Urol Radiol 11:227-229 (1989) Urologic Radiology
Springer-Vedag New York Inc. 1989
Adrenal Venous Sampling and Adrenal Biopsy
Harold A. Mitty Department of Radiology, The Mount Sinai School of Medicine, New York, New York, USA
Abstract. The current status of adrenal vein sam- pling and the role of adrenal gland percutaneous biopsy will be reviewed.
Key words: Adrenal gland -- Venous sampling -- Biopsy.
There are two major forms of venous sampling used in the diagnosis of adrenal disease: direct adrenal vein catheterization and extraadrenal catheteriza- tion for the localization of the source of adrenocor- ticotropic hormone (ACTH).
Adrenal Venous Sampling
Sampling of adrenal venous blood continues to be used in the evaluation of patients with aldosteron- ism. In the era preceding computed tomography (CT), only 60% of adenomas were visualized by venography, whereas sampling localized virtually all of these small tumors [ 1 ]. CT has become the pri- mary modality for the evaluation of patients with aldosteronism, as well as other forms of adrenal disease. The localization ofaldosteronomas has im- proved with the newer CT scanners. Dunnick et al.  demonstrated 61% of aldosteronomas by CT, whereas 100% were localized with venous sampling.
Address reprint requests to: H.A. Mitty, M.D., Department of Radiology, The Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
Geisinger et al.  localized 70% of these tumors with a "standard scanner" in early patients and a high-resolution scanner in later patients. A recent report by Ikeda et al.  in patients with aldosteron- ism claimed an overall CT diagnostic sensitivity for adrenal tumor of 88% with a specificity of 83% and an accuracy of 86%. The problem of evaluating the patient with aldosteronism is complicated by the fact that 15-25% of these patients will have nodular hyperplasia rather than a single adenoma. In addi- tion, the nodules of nodular hyperplasia may be as large as a solitary adenoma. Thus, there continues to be a place for adrenal venous sampling to confirm the presence of a suspected adenoma in the presence of a negative or equivocal CT scan. We continue to confirm the adequacy of adrenal venous samples by measuring cortisol, as well as aldosterone. Adequate samples have revealed differences of 20-200 times between the normal and the tumor-containing gland. In bilateral sampling, patients with hyperplasia gen- erally do not have significant differences in their aldosterone levels. The differentiation of adenoma from hyperplasia is of clinical importance, since ad- enomas are resected, while patients with hyperplasia are treated medically.
Magnetic resonance imaging (MRI) is useful in the evaluation of many adrenal problems. The res- olution of most MR scanners is not yet comparable to state-of-the-art CT scanners. As a result, MRI offers little advantage as an imaging modality in patients with the small lesions causing aldosteron- ism.
Adrenal scintigraphy with NP-59 is also a useful agent with localization results in patients with al- dosteronism similar to those of CT scanning . This agent is not in widespread use.
228 H.A. Mitty: Adrenal Venous Sampling and Adrenal Biopsy
Sampling for ACTH
The group at the National Institutes of Health have emphasized the usefulness of inferior petrosal sinus sampling for the identification of the source of ACTH in patients with Cushing's disease [5, 6]. This is most important, since transsphenoidal hypophysectomy is the treatment of choice for Cushing's disease. Thus, the presence of a gradient from the inferior petrosal sinus is good evidence of pituitary source. The lack of a gradient indicates an ectopic source for ACTH. The ectopic locations may or may not lend them- selves to additional sampling. Ectopic ACTH may be produced by small bronchial carcinoids, thymic lesions, pancreatic islet cell or carcinoid tumors, pheochromocytoma, or other rare locations. In any event, the treatment of an ectopic source of ACTH requires other than pituitary surgery. The appear- ance of the adrenal glands on CT is of some value. Nodular hyperplastic glands in Cushing's disease generally indicate a pituitary source of ACTH, while enlarged glands without nodules are common with ectopic ACTH production. Doppman et al.  re- ported that 14 of 16 patients with an ectopic source for ACTH had adrenal hyperplasia without nodu- larity, while seven of nine patients with macronod- ular hyperplasia had a pituitary adenoma.
with a history of cancer is most likely metastatic disease. Biopsy is reserved for those patients in whom a positive cytology will change therapy. A unilateral nonfunctioning adrenal mass may be encountered in patients without cancer. Lesions smaller than 3 cm that are round or oval, have sharp margins, and homogeneous attenuation are probably benign and can be followed by CT or MRI [9, 10]. There is general agreement that lesions greater than 5 cm should be resected. The incidentally discovered 3- 5 cm mass in an asymptomatic patient should be followed closely.
Patients with cancer and a unilateral adrenal mass are candidates for fine-needle biopsy. MRI and NP-59 scintigraphy show promise in separating nonfunctioning adenomas and metastatic lesions . Glazer et al.  suggest that a combination of these modalities can replace, in some instances, the use of fine-needle biopsy. MRI per se continues to be evaluated as a method of separating benign adenomas from metastatic disease. There are sig- nificant indeterminate lesion rates so that biopsy continues to play a role in the evaluation of these patients. Quantitative standardized data for lesion evaluation by MRI would be useful if such a system became available.
Other Adrenal Sampling
Sampling of adrenal venous blood to confirm an adrenal mass as the source of cortisol is rarely nec- essary. Such sampling may also be misleading . The concentration of cortisol in blood from a cor- tical adenoma causing Cushing's syndrome may be within normal range, while the total volume of blood per unit time is increased. Thus, the patients have normal adrenal venous concentrations despite over- all increased production of corticosteroids.
The interest in the localization of pheochromo- cytomas by means of venous sampling has been replaced by MRI and MIBG scintigraphy.
On rare occasions, sampling of adrenal and go- nadal blood may be of value in the localization of virilizing and feminizing lesions. Since such neo- plasms may have either an adrenal or gonadal ori- gin, sampling can be quite useful in confirming the origin of the excess hormone production.
Adrenal biopsy continues to have an important role in the evaluation of patients with nonfunctioning adrenal masses. Bilateral adrenal masses in a patient
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