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Abdominal Echography as a Screening
Imagistic Method for the Diagnosis of the
Secondary Endocrine Arterial Hypertension

Tamara Bostaca, Olga Cioara, I. Bostaca

Sf. Spiridon Hospital, Iasi, Romania

SUMMARY
Objective: To identify patients with the endocrine arterial hypertension (AH) secondary to adrenal gland masses or to other adrenal and extraadrenal abnormalities by an usual method like abdominal echography as the first intention examination.
Material and Methods: Abdominal echography was performed in a cohort of 650 patients (pts) with arterial hypertension (AH). The target of the imagistic examination was to establish if the adrenal glands masses or abnormal adrenal or extraadrenal structures are involved in the etiopathology of AH. The additional biochemical tests and the complementary imagistic methods such as computed tomography and scintigraphy were used in confirmatory diagnosis. The surgical interventions and the histopathological examinations were accomplished in selected cases with presumptive diagnosis of AH secondary to adrenal glands or extraadrenal abnormalities.
Results: 13 from 650 hypertensive pts were diagnosed with pheochromocytoma by mean of the abdominal echography as the first method in the endocrine AH localization. 11 pts had an adrenal and 2 pts had an extraadrenal localization of the pheochromocytoma proved during the surgical intervention at the site presumed by abdominal echography. The histopathological confirmation was in all cases. 4 female pts were diagnosed with Conn adenoma. The surgical intervention and histopathological examination confirmed the imagistic (initial echography and CT after) suspicion.
Conclusions: In the selected cases with AH, the triad - 1) arterial hypertension + 2) typical biochemical abnormalities + 3) suggestive adrenal mass at the abdominal echography - is an usual algorithm to evoke the adrenal and extraadrenal pheochromocytoma and the Conn adenoma. The abdominal echography can be the first intention method for productive and inexpensive detection of the AH localization and diagnosis of the secondary endocrine AH.

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BACKGROUND AND OBJECTIVES
   Adrenal causes of arterial hypertension (AH) are more common than previously thought (less than 1 percent of all hypertensive diseases). These causes include primary excesses of catecholamines, aldosterone or cortisol. The abdominal echography as an usual method in the screening diagnosis of adrenal or extraadrenal masses can provide a surprising and selected lot of patients having a presumptive treatable cause of AH. The purpose of this study was to identify patients with endocrine arterial hypertension (AH) among the hypertensive patients (pts) considered as primary AH by an usual method like abdominal echography as the first intention examination.

SUBJECTS AND METHODS
   Abdominal echography (3,5-MHz transducer, sagital scan under costal border or intercostal spaces, anterior transverse scan, anterior longitudinal scan) was performed in a cohort of 650 pts with arterial hypertension (AH). The target of the imagistic examination was to establish if the adrenal glands masses or abnormal adrenal or extraadrenal structures are involved in the etiopathology of AH. The additional biochemical tests (urine and/or blood samples for catecholamines, vanilic mandelic acid, cortisol, electrolytes) and the complementary imagistic methods such as computed tomography and scintigraphy (I131 metaidobenzylguanidine) were used in confirmatory diagnosis. The surgical interventions and the histopathological examinations were accomplished in selected cases with presumptive diagnosis of AH secondary to adrenal glands or extraadrenal abnormalities.

RESULTS
   In a cohort of 650 pts with AH only 40 (6,1%) had dimensional and structural sonographic abnormalities of the adrenal glands.

   There was a prevalent feature of the these abnormalities in hypertensive female pts with a 30-50 years peak of age. (Figure 1)

Figure 1

    The dimensions of the adrenal or extradrenal masses have been situated in a large range between 15 and 180 mm.

    All bellow 40 mm expansive lesions had a solid and homogeneous structure but those above 40 mm had a mixed structure including a necrotic core together with solid component and calcifications. The above 30 mm masses determined liver, kidney or inferior vena cava impression.

    13 from 650 hypertensive pts were identified by echographic examination as the first intention imagistic method with an adrenal or extraadrenal mass suggestive for pheocromocytoma.

    The final diagnosis has been established by surgery (adrenal gland removal) and histopathology. The anatomical distribution of the tumors was: right abdominal gland - 6 pts, left adrenal gland - 5 pts and the Zuckerkandl organ (Figure 2) - 2 pts.

Figure 2

   One of the tumors can be integrated in MEN II A type (the association between thyroid carcinoma represented by a hypofunctioning thyroid nodule and adrenal gland mass suggestive for pheocromocytoma). The pheocromocytomas were 24-115 mm in the longitudinal diameter and 15-95 mm in the transverse diameter. In all cases a clear-cut echographic limit between the pheocromocytoma and neighbors organs has been confirmed by surgery. The right pheocromocytomas above 50 mm in diameter determined an impression on right lobe of the liver and on vena cava. These tumors had a mixed structure with a necrotic core and calcifications in the peripheral areas. (Figure 3)

Figure 3

    No invasion or malignancy were found out in surgical or histopathological specimens. CT as a reference imagistic method performed in six cases established a 2 mm minimal and 9 mm maximal deviation of the dimensions in this examination compared to abdominal echography.

    Conventional abdominal echography in the upper abdomen (to identify classical localization of the pheocromocytoma) as well as CT performed to one patient with AH and high level of catecholamines didn't discover the tumor but I131 metaiodobenzylguanidine scintigraphy pointed out an extraadrenal area of interest where a new abdominal echography found out an expansive mass with 56 mm in maximal diameter and paraaortic localization.
4 female pts were diagnosed with Conn adenoma: three adenomas were in right adrenal gland and one adenoma was in left adrenal gland. The confirmation of the presumptive imagistic diagnosis was obtained by surgery (adrenal gland removal) and histopathological examination in all cases (Figure 4).

Figure 4

    The structural qualities of the adenomas were cut-clear limit, homogeneity and hypoechoic aspect (Figure 5) and likewise in CT description. Confirmatory CT offered more details about the tumors with a low density (-20 to -40 uH) and low contrast. (Figure 6)

Figure 5

Figure 6

    Cushing syndrome presents another challenge to sonographer but the lack of any abnormality has been found in 80% of cases with definite syndrome. Only 7 from 40 hypertensive pts with echographic abnormalities of adrenal glands had clinical and biochemical aspect of Cushing syndrome. The correct appreciation became possible when the nodular lesions were above 30 mm.The echographic examination has been extremely difficult in Cushing syndrome because the obesity and gas distention of the abdomen are frequently associated.

    The comparisons of the abdominal echography with surgical and/or histopathological findings emphasized some limits in specificity and diagnostic accuracy of this imagistic method and sometimes no any relation between AH and imagistic findings. For example, 3 images associated with clinically presumptive pheocromocytoma were carcinomas of the adrenal glands - 2 pts or unsecretory adenoma (Figure 7) - 1 patient. 2 tumors described as renoadrenal masses were respectively kidney carcinoma and leiomyosarcoma. 10 images have been considered as incidentalomas because of surprising imagistic findings comparatively with incomplete or discordant clinical, biochemical and histopathological specimens or none relation with AH due to other causes.

Figure 7

CONCLUSIONS
    In the selected cases with AH, the triad - 1) suggestive adrenal or suspect extraadrenal masses at the abdominal echography + 2) AH + 3) biochemical abnormalities - is an usual algorithm to evoke the adrenal and extraadrenal pheocromocytoma or Conn adenoma. This is one of the largest lot of pheocromocytomas and Conn adenomas reported by a single investigator in a cohort of AH patients examined by abdominal echography. This imagistic method can be the first intention method for productive and inexpensive detection of the AH etiology and localization and a certain diagnosis of the secondary endocrine AH can be set from the very beginning. Since the adrenal glands are situated deep in the upper abdomen the sonographic demonstration of the adrenal gland or extraadrenal masses responsible of endocrine AH presents a continuous challenge and only the skill and tenacity of the sonographer can identify abdominal endocrine causes of AH by an usual screening imagistic method as abdominal echography is.

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
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