Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism.

Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p > .05). Readers had low inter-observer agreement (kappa = 0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.

External Validation of Clinical Prediction Models in Unilateral Primary Aldosteronism.

BACKGROUND: Targeted treatment of primary aldosteronism (PA) is informed by adrenal vein sampling (AVS), which remains limited to specialized centers. Clinical prediction models have been developed to help select patients who would most likely benefit from AVS. Our aim was to assess the performance of these models for PA subtyping. METHODS: This external validation study evaluated consecutive patients referred for PA who underwent AVS at a tertiary care referral center in Alberta, Canada during 2006-2018. In alignment with the original study designs and intended uses of the clinical prediction models, the primary outcome was the presence of lateralization on AVS. Model discrimination was evaluated using the C-statistic. Model calibration was assessed by comparing the observed vs. predicted probability of lateralization in the external validation cohort. RESULTS: The validation cohort included 342 PA patients who underwent AVS (mean age, 52.1 years [SD, 11.5]; 201 [58.8%] male; 186 [54.4%] with lateralization). Six published models were assessed. All models demonstrated low-to-moderate discrimination in the validation set (C-statistics; range, 0.60-0.72), representing a marked decrease compared with the derivation sets (range, 0.80-0.87). Comparison of observed and predicted probabilities of unilateral PA revealed significant miscalibration. Calibration-in-the-large for every model was >0 (range, 0.35-1.67), signifying systematic underprediction of lateralizing disease. Calibration slopes were consistently <1 (range, 0.35-0.87), indicating poor performance at the extremes of risk. CONCLUSIONS: Overall, clinical prediction models did not accurately predict AVS lateralization in this large cohort. These models cannot be reliably used to inform the decision to pursue AVS for most patients.

Unilateral Disease Is Common in Patients With Primary Aldosteronism Without Adrenal Nodules.

BACKGROUND: Patients with primary aldosteronism (PA) without apparent adrenal nodularity have not been well characterised in the literature. The aim of this study was to assess for unilateral aldosterone hypersecretion among patients with primary aldosteronism with normal-appearing adrenals using adrenal vein sampling (AVS). METHODS: In this cross-sectional study performed at a Canadian tertiary care centre, we reviewed all consecutive PA patients lacking a definitive adrenal nodule who were referred for AVS in the work-up of PA between January 2006 and May 2018. AVS indications included an elevated aldosterone-to-renin ratio and high-probability features of PA. RESULTS: In total, 174 patients were included (mean age, 52.0 years; 62.6% male), and 70 (40.2%) had unilateral aldosterone hypersecretion. There was a positive linear association between higher age categories (by decade) and lateralisation (P = 0.03). For every decade of age, there was a 30% higher odds of lateralisation (odds ratio, 1.03 per year; 95% confidence interval, 1.00-1.05). The frequency of lateralisation was higher in males compared with females (47.7% vs 27.7%), with a 2-fold greater odds of unilateral disease (odds ratio, 2.38; 95% confidence interval, 1.23-4.61). Traditional biomarkers of lateralisation among patients with adrenal nodules (eg, serum potassium and aldosterone-to-renin ratio levels) were not predictive of lateralisation in this population. CONCLUSIONS: Many patients with PA who lack definitive adrenal nodules have lateralising disease. Efforts to optimise referrals for AVS may be prioritised by focusing on patients most likely to have unilateral disease, especially males and older adults.

Surgical Outcomes Among Primary Aldosteronism Patients Without Visible Adrenal Lesions.

CONTEXT: Many patients with unilateral primary aldosteronism (PA) have normal adrenal imaging, but little is known about their outcome following adrenalectomy. OBJECTIVE: To evaluate biochemical and clinical outcomes after adrenalectomy in patients with unilateral PA and normal-appearing adrenal imaging. DESIGN: Retrospective cohort study of patients seen between January 2006 and May 2018. SETTING: A Canadian tertiary care PA referral center. PATIENTS: Consecutive individuals with PA, normal cross-sectional adrenal imaging, and lateralizing adrenal vein sampling (AVS) who underwent adrenalectomy during the study period. PRIMARY OUTCOME: Biochemical response to adrenalectomy graded according to the Primary Aldosteronism Surgical Outcome criteria. RESULTS: A total of 40 patients were included. Biochemical outcomes were available for 33 people (mean age, 54.7 years; 91% male; median follow-up, 2.7 months), with 28 (85%) showing a complete or partial response and 5 (15%) with no response. Clinical outcomes were available for 36 people (mean age, 54.6 years; 86% male; median follow-up, 9.8 months), with 31 (86%) demonstrating a complete or partial response and 5 (14%) with no response. CONCLUSIONS: The prognosis after adrenalectomy is highly favorable for patients with unilateral PA and normal-appearing adrenal imaging. Patients with lateralizing disease should be considered for surgery despite apparently normal adrenal imaging.

Novel image-guided management of a uterine arteriovenous malformation.

The investigators present a novel image-guided embolization, not previously described, of a uterine arteriovenous malformation (AVM) resistant to endovascular management. The uterus was exposed surgically, and Histoacryl (Braun, Fulda, Germany) was injected directly into the nidus using ultrasound guidance and fluoroscopy. The patient had a successful full-term pregnancy after this procedure. This technique may be a useful alternative management strategy in patients with uterine AVM who fail traditional endovascular embolization and who still desire fertility.

Cavitating pulmonary tuberculosis in children: correlating radiology with pathogenesis.

BACKGROUND: Cavitating pulmonary tuberculosis (PTB) is generally known as a disease of adults, with children typically having features of primary PTB. OBJECTIVE: To group children with PTB and cavities according to possible pathogenesis by evaluating the clinical and radiological findings. MATERIALS AND METHODS: The clinical and radiological findings in ten randomly selected children with PTB and cavitations on chest radiographs were retrospectively reviewed and evaluated. RESULTS: Three groups emerged: group 1 (four children) had cavities, usually single and unilateral in the classic upper lobe distribution of postprimary PTB; group 2 (three children) developed progressive primary spread of disease with extensive and bilateral pulmonary cavities; and group 3 (three children) developed cavities secondary to airway obstruction by mediastinal lymph nodes with consequent distal collapse and consolidation. Children in group 1 responded well to treatment and had unremarkable recoveries. Children in group 2 were all below 2 years of age with complicated recoveries. Children in group 3 had frequent complications resulting in one fatality. CONCLUSION: Cavities in PTB in children may arise by one of three possible mechanisms with a relatively equal incidence. A study is underway to determine the incidence of cavity formation associated with mediastinal lymphadenopathy and airway obstruction.