Role of Selective Venous Adrenal Sampling in ACTH-IndependentMacronodular Adrenal Hyperplasia (AIMAH)

Maurizio Iacobone Æ Gennaro Favia

Published online: 13 November 2008

� Societe Internationale de Chirurgie 2008

We appreciate the comment from Lee and colleagues

[1] on our article concerning the role of unilateral adre-

nalectomy in ACTH-independent macronodular adrenal

hyperplasia (AIMAH) [2]. We confirm that unilateral

adrenalectomy can be an effective strategy in the man-

agement of AIMAH when asymmetric involvement is

evident and the remaining contralateral gland is not

markedly enlarged. However, we agree that a prolonged

follow-up is needed, because of the risk of recurrence of

clinically evident hypercortisolism.

We also agree with Lee and colleagues that selective

adrenal venous sampling with cortisol measurements may

be a useful technique, in addition to computerized

tomography, magnetic resonance imaging, and adrenal

scintigraphy for the identification of the prevalent secreting

adrenal gland, although in our series we never used it.

The limits of percutaneous selective venous adrenal

sampling should be also considered, however, as it is an

invasive method; at times it could be challenging for the

radiologist and extremely uncomfortable for the patient. In

addition, the interpretation of the results may be difficult:

the secretion of glucocorticoids in patients with AIMAH

may be irregular and cyclic owing to the presence of ectopic

and abnormal receptors [3]. Finally, when asymmetric

adrenal involvement is present, recovery from the Cush-

ing’s syndrome is not only related to the excision of the

more actively secreting adrenal gland but especially to the

degree of autonomous hyperfunction of the remaining

adrenal. Because cortisol secretion in AIMAH is positively

correlated with the volume of the adrenals (as we also

demonstrated in our article), we suggest selecting patients

for successful unilateral adrenalectomy according to the

size of the remaining gland, a feature that can be easily

evaluated before operation by computerized tomography

and magnetic resonance imaging.

References

1. Lee S, Su M, Young H, Eom S, Park IB (2008) Role of unilateral

aderenalectomy in ACTH-independent macronodular adrenal

hyperplasia. World J Surg. doi:10.1007/s00268-008-9755-x [epub

ahead of print]

2. Iacobone M, Albiger N, Scaroni C et al (2008) The role of

unilateral adrenalectomy in ACTH-independent macronodular

hyperplasia. World J Surg 32:882–889

3. Albiger NM, Occhi G, Mariniello B et al (2007) Food-dependent

Cushing’s syndrome: from molecular characterization to thera-

peutical results. Eur J Endocrinol 157:771–778

M. Iacobone (&) � G. Favia

Endocrine Surgery, Department of Surgical and

Gastroenterological Sciences, University of Padua, Via

Giustiniani 2, Padua 35128, Italy

e-mail: maurizio.iacobone@unipd.it

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World J Surg (2009) 33:159

DOI 10.1007/s00268-008-9802-7