 and ILR > 2, and 100 of 104 (96.2%) with CLR < 0.25 and ILR > 2 (p = .001 for trend). After adjusting for confounders, modified complete biochemical success was associated with an LI ≥ 10 (odds ratio [OR] = 6.32; 95% confidence interval [CI] = 1.33–29.93) using LI = 3–4 as a reference and combined CLR < 0.25 and ILR > 2 (OR = 11.49; 95% confidence interval [CI] = 2.49–53.01) using combined CLR ≥ 1 and ILR ≤ 2 as a reference. Using combined CLR ≥ 1 and ILR ≤ 2 as a reference, complete clinical success was associated with combined CLR < 0.25 and ILR > 2 (OR = 3.10; 95% CI = 1.03–9.28) and combined CLR = 0.25–1 and ILR > 2 (OR = 4.92; 95% CI = 1.64–14.76). Conclusion LI ≥ 10 may be appropriate for achieving biochemical success. With ILR > 2, CLR < 0.25, and CLR < 1 may be appropriate for achieving biochemical and clinical success, respectively.

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“…Some centers use unilateral sequential sampling, while others use simultaneous bilateral sampling [12]. Different centers perform AVS with or without ACTH stimulation [13,14]. There are no specific guidelines or recommendations regarding whether ACTH stimulation is necessary [15,16].…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, anatomical and physiological factors may influence the SI even if the catheterization was correct at baseline; this problem could be solved by stimulating cortisol secretion through ACTH. At present, there are no standardized ACTH stimulation protocols, and methods of ACTH stimulation include a high-dose bolus, infusion after a bolus and a bolus after infusion [13][14][15][16][20][21][22][23][24][25]. With a very low-dose bolus [16] after infusion and sustained infusion (250 μg/30 min) [20], as performed at some centers, no difference was observed in the SI between baseline and after ACTH.…”

Section: Discussionmentioning

confidence: 99%

“…With a very low-dose bolus [16] after infusion and sustained infusion (250 μg/30 min) [20], as performed at some centers, no difference was observed in the SI between baseline and after ACTH. With the other methods of administration, the SI was significantly increased, and the greatest increase in adrenal cortisol secretion was stimulated by infusion after a bolus [13][14][15][16][20][21][22][23][24][25]. Our center performs simultaneous bilateral catheterization using a medium-dose ACTH bolus (125 μg), followed by a continuous intravenous infusion (125 μg/h); throughout the process, the catheter is not moved.…”

Section: Discussionmentioning

confidence: 99%

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Effect of Adrenocorticotropic Hormone Stimulation During Simultaneous Bilateral Adrenal Vein Sampling in Primary Aldosteronism

et al. 2021

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The aim of the study was to investigate the significance and influence of adrenocorticotropic hormone (ACTH) stimulation in primary aldosteronism (PA) patients with simultaneous bilateral adrenal vein sampling (AVS). All patients diagnosed with PA underwent simultaneous bilateral AVS with ACTH. In 95 patients, the post-ACTH SI significantly increased (p<0.001), and it gradually decreased from t10–t30 after ACTH stimulation (p<0.001). The unsuccessful catheterization decreased after ACTH stimulation. Time points within 20 min after ACTH stimulation were better for sampling, and the selectivity did not increase over longer periods. According to lateralization before and after ACTH stimulation, the patients could be divided into 3 groups (U, unilateral; B, bilateral): U/U , U/B or B/U, and B/B. Compared with the U/U group, in the U/B or B/U and B/B groups, the lateralization index (LI) was lower both at baseline and after ACTH stimulation (p<0.0001), the contralateral index (CLI) was higher after ACTH stimulation (p<0.003), the serum potassium level was higher (p<0.001), and the carbon dioxide combining power (CO2CP) and base excess (BE) levels were lower. In conclusion, in simultaneous bilateral AVS, ACTH stimulation had significant effects on increasing the catheterization selectivity. Lateralization change was observed after stimulation. After ACTH stimulation, fewer patients could be diagnosed with lateralized PA. Patients with consistent lateralized PA showed a more serious phenotype.

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Adrenal Vein Sampling to Distinguish Between Unilateral and Bilateral Primary Hyperaldosteronism: To ACTH Stimulate or Not?

Cited by 12 publications

References 30 publications

What Did We Learn from the Molecular Biology of Adrenal Cortical Neoplasia? From Histopathology to Translational Genomics

What Did We Learn from the Molecular Biology of Adrenal Cortical Neoplasia? From Histopathology to Translational Genomics

Indices of ACTH‐stimulated adrenal venous sampling as predictors of postsurgical outcomes in primary aldosteronism

Effect of Adrenocorticotropic Hormone Stimulation During Simultaneous Bilateral Adrenal Vein Sampling in Primary Aldosteronism

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