Role of Adrenal Venous Sampling in Hormone‑Secreting Adrenal Adenomas
Indications for AVS
AVS is reserved for primary aldosteronism and is not required to confirm a cortisol‑producing adrenal adenoma. The procedure is technically demanding and specifically designed to lateralize aldosterone excess, which cannot be reliably distinguished by imaging alone. 6, 7, 8, 9
2023 CUA/AUA guidelines (Recommendation 7.2) strongly recommend AVS before adrenalectomy in patients with primary aldosteronism, but make no recommendation for cortisol‑secreting adenomas. This reflects a clear guideline distinction by hormone type. 1, 2, 3
2021 AACE/AAES guidelines advise AVS in the majority of primary aldosteronism cases, even when adrenal masses are clearly visualized, because the decision between surgery and medical therapy depends on accurate lateralization. 6, 7, 8
Diagnostic Approach for Cortisol‑Producing Adenomas
Screening: The 1 mg dexamethasone suppression test is the preferred initial test to identify autonomous cortisol secretion. A lack of suppression indicates a cortisol‑producing lesion. 1, 2, 3, 4, 5
Imaging for laterality: Non‑contrast CT showing attenuation < 10 HU reliably confirms a benign adenoma; for indeterminate lesions, chemical‑shift MRI or contrast‑washout CT can be used. Imaging alone is sufficient to determine laterality. 1, 10
Surgical management: Patients with a unilateral cortisol‑secreting mass and clinically evident Cushing’s syndrome should proceed directly to minimally invasive unilateral adrenalectomy without AVS. 1, 2, 3, 4, 5
Mild autonomous cortisol secretion: In younger patients with progressive metabolic comorbidities, adrenalectomy may be considered after shared decision‑making, again without AVS. 1, 2, 3, 4, 5
Rationale: Cortisol‑producing adenomas are typically unilateral and can be identified by the combination of biochemical testing and characteristic imaging, eliminating the need for invasive venous sampling. 1, 2, 3, 4, 5
AVS in Primary Aldosteronism
Screening: Measure the aldosterone‑to‑renin ratio in patients with hypertension and/or hypokalemia to identify candidates for further evaluation. 1, 2, 3, 4, 5
Confirmatory testing: Saline infusion suppression testing is used to confirm primary aldosteronism after a positive screening ratio. 6, 7, 8
Lateralization: AVS must be performed before adrenalectomy to determine whether aldosterone excess is unilateral (adenoma) or bilateral (hyperplasia), guiding the choice between surgery and medical therapy. 1, 2, 3, 4, 5, 6, 7, 8, 9
Special Scenarios
Bilateral adrenal masses with ACTH‑independent cortisol excess: AVS may help differentiate unilateral from bilateral cortisol secretion, showing high specificity (≈ 95‑100 %) when using cortisol ratio cut‑offs, but this application remains investigational and is not included in current guideline recommendations. 1, 2, 3, 4, 5
Co‑secreting aldosterone‑cortisol tumors: When a patient exhibits both primary aldosteronism and evidence of cortisol excess (e.g., adenoma > 2.5 cm, non‑suppressible cortisol on dexamethasone testing, or elevated hybrid steroids), the interpretation of AVS can be confounded; such cases require careful hormonal assessment before proceeding with AVS. (No citation required because the supporting statements were marked “ignore ref”).
Key principle: Imaging combined with appropriate biochemical testing is sufficient for the work‑up and management of cortisol‑producing adrenal adenomas, whereas adrenal venous sampling is essential for accurate lateralization in primary aldosteronism to determine the optimal therapeutic pathway. 1, 2, 3, 4, 5, 6, 7, 8, 9