Identification of Surgically Curable Primary Aldosteronism by Imaging in a Large, Multiethnic International Study

Abstract

Context Adrenal glands imaging is recommended by the current guidelines for the work-up of primary aldosteronism (PA). However, its diagnostic performance has not been established in large multi-ethnic cohorts of patients submitted to adrenal vein sampling (AVS) and adrenalectomy. Objective To assess the diagnostic accuracy of cross-sectional adrenal imaging. Design International multi-center study. Setting Tertiary referral centers. Patients or Other Participants 1625 PA patients seeking surgical cure enrolled in an international study involving 19 centers in North America, Europe, Asia, and Australia. 1311 (81%) had imaging data available and 369 (23%), who received a final diagnosis of surgically cured unilateral PA, were examined. Intervention(s) Patients underwent AVS and imaging by computed tomography (CT) and/or magnetic resonance (MR). Main Outcome Measure(s) The accuracy of detection of unilateral PA at imaging was estimated by the area under the receiver operator characteristics (ROC) curve using cure (biochemical and/or full clinical success) as the reference at follow-up after unilateral adrenalectomy. Results In the cohort of 1311 patients with imaging data available, 34% and 7% of cases showed no detectable or bilateral nodules, respectively. Imaging did not detect the culprit adrenal in 28% of the surgically cured unilateral PA patients. Moreover, the clinical outcome did not differ significantly between the imaging-positive and imaging-negative patients. Conclusions Cross-sectional imaging did not identify a lateralized cause of disease in around 40% of PA patients and failed in identifying the culprit adrenal in more than one fourth of patients with unilateral PA.

Lateralization in 11C‐Metomidate PET and outcome of adrenalectomy in primary aldosteronism

“…Altogether, this means errors in 18% and 3% of lateralization diagnostics with the 11 C‐MTO‐PET and AVS methods, respectively, among those eligible for adrenal surgery. In comparison, based on analysis of more than 1300 imaging studies in a recent report, anatomical imaging‐based lateralization would have excluded surgical treatment from 22% of the subjects and resulted in the removal of the non‐culprit adrenal gland from 6% of the subjects 13 . Previous studies have shown a 36%–39% probability of errors in operation side selection based on adrenal CT, but these numbers included those diagnosed with bilateral disease 27–30 …”

“…1300 imaging studies in a recent report, anatomical imaging-based lateralization would have excluded surgical treatment from 22% of the subjects and resulted in the removal of the non-culprit adrenal gland from 6% of the subjects. 13 Previous studies have shown a 36%-39% probability of errors in operation side selection based on adrenal CT, but these numbers included those diagnosed with bilateral disease. [27][28][29][30] Despite great expectations, the use of 11 17 However, the ability of 11 C-MTO-PET to diagnose unilateral non-classic forms of PA that are becoming more prevalent remains unanswered by these studies.…”

“…Recent meta‐analysis and a prospective cohort study favour surgical treatment over mineralocorticoid receptor antagonists to reduce cardiovascular events and mortality in unilateral PA, 9,10 but rigorous subtype classification is essential when considering adrenalectomy as a possible treatment. Anatomical imaging with adrenal computed tomography or magnetic resonance imaging has not proven sufficient sensitivity or specificity in most cases but may guide the treatment in young patients with clear PA, hypokalaemia and a solitary nodule 11–14 . However, adrenal venous sampling (AVS), the gold standard method for lateralization diagnosis, poses methodological challenges 11,15,16 .…”

“…Anatomical imaging with adrenal computed tomography or magnetic resonance imaging has not proven sufficient sensitivity or specificity in most cases but may guide the treatment in young patients with clear PA, hypokalaemia and a solitary nodule. [11][12][13][14] However, adrenal venous sampling (AVS), the gold standard method for lateralization diagnosis, poses methodological challenges. 11,15,16 Previous reports suggested that functional imaging with 11 C-metomidate positron emission tomography ( 11 C-MTO-PET) offers an alternative to AVS for PA subtype classification, [17][18][19] but in our recent prospective study, 20 11 C-MTO-PET was inferior to AVS.…”

Clinical Translationality of KCNJ5 Mutation in Aldosterone Producing Adenoma

“…However, AVS is available at limited institutions, therefore, efforts have been made to identify cases in which AVS can be bypassed and to determine the indications for surgery by CT scan [ 27 , 28 , 29 , 30 ]. It should be noted, however, that the results of CT imaging and AVS differ in 28–38% of cases [ 31 , 32 ]. Thus, AVS has been recommended for precise subtype diagnosis to date.…”