1. Anatomy and Pathology of Adrenal Glands for Understanding Primary Aldosteronism
Department of Pathology and Clinical Hypertension, Endocrinology & Metabolism1),
Tohoku University School of Medicine
Hironobu Sasano, Yuto Yamazaki, Yasuhiro Nakamura, Fumitoshi Satoh1)
Aldosterone is the mineralocorticoid exclusively produced and secreted from the zona glomerulosa in human adrenal cortex. Primary aldosteronism is defined as the cortical lesions associated with overproduction and secretion of aldosterone with suppressed plasma renin activity. It is important to note that not all the zona glomerulosa cells are involved in aldosterone production in more than half of general public and in these subjects, aldosterone producing zona glomerulusa cells are focally clustered. The adrenocortical lesions causing primary aldosteronism are classified into neoplastic and non-neoplastic ones. The former are predominantly benign adrenocortical adenoma but adrenocortical carcinoma associated with only overproduction of aldosterone could be present, which the clinicians should always consider as the differential diagnosis. In aldosterone producing adenomas, recently more cases of small or CT negative ones as well as bilateral adenomas have been detected with the advent of adrenal venous sampling and others. In non-neoplastic primary aldosteronism, the predominant form is IHA or idiopathic hyperaldosteronism or IHA. IHA is histopathologically characterized by diffuse hyperplasia of the zona glomerulosa involving overproduction of aldosterone. Others include dexamethasone suppressive hyperaldosteronism or UMN (unilateral hyperaldosteronemia due to multiple adrenocortical micronodules). They have been considered rare but UMN are currently considered more frequent than previously considered as a result of immunohistochemical evaluation of steroidenic enzymes involved in aldosterone biosynthesis.
2. Surgery for Primary Aldosteronism
Department of Urology, Yokohama Rosai Hospital
Laparoscopic surgery has become a standard method for treatment of adrenal disease.Between June 1994 and June 2015, we performed 604 laparoscopic adrenalectomies includingprimary aldosteronism.
Recently there has been growing advocacy to perform partial adrenalectomy for aldosteroneproducing adenomas(APA), when proved to be causing hyperaldosteronism by SegmentalAdrenal Tributary Sampling(S-ATS).
We describe our technique with laparoscopic total and partial adrenalectomy using the transperitoneal approach for APA.
Laparoscopic total and partial adrenalectomy was complete in all cases without conversionto open surgery and blood transfusion, and most complications in our cohort were minor andthere was no mortality. These results show the procedure to be safe and effective.
Partial adrenalectomy compared favorably to total adrenalectomy for some perioperativeoutcomes. Operative duration was 123 and 96 minutes in total and partial adrenalectomyrespectively(P<0.01). Hypertension resolution rate was 39.3% and 65.9% in the total and partialcases respectively(P<0.05).
Laparoendoscopic single-site surgery(LESS) was introduced to our hospital in November2011. LESS is a good indication of adrenalectomy because the adrenal tumor is often small. InLESS, all of the instrument to used perform the procedure must be placed through a singleincision, often concealed within the umbilicus. It has evolved to improve upon cosmesisassociated with standard laparoscopic surgery. We show our experience with LESS.
- Primary Aldosteronism
- Adrenal Surgery
- Laparoscopic Adrenalectomy
3. Adrenal Venous Sampling and Radiofrequency Ablation for Primary Aldosteronism
Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine
Hypertension has a high morbidity with approximately one of three individuals affected. Most hypertension is incorrectly assumed to be essential hypertension, and drug therapy is often selected without reasonable consideration. Secondary hypertension is assumed to account for approximately 20% of all hypertension cases. Particularly primary aldosteronism is a frequent disease underlying secondary hypertension, supposedly 5 to 20% of all hypertension cases. MDCT and MRI are not reliable methods in the differential diagnosis of primary aldosteronism because aldosterone may be produced on the side contralateral to the adrenal adenoma. Selective adrenal venous sampling is the standard to diagnose the laterality of aldosterone hypersecretion. If hypersecretion of aldosterone is confirmed in a unilateral adrenal gland by appropriate adrenal venous sampling (AVS), complete cure or improvement of hypertension can be expected by laparoscopic unilateral adrenalectomy. However, right adrenal vein sampling generally remains difficult with a success rate of approximately 70% because of unpredictability of the variable anatomy of the right adrenal vein in advance. MDCT enabled the identification of the adrenal vein and delineation of its anatomy. Use of adequate adrenal venous catheters based on the preoperative anatomical information facilitates accurate catheterization. Segmental sampling allowed the identification of the location of intraadrenal aldosterone hypersecretion, which has the potential to diagnose patients with bilateral aldosterone producing adenoma which otherwise might be misdiagnosed. An investigatorinitiated clinical trial of radiofrequency ablation of adrenal adenoma is ongoing.
- Adrenal gland
- Primary aldosteronism
- Adrenal venous sampling
4. Endovascular Treatment for an Aldosterone Producing Adrenal Adenoma
Department of Radiology, Faculty of Medicine, Kagoshima University1), Ryokusenkai Yonemori Hospital2)
Yasutaka Baba1, 2), Sadao Hayashi1), Kohei Nagasato1), Takashi Yoshiura1)
Department of Radiology, Imakiire Hospital
Department of Radiology, Kagoshima Medical Association Hospital
Traditionally, endovascular treatment for adrenal tumors (Cushing syndrome, Pheochromocytoma, Adrenal carcinoma) has been done for the purpose of mitigating symptoms associated with hormonal hypersecretion. The aim of endovascular treatment for an aldosterone producing adrenal adenoma (APAA) is to mainly achieve a normalization of serum aldosterone and renin activity. Another goal of endovascular treatment for APAA is to achieve normalization of the blood pressure.
In this article, we will illustrate our experience of endovascular treatment for APAA.
Especially, we will also emphasize and discuss not only the technique of endovascular treatment for APAA, but also the outcome of patients with APAA.
- Aldosterone producing adrenal adenoma(APAA)
- Endovascular treatment