Association Between Size of Dominant Candidate Lesion on Four-Dimensional CT and Four-Gland Hyperplasia among Patients with Primary Hyperparathyroidism.

BACKGROUND: Four-dimensional (4D) CT localization allows minimally invasive parathyroidectomy as treatment for primary hyperparathyroidism (PHPT), but false positive localization is frequent. We sought to characterize the ability of 4D CT to predict four-gland hyperplasia (HP) based on the size of candidate lesions. STUDY DESIGN: We retrospectively analyzed patients with PHPT who underwent 4D CT imaging and parathyroidectomy between 2014 and 2020 from a prospectively collected institutional database. The cohort was stratified into two groups, HP vs single adenoma (SA) and double adenoma (DA), based on operative findings and pathology. Logistic regression models assessed the association between the greatest diameter of the dominant candidate lesion on 4D CT and the outcomes of four-gland hyperplasia vs SA and DA. RESULTS: Among a cohort of 240 patients, 41 were found to have HP, and 199 had adenomas (SA = 155, DA = 44). Patients with HP were less likely to have a preoperative calcium level greater than 1 mg/dL above the upper limit of normal compared with patients with adenomas (63% vs 81%, p = 0.02) and more likely to report symptoms (61% vs 43%, p = 0.04). After adjusting for BMI, we found an estimated 13% reduction in odds of HP for every 1-mm increase in the greatest diameter of dominant candidate lesions identified on 4D CT scan (odds ratio 0.87, 95% CI 0.78 to 0.96, p = 0.009). CONCLUSIONS: A smaller size of the dominant lesion on 4D CT scan is associated with an increased risk of HP in PHPT. Use of 4D CT imaging localization may provide evidence for differentiating HP from adenomas.

Morphologically Normal-Appearing Adrenal Glands as a Prevalent Source of Aldosterone Production in Primary Aldosteronism.

BACKGROUND: Normal-appearing adrenal glands on cross-sectional imaging may still be the source of aldosterone production in primary aldosteronism (PA). METHODS: We evaluated the prevalence of aldosterone production among morphologically normal-appearing adrenal glands and the impact of this phenomenon on interpretations of localization studies and treatment decisions. We performed a retrospective cohort study of PA patients with at least 1 normal adrenal gland and reanalyzed contemporary studies to assess interpretations of imaging and adrenal venous sampling (AVS) at the individual patient and adrenal levels. RESULTS: Among 243 patients, 43 (18%) had bilateral normal-appearing adrenals and 200 (82%) had a unilateral normal-appearing adrenal, for a total of 286 normal-appearing adrenal glands. 38% of these normal-appearing adrenal glands were a source of aldosteronism on AVS, resulting in discordance between imaging and AVS findings in 31% of patients. Most patients with lateralizing PA underwent curative unilateral treatment (80%); however, curative treatment was pursued in 92% of patients who had concordant imaging-AVS results but in only 38% who had discordant results (P < 0.05). In young patients, imaging-AVS discordance was detected in 32% of those under 45 years and 21% of those under 35 years. Among 20 contemporary studies (including 4,904 patients and 6,934 normal-appearing adrenal glands), up to 64% of normal-appearing adrenals were a source of aldosteronism resulting in 31% of patients having discordant results. CONCLUSIONS: Morphologically normal-appearing adrenal glands are commonly the source of aldosterone production in PA, even among young patients. The lack of awareness of this issue may result in inappropriate treatment recommendations.

Diagnostic Impact of Adrenal Vein Sampling in Adrenal Cushing's Syndrome.

BACKGROUND: Adrenal Cushing's syndrome is characterized by ACTH-independent hypercortisolism. Adrenal vein sampling (AVS) is not routinely employed prior to management decisions, and few studies have investigated the value of AVS in this population. We assessed whether AVS provides a diagnostic benefit for treatment planning. MATERIALS AND METHODS: Six patients with imaging and biochemical evidence of adrenal Cushing's syndrome undergoing AVS at our institution from 2015 to 2020 were analyzed retrospectively, including demographic and clinical characteristics. AVS lateralization index was determined by comparing the (cortisol/ipsilateral reference hormone) ratios of both adrenal veins. lateralization index of 2 or greater was considered diagnostic of unilateral disease. Post-management clinical improvement was defined as serum cortisol normalization, symptomatic improvement, or both. RESULTS: Cross-sectional imaging noted bilateral adrenal enlargement or nodules in three patients, and unilateral nodules in three patients. AVS results were discordant with imaging in three patients. Treatment included medical management in two patients, percutaneous radiofrequency ablation in one patient, and laparoscopic adrenalectomy in two patients. One patient was lost to follow up. AVS results aided management planning in five patients, definitively changing treatment from surgery to medical management in one patient. All five patients demonstrated clinical improvement. CONCLUSIONS: AVS offered useful information for determining appropriate management of adrenal Cushing's syndrome, especially distinguishing unilateral from bilateral disease. Even in bilateral disease, AVS may show a dominant gland, potentially allowing a staged unilateral adrenalectomy, before assessing the need for completion adrenalectomy or medical management. Larger studies are needed to better establish whether AVS offers significant benefit for this population.

Can Cytologic and Sonographic Features Help Prevent Overtreatment of Bethesda V Thyroid Nodules?

BACKGROUND: Although nearly half of thyroid nodules with Bethesda V cytology (suspicious for malignancy) may be benign or harbor low-grade neoplasms that can be sufficiently treated with lobectomy, many patients with Bethesda V cytology continue to be treated with total thyroidectomy. The objectives of this study were to establish whether cytomorphologic and ultrasonographic features can determine appropriate surgery for thyroid nodules with Bethesda V cytology and how often patients are overtreated with total instead of partial thyroidectomy. METHODS: Utilizing a 10-y prospective database starting January 1, 2004, cytomorphologic and ultrasonographic features of thyroid nodules with Bethesda V cytology were reviewed. Overtreatment was defined as total thyroidectomy when histopathology revealed benign nodule, noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) or a unilateral < 4 cm low risk cancer. RESULTS: Sixty-three patients were included in the study. Seventeen (27%) had benign, 14 (22%) NIFTP, and 32 (51%) malignant nodules. On cytology, nuclear pseudoinclusions, and on ultrasound, taller-than-wide configuration, were more common in malignant than benign or NIFTP nodules. Among 56 patients who underwent total thyroidectomy, 14 and 11 had a benign or NIFTP nodule, respectively, and 13 had a unilateral < 4 cm low risk cancer, suggesting that 68% (38/56) were overtreated. CONCLUSIONS: Total thyroidectomy for Bethesda V thyroid nodules may result in overtreatment in more than half of the patients. Although certain cytomorphologic and ultarsonographic features may be helpful in determining appropriate surgery for Bethesda V thyroid nodules, additional characteristics are needed to reduce overtreatment of these nodules.

Adrenocorticotropic Hormone-Stimulated Adrenal Venous Sampling Underestimates Surgically Curable Primary Aldosteronism: A Retrospective Cohort Study and Review of Contemporary Studies.

[Figure: see text].

Variability of Aldosterone Measurements During Adrenal Venous Sampling for Primary Aldosteronism.

BACKGROUND: Variability of aldosterone concentrations has been described in patients with primary aldosteronism. METHODS: We performed a retrospective cohort study of 340 patients with primary aldosteronism who underwent adrenal venous sampling (AVS) at a tertiary referral center, 116 of whom also had a peripheral venous aldosterone measured hours before the procedure. AVS was performed by the same interventional radiologist using bilateral, simultaneous sampling, under unstimulated and then stimulated conditions, and each sample was obtained in triplicate. Main outcome measures were: (i) change in day of AVS venous aldosterone from pre-AVS to intra-AVS and (ii) variability of triplicate adrenal venous aldosterone concentrations during AVS. RESULTS: Within an average duration of 131 minutes, 81% of patients had a decline in circulating aldosterone concentrations (relative decrease of 51% and median decrease of 7.0 ng/dl). More than a quarter (26%) of all patients had an inferior vena cava aldosterone of ≤5 ng/dl at AVS initiation. The mean coefficient of variation of triplicate adrenal aldosterone concentrations was 30% and 39%, in the left and right veins, respectively (corresponding to a percentage difference of 57% and 73%), resulting in lateralization discordance in up to 17% of patients if the lateralization index were calculated using only one unstimulated aldosterone-to-cortisol ratio rather than the average of triplicate measures. CONCLUSIONS: Circulating aldosterone levels can reach nadirs conventionally considered incompatible with the primary aldosteronism diagnosis, and adrenal venous aldosterone concentrations exhibit acute variability that can confound AVS interpretation. A single venous aldosterone measurement lacks precision and reproducibility in primary aldosteronism.

Intraindividual Variability of Aldosterone Concentrations in Primary Aldosteronism: Implications for Case Detection.

Primary aldosteronism is an underdiagnosed cause of hypertension. Although inadequate screening is one reason for underdiagnosis, another important contributor is that clinicians may inappropriately exclude the diagnosis when screening aldosterone concentrations fall below traditionally established thresholds. We evaluated the intraindividual variability in screening aldosterone concentrations and aldosterone-to-renin ratios, and how this variability could impact case detection, among 51 patients with confirmed primary aldosteronism who had 2 or more screening measurements of renin and aldosterone on different days. There were a total of 137 screening measurements with a mean of 3 (range 2-6) per patient. The mean intraindividual variability, expressed as coefficients of variation, was 31% for aldosterone and 45% for the aldosterone-to-renin ratio. Aldosterone concentrations ranged from 4.9 to 51 ng/dL; 49% of patients had at least one aldosterone measurement below 15 ng/dL, 29% had at least 2 aldosterone measurements below 15 ng/dL, and 29% had at least one measurement below 10 ng/dL. Individual aldosterone-to-renin ratios ranged from 8.2 to 427 ng/dL per ng/mL·hour; 57% had at least one ratio below 30 ng/dL per ng/mL·hour, 27% had at least 2 ratios below 30 ng/dL per ng/mL·hour, and 24% had at least one ratio below 20 ng/dL per ng/mL·hour. Aldosterone concentrations and aldosterone-to-renin ratios are highly variable in patients with primary aldosteronism, with many screening values falling below conventionally accepted diagnostic thresholds. The diagnostic yield for primary aldosteronism may be substantially increased by recalibrating the definition of a positive screen to include more liberal thresholds for aldosterone and the aldosterone-to-renin ratio.

Papillary thyroid cancer with extrathyroidal extension of desmoid-type fibromatosis. A case report of an aggressive presentation of an uncommon pathologic entity.

INTRODUCTION: Papillary thyroid cancer with desmoid-type fibromatosis (PTC-DTF) is an uncommon tumor characterized by extensive stromal proliferation of fibroblasts and myofibroblasts with a small component of PTC. We report a case of PTC-DTF with infiltration of the mesenchymal component of tumor into perithyroidal muscle and early recurrence of desmoid after thyroidectomy, an outcome previously not reported. PRESENTATION OF CASE: A 20-year-old man underwent left hemithyroidectomy for a thyroid nodule. Pathology demonstrated a 4.2 cm tumor with PTC-DTF with the PTC comprising <10% of the tumor. The stromal component extended into adjacent skeletal muscle. After completion thyroidectomy, histopathology of the right thyroid lobe revealed no malignancy or fibromatosis. Neck MRI 16 months after the initial operation revealed a 10.5 cm tumor in the left thyroid bed. Core biopsy and open excisional biopsy showed desmoid-type fibromatosis without PTC. The patient is undergoing chemotherapy of his recurrent desmoid-type fibromatosis. DISCUSSION: In patients with PTC-DTF there is a risk of recurrence of the benign component of the tumor. In recent reports, the role of less aggressive surgery, or even non-surgical management, of patients with recurrent DTF has been emphasized, in particular when extensive surgery may be associated with high risk of functional loss. The management of our patient adheres to modern recommendations for the treatment of DTF. CONCLUSION: Patients with PTC-DTF should be carefully monitored after thyroidectomy for both recurrent PTC and local recurrence of the fibrous component of the tumor.

Radiofrequency ablation treatment for aldosterone-producing adenomas.

PURPOSE OF REVIEW: To review the current status of radiofrequency ablation as a primary treatment for hyperfunctioning adrenal nodules, predominantly aldosterone-producing adenomas (APAs). RECENT FINDINGS: Radiofrequency ablation is an established treatment for focal benign and malignant lesions, including metastatic disease to the adrenal gland. Hyperaldosteronism is the leading cause of secondary hypertension with up to 80% due to APA, statistically the most common functioning adrenal nodule. Although surgery remains the recommended treatment of choice for confirmed unilateral functioning adrenal nodules, radiofrequency ablation offers a less-invasive approach, with results comparable with surgery. SUMMARY: Radiofrequency ablation of functioning adrenal nodules is a newer application of a technology in use for almost 2 decades. Although limited, reports to date suggest that results are comparable with those of laparoscopic adrenalectomy, but with advantages including being a less-invasive outpatient procedure with lower morbidity, faster recovery, and lower cost. However, the current data are all retrospective, the number of patients treated is small, and reported long-term results are limited.

The Essentials of Parathyroid Hormone Venous Sampling.

Hyperparathyroidism is an excess of parathyroid hormone in the blood due to over-activity of one or more parathyroid gland. Localization of abnormal glands with noninvasive imaging modalities, such as technetium sestamibi scan and cross-sectional imaging, has a high success rate. Parathyroid venous sampling is performed for patients with persistent or recurrent disease after previous parathyroid surgery, when repeat noninvasive imaging studies are negative or discordant. The success of invasive localization studies and results interpretation is dependent on the interventional radiologist's understanding of the normal and ectopic anatomic locations of parathyroid glands, as well as their blood supply and venous drainage. Anatomic and technical considerations for selective parathyroid venous sampling are reviewed.

Clinical Outcomes following Percutaneous Radiofrequency Ablation of Unilateral Aldosterone-Producing Adenoma: Comparison with Adrenalectomy.

PURPOSE: To compare adrenal radiofrequency (RF) ablation with adrenalectomy in treating unilateral aldosterone-producing adenoma (APA). MATERIALS AND METHODS: Between April 2008 and September 2013, 44 patients with adrenal venous sampling-confirmed (lateralization index ≥ 4) unilateral APA underwent adrenal RF ablation (12/44 [27%]) or adrenalectomy (32/44 [73%]). Outcomes of adrenal RF ablation (patient age, 51 y ± 11; 4/12 men) were compared with adrenalectomy (patient age, 50 y ± 11; 19/32 men). Blood pressure (145/94 mm Hg ± 19/13 vs 144/89 mm Hg ± 10/8, P = .92), number of antihypertensives (3.0 ± 1.3 vs 2.7 ± 0.89, P = .38), and serum potassium (3.2 mEq/L ± 0.6 vs 3.5 mEq/L ± 0.6, P = .65) of patients were similar before treatment. RESULTS: RF ablation and adrenalectomy resulted in normokalemia (RF ablation, 4.2 mEq/L ± 0.1, P = .0004; adrenalectomy, 4.3 mEq/L ± 0.6, P < .0001) and normotension (RF ablation, 129/81 mm Hg ± 11/11, P = .02/P = .001; adrenalectomy, 128/85 mm Hg ± 13/12, P < .0001/P = .07) in all patients. Proportions of RF ablation and adrenalectomy patients cured of hypertension (2/12 [17%] vs 12/32 [38%], P = .28) or requiring fewer antihypertensives (7/12 [58%] vs 13/32 [40%], P = .29) were similar. RF ablation patients had a shorter length of stay (0.6 d ± 0.8 [range, 0-2 d] vs 1.7 d ± 1.4 [range, 0-7 d]; P = .01) and less intraoperative blood loss (1.2 mL ± 3 vs 40 mL ±85; P = .01). Procedural complications occurred in 5/32 (15%) adrenalectomy patients (2 major, 3 minor) and in 0/12 RF ablation patients. CONCLUSIONS: RF ablation to treat APA can achieve similar clinical outcomes as adrenalectomy and results in shorter hospital stays. Larger, prospective trials are needed to validate these results.

Superselective splenic artery embolization for the management of splenic laceration following colonoscopy.

Splenic injury is a rare complication following colonoscopy with fewer than 100 reported cases worldwide to date. We describe a case of splenic laceration presenting 5 days following diagnostic colonoscopy. Although hemodynamically stable, active contrast extravasation on contrast-enhanced multidetector computed tomography predicted likely failure of conservative management. Splenic artery angiography confirmed active extravasation from the lower splenic pole and the patient was successfully treated with super selective coil embolization of a lower pole splenic artery branch. This is the eighth reported case of endovascular treatment of splenic injury following colonoscopy. To our knowledge, however, superselective splenic artery embolization has not been previously reported to treat this rare endoscopic complication.

Adrenal venous sampling: promises and pitfalls.

PURPOSE OF REVIEW: To describe the current indications for adrenal vein sampling (AVS), variability in institutional protocols for performing the procedure, shortage of expert interventional radiologists trained in this procedure, pitfalls in technique and strategies to improve success. A major emphasis of the review will focus on the interpretation of the AVS results. RECENT FINDINGS: Published protocols for performance of the AVS procedure and variability in the diagnostic criteria differentiating aldosterone-producing adenoma from bilateral adrenal hyperplasia vary significantly. Inability to catheterize the right adrenal vein is the major reason for technical failure of AVS. Preplanning computed tomography, stat intraprocedural cortisol levels and cone-beam computed tomography are helpful in identifying the right adrenal vein. The administration of adrenocorticotropic hormone stimulation during AVS varies significantly between different studies. SUMMARY: More interested interventional radiologists need to acquire the necessary technical expertise for AVS due to increased demand for the procedure, which is the diagnostic reference standard for primary aldosteronism. Unresolved issues include variability in the AVS procedure protocol, use of adrenocorticotropic hormone stimulation and standardization of the interpretation of the results. Despite all these variables, many different approaches still appear to be clinically successful, as indicated by the extensive published reports.

Embolotherapy for lower urinary tract hemorrhage.

The patient characteristics, techniques used, and outcomes of 11 patients with lower urinary tract hemorrhage treated with embolotherapy are described. The authors focus on bilateral superselective embolization of the arterial supply to the bladder and techniques to embolize multiple small vessels supplying the bladder when the vascular anatomy is complicated and superselective catheterization is not possible. The immediate success rate was 100%, with three later recurrences. One procedure was complicated by asymptomatic occlusion of the posterior division of the internal iliac artery. Embolotherapy can provide at least short-term success adequate to improve quality of life for palliation with few complications.