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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

CONN'S ADENOMA


D Mutter , MD , PhD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This case report describes a young patient who presents with hypertension resistant to medical therapy, secondary to a Conn's adenoma.

2. Patient


Male, 36-year-old

3. Past medical history


Medical: Hypertension, smoking
Surgical: None

4. History of present illness


The patient presents with hypertension for 5-6 years. Recently, the hypertension became unstable requiring 4 drug therapies and frequent antihypertensive dosage adjustments. This is associated with frequent headaches, easy fatigability and lower extremity cramps. Physical examination was within normal limits.

5. Clinical progression


Diagnosis: Conn syndrome secondary to a left adrenal adenoma

6. Physical examination


Potassium: 3.0 (3.6-5.2)
Renin supine: <2.5 ng/L (3.6-20.1 ng/L)
Renin upright: <2.5 ng/L (5.1-38.7 ng/L)
Aldosterone supine: 1053 pmol/L (N<477)
Aldosterone upright: 996 pmol/L (N<985)
Cortisol, metanephrines et normetanephrines: N

7. CT scan


Left adrenal lesion measuring 2.5 cm in diameter.

8. Scintigraphy


Iodonorcholesterol scintigraphy: left adrenal localization

9. Surgical procedure


Intervention: laparoscopic adrenalectomy.

10. Discussion


Primary aldosteronism was thought to be a rare cause of hypertension (1-2%). However, with improved screening methodologies, it appears that primary aldosteronism is the most common form of secondary hypertension. It is twice as common in females than in males. Patients with hypertension and hypokalemia and most patients with treatment-resistant hypertension should undergo screening for primary aldosteronism. A random and ambulatory ratio of plasma aldosterone concentration (ng/dl) to plasma renin activity (ng/ml per hour) >20 and a plasma aldosterone concentration >15 ng/dl is a positive screen for primary aldosteronism. Primary aldosteronism must be confirmed by demonstrating inappropriate aldosterone secretion with either the intravenous saline suppression test or measurement of 24-hour urinary aldosterone while on a high-sodium diet. The 2 major subtypes of primary aldosteronism are unilateral aldosterone-producing adenoma and bilateral idiopathic hyperplasia. Patients with aldosterone-producing adenoma are usually treated with unilateral adrenalectomy, and patients with idiopathic hyperplasia are treated medically. The subtype evaluation may require one or more tests, the first of which is imaging the adrenals with computed tomography (CT). When CT reveals a solitary unilateral macro-adenoma (>1 centimeter) and normal contralateral adrenal morphology in a patient with primary aldosteronism, unilateral laparoscopic adrenalectomy has become the modality of choice due to its efficacy and low morbidity . However, in many cases, CT imaging may reveal normal-appearing adrenals or ambiguous findings. In such cases we advocate the use of Iodonorcholesterol scanning which may help localize the lesion in 50-70% of cases. Pre-imaging treatment with dexamethasone to reduce ACTH secretion improves the sensitivity of the test. Adrenal venous sampling can be helpful in solving these clinical dilemmas if the above imaging modalities are negative and localizes the lesion to one side or the other in 80% of cases. The high incidence of adrenal vein thrombosis following sampling has led to a decrease in the use of this technique.

11. References


  1. Ikeda DM, Francis IR, Glazer GM, Amendola MA, Gross MD, Aisen AM. The detection of adrenal tumors and hyperplasia in patients with primary aldosteronism: comparison of scintigraphy, CT, and MR imaging. AJR Am J Roentgenol 1989;153:301-6.
  2. Shen WT, Lim RC, Siperstein AE, Clark OH, Schecter WP, Hunt TK, et al. Laparoscopic vs open adrenalectomy for the treatment of primary hyperaldosteronism. Arch Surg 1999;134:628-31; discussion 631-2.
  3. Young WF, Jr. Primary aldosteronism: A common and curable form of hypertension. Cardiol Rev 1999;7:207-14.