Diagnostic Impact of Adrenal Vein Sampling in Adrenal Cushing's Syndrome

Background: Adrenal Cushing's syndrome is characterized by ACTH-independent hypercortisolism. Adrenal vein sampling (AVS) is not routinely employed prior to management de-cisions, and few studies have investigated the value of AVS in this population. We assessed whether AVS provides a diagnostic benefit for treatment planning. Materials and Methods: Six patients with imaging and biochemical evidence of adrenal Cush-ing's syndrome undergoing AVS at our institution from 2015 to 2020 were analyzed retrospectively, including demographic and clinical characteristics. AVS lateralization index was determined by comparing the (cortisol/ipsilateral reference hormone) ratios of both adrenal veins. lateralization index of 2 or greater was considered diagnostic of unilateral disease. Post-management clinical improvement was defined as serum cortisol normaliza-tion, symptomatic improvement, or both. Results: Cross-sectional imaging noted bilateral adrenal enlargement or nodules in three patients, and unilateral nodules in three patients. AVS results were discordant with imaging in three patients. Treatment included medical management in two patients, percutaneous radiofrequency ablation in one patient, and laparoscopic adrenalectomy in two patients. One patient was lost to follow up. AVS results aided management planning in five patients, definitively changing treatment from surgery to medical management in one patient. All five patients demonstrated clinical improvement. Conclusions: AVS offered useful information for determining appropriate management of adrenal Cushing's syndrome, especially distinguishing unilateral from bilateral disease. Even in bilateral disease, AVS may show a dominant gland, potentially allowing a staged uni-lateral adrenalectomy, before assessing the need for completion adrenalectomy or medical management. Larger studies are needed to better establish whether AVS offers significant benefit for this population. (c) 2021 Elsevier Inc. All rights reserved.

Automated summary

Adrenal vein sampling (AVS) provides valuable information for determining appropriate management of adrenal Cushing's syndrome, especially in distinguishing unilateral from bilateral disease. Even in cases of bilateral disease, AVS may identify a dominant gland, allowing for staged unilateral adrenalectomy before considering complete adrenalectomy or medical management. Larger studies are needed to further establish the significant benefit of AVS for this population.