Hirose Rei, Tannai Hiromitsu, Nakai Kazuki, Makita Kohzoh, Matsui Seishi, Saito Jun
Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan.
Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
Endocrinol Diabetes Metab Case Rep. 2023 Aug 2;2023(3):23-0041. doi: 10.1530/EDM-23-0041.
A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed.
Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein. The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling. Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.
一名42岁女性患者因高血压和低钾血症转诊至我院，被诊断为原发性醛固酮增多症。动态对比增强计算机断层扫描图像显示左肾上腺外侧段有一个13毫米的结节，结节与附近突出的肾包膜静脉之间有细小的静脉连接。在肾上腺静脉采样期间，用微导管对左外侧支流进行静脉造影证实有血液经左肾包膜静脉引流，遂增加了左肾包膜静脉采样。使用侧别指数（48.3）以及促肾上腺皮质激素刺激后左外侧支流较高的血浆醛固酮浓度（PAC）（66700 pg/mL），该患者被诊断为左侧醛固酮瘤（APA）。此外，观察到左肾包膜静脉血中的PAC（224000 pg/mL）明显高于左肾上腺中央静脉（45000 pg/mL）和支流，从而确诊。腹腔镜下左肾上腺部分切除术及随后的组织病理学分析显示为CYP11B2阳性肾上腺皮质腺瘤。6个月后原发性醛固酮增多症在临床和生化方面取得了完全成功。已证实APA血液经静脉引流至肾包膜静脉的直接证据。如果假定存在这种APA血液引流，从替代引流途径进行采样可能有助于APA的诊断。
醛固酮瘤可能将血液引流至肾上腺静脉以外的替代途径。在肾上腺静脉采样期间，通过对比增强计算机断层扫描或静脉造影可以推测存在替代静脉引流。在替代引流静脉中采样并证明醛固酮水平升高有助于诊断醛固酮瘤。
