4.4 Article

Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism

Journal

CLINICAL ENDOCRINOLOGY
Volume 87, Issue 6, Pages 665-672

Publisher

WILEY
DOI: 10.1111/cen.13442

Keywords

adrenal vein sampling; aldosterone producing adenoma; CYP11B2; primary aldosteronism

Funding

  1. National Institute of Diabetes and Digestive and Kidney Diseases [1K08DK109116 R21DK103183]
  2. National Cancer Institute [P30CA046592]

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ObjectiveCorrect subtyping of primary aldosteronism (PA) is essential for good surgical outcomes. Adrenal vein sampling (AVS) and/or computed tomography (CT) are used for PA subclassification. Clinical and/or biochemical improvement after surgery, however, is not always achieved in patients with presumed unilateral PA. We aimed to identify the pitfalls in PA subclassification leading to surgical treatment failures. Patients and DesignWe retrospectively studied 208 patients who underwent adrenal vein sampling (AVS) for PA subclassification in a tertiary referral centre, between January 2009 and August 2016. Simultaneous bilateral AVS was performed before and after cosyntropin administration. We implemented immunohistochemistry for aldosterone synthase (CYP11B2) and 17-hydroxylase/17,20 lyase (CYP17A1) in adrenal glands resected from patients without improvement of PA after surgical treatment and from those with limitations in AVS interpretation. ResultsOf 55 patients who underwent adrenalectomy, three (5.5%) had no improvement of PA. All three patients underwent partial adrenalectomy to remove a CT-detected nodule present on the same side with AVS lateralization. Immunohistochemistry revealed a CYP11B2-negative nodule in both cases available. All patients who underwent total adrenalectomy based on AVS lateralization benefitted from surgery, including three patients with unilateral unsuccessful AVS and aldosterone suppression in the catheterized side vs inferior vena cava. ConclusionsRadiographically identified adrenal nodules are not always a source of PA, even when ipsilateral with AVS lateralization. These data caution against reliance on imaging findings, either alone or in conjunction with AVS, to guide surgery for PA.

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