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


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. 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. 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.

Authors: Elle C. J. van de Wiel, Benno Küsters, Ritse Mann, Andor Veltien, Tilly W. Aalders, Gerald W. Verhaegh, Kuniaki Mukai, Jaap Deinum, Johan F. Langenhuijsen
Keywords: partial adrenalectomy, aldosterone-producing nodules, endoscopic ultrasound, solitary adenomas, multinodularity
DOI Number: 10.1097/JU.0000000000001752      Publication Year: 2021

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