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Diagnosis and Treatment of Primary Aldosteronism
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IN RESPONSE:
Rossi and colleagues raise several points about the preoperative diagnostic tests for primary aldosteronism discussed in our paper [1].
Patients in our study were categorized as having an adenoma or nonadenomatous adrenal hyperplasia, according to whether an encapsulated adrenal tumor could be identified by the pathologist. Rossi and colleagues suggest that an occult microscopic adenoma may have been missed by CT scanning in the patients who were characterized as having nonadenomatous hyperplasia and that more sensitive imaging techniques may have identified these adenomas before surgery. Although possible, this scenario seems unlikely because we and others continue to identify patients with lateralizing nonadenomatous adrenal hyperplasia that is curable by unilateral adrenalectomy, despite ongoing improvements in the resolution of available radiographic techniques. Although we have not systematically compared the diagnostic sensitivity and specificity of contrast-enhanced CT scanning with MRI for identification of adrenal tumors, we have detected adenomas by CT scanning that were not found by MRI. As the technology used in each of these imaging techniques improves, we expect that their capabilities for characterizing adrenal lesions will leapfrog several times. The imaging method of choice will therefore be influenced by the resources available at each diagnostic center and by the experience of the consulting radiologist. The general experience with radiolabeled cholesterol scanning, however, is less favorable, and we note that Rossi and colleagues find it highly specific only in “selected series.”
Data from our study support the view that no single laboratory or radiographic test currently available is sufficient to determine whether hypertension associated with primary aldosteronism will be cured by unilateral adrenalectomy. The preferred approach remains one in which a biochemical, physiologic, and radiographic profile is established. These techniques may vary among institutions, depending on the local resources and expertise. It is also worth re-emphasizing that, in view of the relatively low surgical cure rate for hypertension in patients with unequivocal evidence for a functioning adenoma, both the state of these diagnostic studies and our understanding of primary aldosteronism remain inadequate.
Jon D. Blumenfeld, MD
The New York Hospital-Cornell Medical Center; New York, NY 10021
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
