The Current Status of Minimally Invasive Adrenalectomy for Aldosterone Producing Adenoma: Controversial Issues, and Realistic Expectations of Clinical Cure
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Purpose: Minimally invasive adrenalectomy is the standard of care for primary lateralized aldosteronism. Controversy related to clinical cure rates, prediction scores, and the role of adrenal vein sampling (AVS) for lateralization abound. Methods: Retrospective analysis of 53 consecutive adrenalectomy patients from 2013–2021, consisting of demographics, descriptive epidemiology, statistical comparison of pre- and post-adrenalectomy blood pressure, anti-hypertensive medications, plasma aldosterone and renin activity values, comparison of predictive scores, concordance of AVS for lateralization with cross-sectional imaging. Results: Forty-seven (89%) had a beneficial outcomes—19 (36%) achieving both biochemical/clinical cure, 28 (53%) clinically improved. The Utsumi score was superior to the aldosteronoma resolution score (ARS) in discriminating likelihood of cure, particularly in patients <40 years old. Sixteen patients (30%) with pathologic proven hyperplasia, had lower rates of cure or improvement. Forty-seven patients (89%) underwent both cross-sectional imaging and AVS; of those, 45/47 (96%) had concordant lateralization. In a broader cohort of 119 patients at our institution AVS, concordance rates decreased (63%). Conclusion: Adrenalectomy for primary aldosteronism leads to clinical improvement in most, but a far lower fraction achieve full clinical cure of hypertension. Proper expectations of adrenalectomy, must incorporate the Utility of predictive scores, and the significance of any form of unilateral hyperplasia. AVS is broadly nonconcordant with cross-sectional imaging in 33%, but in carefully selected patients can be highly concordant raising the possibility of selective bypassing of AVS in in those <40 years old
Abstract
Purpose: Minimally invasive adrenalectomy is the standard of care for primary lateralized aldosteronism. Controversy related to clinical cure rates, prediction scores, and the role of adrenal vein sampling (AVS) for lateralization abound. Methods: Retrospective analysis of 53 consecutive adrenalectomy patients from 2013–2021, consisting of demographics, descriptive epidemiology, statistical comparison of pre- and post-adrenalectomy blood pressure, anti-hypertensive medications, plasma aldosterone and renin activity values, comparison of predictive scores, concordance of AVS for lateralization with cross-sectional imaging. Results: Forty-seven (89%) had a beneficial outcomes—19 (36%) achieving both biochemical/clinical cure, 28 (53%) clinically improved. The Utsumi score was superior to the aldosteronoma resolution score (ARS) in discriminating likelihood of cure, particularly in patients <40 years old. Sixteen patients (30%) with pathologic proven hyperplasia, had lower rates of cure or improvement. Forty-seven patients (89%) underwent both cross-sectional imaging and AVS; of those, 45/47 (96%) had concordant lateralization. In a broader cohort of 119 patients at our institution AVS, concordance rates decreased (63%). Conclusion: Adrenalectomy for primary aldosteronism leads to clinical improvement in most, but a far lower fraction achieve full clinical cure of hypertension. Proper expectations of adrenalectomy, must incorporate the Utility of predictive scores, and the significance of any form of unilateral hyperplasia. AVS is broadly nonconcordant with cross-sectional imaging in 33%, but in carefully selected patients can be highly concordant raising the possibility of selective bypassing of AVS in in those <40 years old
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