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Diagnosis and Treatment of Primary Aldosteronism
- GianPaolo Rossi, MD;
- Michele Gregianin, MD; and
- Mattco Chisura-Corona, MD
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TO THE EDITOR:
In their review of primary aldosteronism, Blumenfeld and colleagues [1] reported that a high proportion (almost 10%) of their 82 patients had adrenalectomy despite the presence of idiopathic hyperaldosteronism. However, medical treatment with aldosterone antagonists (not surgery) is deemed to be the treatment of choice for such conditions [2]. Blumenfeld and colleagues reported that three such patients (37.5%) were cured and one had improved after adrenalectomy but failed to provide any histologic data to corroborate the diagnosis of idiopathic hyperaldosteronism. Therefore, it remains possible that those patients, two of whom had lateralized aldosterone secretion, had a small aldosterone-producing adenoma that was undetectable by computed tomographic (CT) scanning.
We have recently reported the results of a prospective comparison of contrast-enhanced CT scanning and magnetic resonance imaging (MRI) in patients with suspected primary aldosteronism [3]. We found that MRI, because of its better tissue characterization, provided better sensitivity than did CT scanning for identifying small aldosterone-producing adenomas.
To differentiate small aldosterone-producing adenomas from idiopathic hyperaldosteronism, Blumenfeld and colleagues proposed the postural test or the measurement of 18-hydroxycorticosterone or of 18-hydroxycortisol and 18-oxocortisol. However, the fact that 16% of their patients with adenomas and 22% with idiopathic hyperaldosteronism had a negative and a positive postural test result, respectively, raises doubts about the usefulness of such testing. In fact, the identification of angiotensin-responsive aldosterone-producing adenomas, which mimic idiopathic hyperaldosteronism, and of functionally autonomous forms of bilateral hyperplasia, may provide a rational explanation for an overlap of responses to the postural test between the two conditions [4, 5]. In addition, 18-hydroxycortisol and 18-oxocortisol cannot currently be measured in most endocrine laboratories in Europe.
During the past decade, we have been using dexamethasone-suppressed Selemium-75-Nor-cholesterol adrenal scintigraphy at our institution, either to corroborate equivocal adrenal vein sampling results or as an alternative to adrenal sampling in patients who refused to have the procedure. When applied to selected series, adrenal scintigraphy was highly specific (close to 100%) in ruling out aldosterone-producing adenomas. Accordingly, it allowed us to avoid unnecessary adrenalectomy in patients with idiopathic hyperaldosteronism.
GianPaolo Rossi, MD
Michele Gregianin, MD
Mattco Chisura-Corona, MD
University of Padua; 35126 Padua; Italy
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
