Partial Adrenalectomy Carries a Considerable Risk of Incomplete Cure in Primary Aldosteronism

No AccessJournal of UrologyAdult Urology1 Aug 2021Partial Adrenalectomy Carries a Considerable Risk of Incomplete Cure in Primary Aldosteronism Elle C. J. van de Wiel, Benno Küsters, Ritse Mann, Andor Veltien, Tilly W. Aalders, Gerald W. Verhaegh, Kuniaki Mukai, Jaap Deinum, and Johan F. Langenhuijsen Elle C. J. van de WielElle C. J. van de Wiel *Correspondence: Department of Urology, Radboud UMC, P.O. Box 9101, 6500 HBNijmegen, Gelderland , The Netherlands E-mail Address: [email protected] http://orcid.org/0000-0002-7902-4560 Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author , Benno KüstersBenno Küsters Radboud University Medical Center, Department of Pathology, Nijmegen, the Netherlands More articles by this author , Ritse MannRitse Mann Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands Financial interest and/or othe relationship with Siemens Healthineers, Medtronic, Bayer, BD, Screenpoint Medical, Send Medical and Koning. More articles by this author , Andor VeltienAndor Veltien Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands More articles by this author , Tilly W. AaldersTilly W. Aalders Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author , Gerald W. VerhaeghGerald W. Verhaegh Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author , Kuniaki MukaiKuniaki Mukai Keio University School of Medicine, Medical Education Center, Tokyo, Japan More articles by this author , Jaap DeinumJaap Deinum Radboud University Medical Center, Department of Internal Medicine, Nijmegen, the Netherlands More articles by this author , and Johan F. LangenhuijsenJohan F. Langenhuijsen Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001752AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Laparoscopic adrenalectomy is standard treatment for patients with unilateral aldosterone-producing adenomas, but surgeons are increasingly tempted to perform partial adrenalectomy, disregarding potential multinodularity of the adrenal. We assess the diagnostic value of endoscopic ultrasound for differentiating solitary adenomas from multinodularity by examining in-depth adrenal pathology with ex vivo 11.7 T magnetic resonance imaging and immunohistochemistry. Materials and Methods: In 15 primary aldosteronism patients, we performed intraoperative endoscopic ultrasound, ex vivo magnetic resonance imaging and histopathological examination. Every adrenal was intraoperatively and postoperatively assessed for solitary adenomas or multinodular hyperplasia. After unblinding for ex vivo magnetic resonance imaging results a second detailed histopathological examination, including immunohistochemistry analysis with CYP11B2 (aldosterone synthase) and chemokine receptor 4 (CXCR4), a new marker for aldosterone-producing adenomas, was performed. Finally, presence of somatic mutations linked to aldosterone-producing adenomas was assessed. Results: The sensitivity and specificity of endoscopic ultrasound to identify multinodularity were 46% and 50%, respectively. We found multinodular hyperplasia in 87% of adrenals with ex vivo magnetic resonance imaging combined with detailed histopathology, and 6 adrenals contained multiple CYP11B2-producing nodules. Every CYP11B2 positive nodule and 61% of CYP11B2 negative nodules showed CXCR4 staining. Finally, in 4 adrenals (27%) we found somatic mutations. In multinodular glands, only 1 nodule harbored this mutation. Conclusions: Intraoperative endoscopic ultrasound in primary aldosteronism patients has low accuracy to identify multinodularity. Ex vivo magnetic resonance imaging can serve as a tool to direct detailed histopathological examination, which frequently shows CYP11B2 production in multiple nodules. Therefore, partial adrenalectomy is inappropriate in primary aldosteronism as multiple aldosterone-producing nodules easily stay behind. References 1. : The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016; 101: 1889. Google Scholar 2. : Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. Lancet Diabetes Endocrinol 2017; 5: 689. 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Google Scholar 21. : Intraoperative ultrasound aids in dissection during laparoscopic partial adrenalectomy. J Urol 2002; 168: 1352. Link, Google Scholar Funded by Radboud University Medical Center. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue 2August 2021Page: 219-228Supplementary Materials Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.Keywordsimmunohistochemistryhyperaldosteronismmagnetic resonance imagingendosonographyadrenalectomyAcknowledgmentThe authors thank Heidi Küsters-Vandevelde (pathologist, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands) for scoring the IHC slices as a second observer to assess interobserver reliability.MetricsAuthor Information Elle C. J. van de Wiel Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands *Correspondence: Department of Urology, Radboud UMC, P.O. Box 9101, 6500 HBNijmegen, Gelderland , The Netherlands E-mail Address: [email protected] More articles by this author Benno Küsters Radboud University Medical Center, Department of Pathology, Nijmegen, the Netherlands More articles by this author Ritse Mann Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands Financial interest and/or othe relationship with Siemens Healthineers, Medtronic, Bayer, BD, Screenpoint Medical, Send Medical and Koning. More articles by this author Andor Veltien Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands More articles by this author Tilly W. Aalders Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author Gerald W. Verhaegh Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author Kuniaki Mukai Keio University School of Medicine, Medical Education Center, Tokyo, Japan More articles by this author Jaap Deinum Radboud University Medical Center, Department of Internal Medicine, Nijmegen, the Netherlands More articles by this author Johan F. Langenhuijsen Radboud University Medical Center, Department of Urology, Nijmegen, the Netherlands More articles by this author Expand All Funded by Radboud University Medical Center. Advertisement Loading ...