P. P. Raje1,2, B. Sacks1,2, B. James1,2 1Beth Israel Deaconess Medical Center,General Surgery,Boston, MA, USA 2Harvard Medical School,Boston, MA, USA
Introduction:
Adrenal vein sampling (AVS) is a procedure involving simultaneous sampling of both adrenal veins to measure autonomous hormone production. AVS is routinely performed in hyperaldosteronism to differentiate adenoma from hyperplasia. AVS is not routine in the workup of adrenal Cushing’s syndrome prior to surgical planning. We aim to assess whether AVS provides a significant benefit for treatment planning.
Methods:
A search of patients with adrenal Cushing's whose workup included AVS revealed 8 patients at our institution from 2015 to 2020. 1 was lost to follow up after undergoing AVS. The remaining 7 patients were included for final analysis. Patients ranged from ages 37 to 75, 3 were male and 4 were female, and 5 were Caucasian and 2 were African American. Clinical improvement was defined as either reduced serum cortisol or symptomatic improvement, or both.
Results:
AVS results were concordant with imaging results in 3 out of 7 (43%) patients and discordant in 4 out of 7 (57%). AVS changed management to medical therapy in 1 discordant case, confirmed management with ablation in 1 concordant case, and did not appear to affect management in 5 cases. Management consisted of unilateral adrenalectomy for 2 patients, radiofrequency ablation for 2 patients, and medical therapy for 2 patients. All 3 management strategies were employed in both concordant and discordant cases. Ultimately, 5 out of 7 patients had clinical improvement, 1 that underwent medical therapy is still being evaluated for response, 1 patient was lost to follow up after AVS. In 2 out of 4 discordant cases, AVS suggested bilateral disease while CT suggested unilateral disease.
Conclusion:
The role of AVS in in adrenal Cushing’s is still unclear. Our results suggest AVS may impact management in some patients. AVS results were discordant with CT results in over half our patient cohort, suggesting that basing management on cross sectional imaging alone may not be reliable. Indeterminate AVS results in 1 patient whose CT lateralized disease to the right side led to the decision for medical therapy instead of surgical. The decision was also influenced by the patient’s mild symptoms. In an institution with AVS technical expertise, the procedure is low risk and may provide useful information. In patients with discordant results and more severe symptoms, surgery or radiofrequency ablation guided primarily by imaging was pursued. Interpretation of the AVS is nuanced and dependent on symptom severity, clarity of CT results, and discussion of options with the patient. The role of AVS needs to be studied in larger cohorts to decide whether it should routinely be adopted as a diagnostic tool in adrenal Cushing’s.
