Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism.

PURPOSE: To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA). METHODS: A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis. RESULTS: This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4. CONCLUSION: A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.

Diagnostic Value of Unenhanced CT Attenuation and CT Histogram Analysis in Differential Diagnosis of Adrenal Tumors.

Background and Objectives: Our aim was to verify the optimal cut-off value for unenhanced CT attenuation and the percentage of negative voxels in the volume CT histogram analysis of adrenal masses. Materials and Methods: We retrospectively analyzed the CT data of patients who underwent an adrenalectomy in the period 2002-2019. In total, 413 adrenalectomies were performed. Out of these, 233 histologically verified masses (123 adenomas, 58 pheochromocytomas, 18 carcinomas, and 34 metastases) fulfilled the inclusion criteria and were selected for analysis. The mean unenhanced attenuation in Hounsfield units (HU) and the percentage of voxels with attenuation less than 0 HU (negative voxels) were measured in each mass. Results: The mean unenhanced attenuation with a cut-off value of 10 HU reached a sensitivity of 59.4% and a specificity of 99.1% for benign adenomas. The mean unenhanced attenuation with a cut-off value of 15 HU reached a sensitivity of 69.1% and a specificity of 98.2%. For the histogram analysis, a cut-off value of 10% of negative pixels reached a sensitivity of 82.9% and a specificity of 98.2%, whereas a cut-off value of 5% of negative pixels reached a sensitivity of 87.8% and a specificity of 75.5%. The percentage of negative voxels reached a slightly better area under the curve (0.919) than unenhanced attenuation (0.908). Conclusion: Mean unenhanced attenuation with a cut-off value of 10 HU represents a simple tool, and the most specific one, to distinguish adrenal adenomas from non-adenomas. CT histogram analysis with cut-off values of 10% of negative voxels improves sensitivity without any loss of specificity.

Thymoma - diagnostics options.

Various types of tumors (either benign or malignant) can be found in mediastinum. Early diagnosis and treatment may help to improve survival and quality if life in these patients. Compared to direct mediastinoscopy, used for obtaining a specimen for histological analysis in previous decades, modern imaging methods, specifically the CT navigated biopsy, represent an effective and less invasive approach to the diagnosis. In our publication, we present a patient with thymoma, rather rare type of anterior mediastinum tumor.

Differential diagnosis of hypoglycemia.

Our review summarizes the possible differential diagnoses of hypoglycemia. It confirms the absolute necessity of fulfilling all the three Whipple hypoglycemia criteria. Briefly is mentioned Clinical symptoms of hypoglycemia are briefly mentioned and several ways to classify the hypoglycemic events are offered. Highlighted is the recommended approach to distinguish patients as seemingly ill and healthy and also as hypoglycemia occurring in diabetic and non-diabetic. All the classifications and recommendations are summarized in attached tables and schemes.

Hypoglycemia as a Symptom of Neoplastic Disease, with a focus on Insulin-like Growth Factors Producing Tumors.

This article reviews the current knowledge of uncommon causes of hypoglycemia, with a focus on neoplastic disease. However, these situations are rare. They commonly accompany severely ill patients and therefore a proper diagnosis is the basis for relevant treatment. Here we discuss the pathophysiological foundation of hypoglycemia - situations caused by increased insulin production or sensitivity - but we also focus on different cytokines which could cause hypoglycemia, especially IGF-II production in what are called nonislet cell tumors. From the clinical perspective we can divide the patients who are affected into "seemingly ill" or "healthy patients" and lead the diagnostic process accordingly.

Characteristic CT features of pheochromocytomas - probability model calculation tool based on a multicentric study.

OBJECTIVES: The aim of the study was to evaluate the CT features of adrenal tumors in an effort to identify features specific to pheochromocytomas and second, to define a feasible probability calculation model. METHODS: This multicentric retrospective study included patients from the period 2003 to 2017 with an appropriate CT examination and a histological diagnosis of an adrenal adenoma, pheochromocytoma, adrenocortical carcinoma, or metastasis. In total, 346 patients were suitable for the CT image analysis, which included evaluation of the largest diameter, the shape of the lesion, the presence of central necrosis and its margins, and the presence of an enhancing peripheral rim ("ring sign"). RESULTS: Pheochromocytomas have a significantly more spherical shape (P<0.001), whereas an elliptical shape significantly reduces the probability of a pheochromocytoma (odds ratio = 0.015), as does another shape (odds ratio = 0.006). A "ring sign" is also more frequent in pheochromocytomas compared to other adrenal tumors (P=0.001, odds ratio = 6.49). A sharp necrosis also increases the probability of a pheochromocytoma more than unsharp necrosis (odds ratio 231.6 vs. 20.2). The probability calculation model created on the basis of the results confirms a high sensitivity and specificity (80% and 95%). CONCLUSION: This study confirms the value of anatomical features in the assessment of adrenal masses with the ability to significantly improve the identification of pheochromocytomas. Advanced assessment of the tumor shape was defined and a original comprehensive calculating tool of the pheochromocytoma probability was created on the basis of the results presented here and could be used in clinical routine.

Influence of slice thickness on result of CT histogram analysis in indeterminate adrenal masses.

PURPOSE: The aim was to determine the optimal slice thickness of CT images and the optimal threshold of negative voxels for CT histogram analysis to distinguish adrenal adenomas from non-adenomas with a mean attenuation more than 10 Hounsfield units (HU). METHODS: Volume CT histogram analysis of 83 lipid-poor adenomas and 80 non-adenomas was performed retrospectively. The volume of interest was extracted from each adrenal lesion, and the mean attenuation, standard deviation (SD), and percentage of voxels with a negative CT value were recorded using reconstructions with different slice thicknesses (5 mm, 2.5 mm, 1.25 mm). The percentage of negative voxels was correlated with SD as a measure of image noise and with the reference splenic tissue values. The sensitivity, specificity, and positive predictive value (PPV) for the identification of adenomas were calculated using reconstructions with different slice thicknesses and three different thresholds of negative voxels (1%, 5%, 10%). RESULTS: The percentage of negative voxels increased with a thinner slice thickness and correlated with increasing CT image noise in adenomas, non-adenomas, and spleen. Using a threshold of 10% negative voxels and a slice thickness of 5 mm, we reached a sensitivity of 53.0%, specificity of 98.8% and the highest PPV, and thus we propose this combination for clinical use. Other combinations achieved a clearly lower specificity and PPV as a result of the increasing noise in CT images. CONCLUSION: The CT slice thickness significantly affects the result and diagnostic value of histogram analysis. Thin CT slice reconstructions are inappropriate for histogram analysis.

ECG non-gated multi-detector computed tomography protocol prior to catheter ablation of atrial fibrillation provides sufficient data quality with lower radiation exposure compared to ECG-gated protocol - results of a prospective, randomized and blinded study.

BACKGROUND: The role of ECG-gating in left atrium (LA) computed tomography (MDCT) imaging is not precisely defined. METHODS AND RESULTS: 62 patients were randomized according to ECG gating with prospective evaluation of image quality, Volume CT Dose Index, Dose Length Product, Effective Dose and registration error between anatomical map and MDCT. We found significant difference in all radiation variables, but not in visual quality, registration error, CA duration, CA fluoroscopy time and CA fluoroscopy dose. CONCLUSION: Helical non-gated MDCT achieved a radiation dose more than four times lower with comparable image quality and course of ablation compared to ECG-gated protocol.

Current diagnostic imaging of pheochromocytomas and implications for therapeutic strategy.

The topic of pheochromocytomas is becoming increasingly popular as a result of major advances in different medical fields, including laboratory diagnosis, genetics, therapy, and particularly in novel advances in imaging techniques. The present review article discusses current clinical, biochemical, genetic and histopathological aspects of the diagnosis of pheochromocytomas and planning of pre-surgical preparation and subsequent surgical treatment options. The main part of the paper is focused on the role of morphological imaging methods (primarily computed tomography and magnetic resonance imaging) and functional imaging (scintigraphy and positron emission tomography) in the diagnosis and staging of pheochromocytomas.

Adrenal disease: a clinical update and overview of imaging. A review.

AIM: The aim of this article is to provide an overview of the most frequent clinically significant adrenal diseases and to describe the latest trends in their diagnostics, particularly by means of imaging techniques. METHODS: The authors reviewed standard textbooks and subsequently conducted a search using the PubMed (Public/Publisher MEDLINE) electronic database by the year 2013 with the following search terms: adrenal masses, adrenal adenoma, phaeochromocytoma, adrenocortical carcinoma, metastases, incidentalomas, hypercortisolism, hyperaldosteronism. RESULTS: If adrenal disease is clinically suspected, hormone tests are performed to detect adrenal hyperfunction and imaging studies are used to assess the nature of adrenal lesion. The most frequent syndromes include hypercortisolism, primary hyperaldosteronism, and phaeochromocytoma. The clinically most significant pathologies of the adrenal glands are adenomas and adrenal hyperplasia, adrenocortical carcinomas, phaeochromocytomas, and metastases. Given the availability and improved quality of imaging techniques, adrenal incidentalomas are detected increasingly often. In these cases, it is necessary to rule out hormonal activity and malignancy. Incidentalomas can be associated with clinical syndromes of adrenal hormone overproduction. In most cases, they are clinically silent. In some cases, the definitive diagnosis can be determined as early as during the initial examination with an imaging technique (most frequently, a CT scan). If the finding is inconsistent, other imaging techniques can be used: CT contrast washout analysis, MRI, SPECT or PET/CT. CONCLUSION: In the case of adrenal gland disorders, correct interpretation of the results of laboratory tests and imaging studies is essential for further management of these patients.

Comparison of imaging methods in POEMS syndrome.

BACKGROUND: POEMS syndrome is a clinical condition with a very heterogeneous clinical manifestation. Its presentation as well as monitoring is complex and dependent on the clinician's experience. One of the leading presenting symptoms is based on evaluation of skeletal damage with typical osteosclerotic or mixed lesions. AIMS AND METHODS: Our aim was to compare the usefulness of different imaging methods in the diagnostics of POEMS syndrome, such as conventional radiography, densitometry, technetium scintigraphy, PET/CT scan, MRI and angiography on a series of three patients with POEMS syndrome with different clinical manifestations and course of disease. RESULTS: Our series demonstrates different types of skeletal involvement in POEMS syndrome. Although conventional X-ray is the imaging method mostly used for the evaluation, its sensitivity and specificity is low. Under specific conditions, other imaging methods should be considered, giving a more complex outlook of the disease's skeletal involvement. Nevertheless, FDG-PET/CT confirmed its superiority in defining both skeletal lesions as well as the activity of the neoplastic process. CONCLUSIONS: We conclude that the different manifestation of the disease implies the necessity of a complex evaluation of imaging methods in mutual concordance. FDG-PET/CT emerges as the most contributive method for the evaluation of both the extent and activity of the disease.

Differential diagnosis of incidentally detected adrenal masses revealed on routine abdominal CT.

PURPOSE: The aim of this study was to compare CT findings of adrenal incidentalomas with a definitive histological diagnosis in order to establish CT features characteristic for individual types of lesions. PATIENTS AND METHODS: The retrospective study comprised of patients with adrenal lesions detected on abdominal CT. The patients with these incidental findings subsequently underwent adrenalectomy. The adrenalectomy was followed by a histological assessment of the expansion process. The study consisted of 62 adrenal expansions found in 55 patients (in seven patients bilateral lesions were found). According to the definitive histological diagnosis after adrenalectomy, the lesions were divided into the following six groups: primary adrenocortical carcinoma (n=4), metastasis (n=7), adrenocortical adenoma (n=37), pheochromocytoma (n=9), myelolipoma (n=2), and others (n=3). CT observations were categorized as follows: size, shape, margins, density, side of the expansion, homogeneous or heterogeneous density before and after contrast application, presence of central hypodensity, presence of central calcifications and fat deposits. Statistical analysis was carried out using the chi(2)-test, Kruskal-Wallis test and Mann-Whitney test. To estimate the differences between the subgroups, the t-test was used. For the evaluation of the mutual relations of maximum size, mean size, and volume, regression analysis (coefficient of determination R(2)) was used. RESULTS: The correlation and regression analysis suggest that there will be no statistically significant error if the maximum size measurements are used instead of the mean size or volume measurements of the lesion. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value for distinguishing adenomas and non-adenomas using a cut-off diameter of 41.5mm were 81.1%, 70.0%, 77.2%, 83.3%, 66.7%, respectively; using the non-contrast density threshold of 23 HU, they were 89.2%, 100%, 93%, 100%, 83.3%, respectively; using the post-contrast density threshold of 47.5 HU, they were 80.6%, 100%, 88.2%, 100%, 76.9%, respectively; using the increase of density threshold of 34.5 HU, they were 74.2%, 70.0%, 72.5%, 79.3%, 63.6%, respectively. A study of receiver operating characteristics (ROC) analyses resulted in the following conclusions: (a) the most accurate parameter for distinguishing adenomas from non-adenomas is the value of non-contrast density, (b) the second most accurate parameter is the post-contrast density, (c) the least suitable parameters are the size of the lesion and increase of density, (d) therefore, in practice, the value of non-contrast density parameter should be used. CONCLUSION: Standard CT of the abdomen (not specifically aimed at adrenal glands) is a suitable method for distinguishing adrenal lesions which need to be operated on from those which are probably benign but need to be monitored.