J. Shank1, N. Nagarajan1, B. Holly2, A. Mathur1, J. Canner1, J. D. Prescott1 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Radiology And Radiological Sciences,Baltimore, MD, USA
Introduction:
Adrenal venous sampling (AVS) is the gold standard test for lateralizing aldosterone hypersecretion/identifying bilateral disease in cases of primary hyperaldosteronism. Though efficacious, AVS is expensive, invasive, requires significant technical expertise and is not universally available. The utility of less expensive, less morbid imaging techniques for disease lateralization has been limited by relatively poor associated sensitivity and specificity. Nonetheless, medical imaging technology is continually improving, making periodic reassessment of imaging lateralization accuracy, relative to AVS, necessary.
Methods:
A retrospective review was performed to identify patients who underwent AVS between July 1st 2003 and April 30th 2015 at our academic tertiary care center. Patients were excluded if AVS was not performed for hyperaldosteronism, if CT and/or MRI adrenal imaging was not done and if disease management was unknown. Data were extracted for demographic, clinical, biochemical and treatment variables. Continuous variables were summarized using medians and interquartile range (IQR). Binary/categorical variables were summarized as proportions.
Results:
A total of 204 AVS patients were identified, of whom 112 met inclusion criteria. Overall, 71 patients underwent unilateral adrenalectomy. Among the 53 patients in this group having concordant AVS and imaging findings, postoperative serum aldosterone values were available for 34, with biochemical cure achieved in 32 (94.1%). When AVS and imaging were discordant (n=14), AVS lead to surgical cure in 77.8 % of patients, none of whom would have been referred for surgery on the basis imaging findings alone (bilateral adrenal nodules). When discordant, 4 patients underwent surgery based on imaging postoperative aldosterone was only available for 1 patient who showed biochemical cure. Among the 41 patients treated medically, concordance was 48.8%, with discordance resulting primarily from unilateral imaging findings in the context of bilateral AVS results. Overall, an imaging only-based management plan was, or would have been, incorrect in 28.6% of the cohort (inappropriate surgery or inappropriate medical management).
Conclusion:
Our findings identify high discordance rates between AVS and contemporary abdominal imaging techniques when assessing disease laterality among patients diagnosed with primary hyperaldosteronism. AVS thus remains critical to accurate clinical decision-making for these patients.
