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BIDMC, PACS Stowasser, University of Queensland, AU Radiofrequency Ablation of Aldosteronomas (Conn’s Syndrome): A New Application of IR Leah Hawkins, HMS III Gillian Lieberman, MD December 13, 2010 Dupuy D E et al. Radiographics 2002;22:S259-S269 Leah Hawkins, MSIII Gillian Lieberman, MD Mayo-Smith W W et al Radiographics 2001;21:995-1012 Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1: History and Physical Exam History PMH Fam Hx Meds 48yo M presents with refractory hypertension associated with hypokalemia since age 30. none noncontributory HCTZ, Amlodipine, Terazosin, Metoprolol, K supplement Leah Hawkins, MSIII Gillian Lieberman, MD Indications for Secondary HTN Screening MRA: Severe Proximal Renal Artery Stenosis Severe or refractory (Refractory to 3+ bp meds) Negative family history Acute rise in bp or creatinine Onset <puberty or >50 Asymmetry in renal disease Abdominal bruit. Kaplan, Rose. Screening for Renovascular or Other Causes of Secondary Hypertension UpToDate. 2010; 18.3 Leah Hawkins, MSIII Gillian Lieberman, MD Source: Dong Q et al. Radiographics 1999;19:1535-1554 Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Differential Diagnosis of Secondary Hypertension Common Uncommon Primary Aldosteronism (PA) Present in up to 10% patients with hypertension Primary Renal disease Renovascular Hypertension (RAS) Pheochromocytoma Cushing’s syndrome Coarctation of the Aorta (Other): Obesity, Alcoholism, Sleep apnea Reninoma Leah Hawkins, MSIII Gillian Lieberman, MD Rossi, G. Prevalence and Diagnosis of Primary Aldosteronism. Current Hypertension Reports 2010; 12:342-348. Patient 1’s Initial Workup The first step in his workup for secondary hypertension was a renal doppler ultrasound. Images from this ultrasound were unavailable, but similar images in a patient with the same diagnosis will be described on the next slide. Leah Hawkins, MSIII Gillian Lieberman, MD Companion Patient 1: Renal Doppler US Shows no evidence of RAS Left Kidney Doppler US Right Kidney Doppler US Source: BIDMC, PACS Source: BIDMC, PACS US assesses renal arteries anatomically and functionally Best indicator of RAS is increased peak systolic velocity Leah Hawkins, MSIII Gillian Lieberman, MD Williams, GJ et al. Comparitive accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis. AJR. AM J Roentgenol 2007; 188:798. This raises the question: is a renal doppler ultrasound indicated in the initial work-up of a patient with refractory hypertension? Leah Hawkins, MSIII Gillian Lieberman, MD ACR Appropriateness Criteria Renal doppler US is an inappropriate first step in the evaluation of secondary hypertension. Renovascular HTN is not the most common cause of secondary HTN. Kahn, S. Techniques in Vascular and Interventional Radiology 2010; 13.2: 110-125 Even if Renovascular HTN suspected: C+ MRA and/or CTA Rating of 8 US Kidney +Doppler Rating of 6 Prasad S et al. Renovascular Hypertension, ACR Appropriateness Criteria. American College of Radiology; 2009; 1-8. accessed 12.9.2010 Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1 MRA: No evidence of RAS Patent Renal Arteries bilaterally Accessory Left Renal Artery Source: BIDMC, PACS Courtesy of Dr. Knutson Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1 MRA: Incidental Adrenal Nodule Left Adrenal Mass: Source: BIDMC, PACS Leah Hawkins, MSIII Gillian Lieberman, MD Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Origin of the Adrenals (Embryology) Source: http://www.autismpedia.org/wiki/index.php?title=Image:Adrenal-core.gif Leah Hawkins, MSIII Gillian Lieberman, MD Adrenals in the body (Gross Anatomy) •Diaphragms •Adrenals •Kidneys Leah Hawkins, MSIII Gillian Lieberman, MD Source: Drake et al. Gray’s anatomy. Pp.320-328. Adrenals on MRI (Living anatomy) Left Adrenal Right Adrenal IVC Aorta Source: BIDMC, PACS Courtesy of Dr. Knutson Adrenals: wispy, y-shaped, low signal masses Leah Hawkins, MSIII Gillian Lieberman, MD Adrenal Mass: Etiologies Benign Lesions Cysts Myelolipomas Sequelae of previous trauma Adrenal Hyperplasia Benign Neoplasms Pheochromocytoma Adenomas -nonfunctioning -hormone-secreting Malignant Neoplasms Metastases Lymphoma Adrenocortical carcinoma Angiosarcomas Neuroblastoma Pheochromocytoma Source: http://healthpictures.com/images/Pheochromocytoma.jpg Leah Hawkins, MSIII Gillian Lieberman, MD Not So Fast!!! “Pseudolesions” include: GI Colon Pancreas Liver Stomach Reticuloendothelial Gastric diverticulum Gastric fundus Dilated colon Hepatic mass Splenules Splenic lobulations Renal Artery Left Adrenal Mass Vascular (noncontrast) Varices Splenic, Renal a. aneurysm Spleen Source: BIDMC, PACS Courtesy of Dr. Knutson Leah Hawkins, MSIII Gillian Lieberman, MD Johnson. Pamela T, Horton, Karen M. Adrenal Mass Imaging with Multidetector CT: Pathologic Conditions, Pearls, and Pitfalls. Radiographics 2009;29:1333-1351. Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Adrenal Gland: Menu of Radiologic Tests CT +/- contrast MRI +/- contrast Better soft tissue differentiation Chemical Shift imaging evaluates lesions not adequately characterized by CT Radiography Modality of choice for initial characterization of adrenals but is nonspecific for masses 3-Phase (delayed contrast) CT evaluates washout characteristics of adrenal masses Fluoroscopy-guided procedures Less Commonly used tests: Ultrasound Only readily identifies large masses Nuclear Scintigraphy I-131 meta-iodobenzylguanidine (MIBG) assesses medullary function I-131 6-beta-iodomethyl-19-norcholesterol (NP-59) assesses cortex Leah Hawkins, MSIII Gillian Lieberman, MD C- CT is nonspecific for Adrenalomas In majority of adenomas, CT is inaccurate or noncontributory. On CT, Adenomas are: Magill SB, Raff H, Shaker JL, et al. Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism. J Clin Endocrinol Metab 2001;86:1066-1071 Small but can be large (4-6cm) Homogenously enhancing or heterogenous if hemorrhage Lipid-rich (HU<10) or up to 25HU if lipid-poor 3 Phase C+ CT increases specificity: Adenomas demonstrate rapid washout (APW >60%, RPW >40%) but not absolute, requires contrast administration Leah Hawkins, MSIII Gillian Lieberman, MD 3-Phase CT: calculating APW, RPW “Washout” = Comparison of Attenuation Measurements during 3 phases of C+ CT Absolute Percent Washout = APW = X/Y Relative Percent Washout=RPW=X/ HUPortal Venous Phase 1- Precontrast 2- Portal Venous 3- Delayed phase HUPortal Venous Phase – HUPrecontrast Phase = Y HUPortal Venous Phase – HUDelayed Phase = X Typically, Adenomas have APW >60% and RPW >40% Johnson. Pamela T, Horton, Karen M. Adrenal Mass Imaging with Multidetector CT: Pathologic Conditions, Pearls, and Leah Hawkins, MSIII Gillian Lieberman, MD Pitfalls. Radiographics 2009;29:1333-1351. Imaging Algorithm for Adrenal Incidentalomas Leah Hawkins, MSIII Gillian Lieberman, MD Mayo-Smith 2001; 21:995-1012 The Imaging Algorithm for Adrenal Incidentalomas is not useful in Patient 1’s case, as he had an MRA before CT. Let’s return to his MRA in attempts to further characterize his adrenal mass. Leah Hawkins, MSIII Gillian Lieberman, MD Our Patient: Incidental Adrenal Nodule on MRA Left Adrenal Mass: Source: BIDMC, PACS Leah Hawkins, MSIII Gillian Lieberman, MD Our Patient: Shift Imaging reveals adenoma Out of Phase MRI In Phase MRI Source: BIDMC, PACS Low signal mass Source: BIDMC, PACS Leah Hawkins, MSIII Gillian Lieberman, MD Lower signal, similar to spleen MR Chemical Shift Imaging: The Basics Protons in fat and water resonant at different frequencies Tissue containing lipid and water (spleen, kidneys, adenomas) demonstrate lower signal density on outof-phase (destructive) than in-phase (additive) images Mayo-Smith 2001;21:995-1012 http://www.green-planet-solarenergy.com/images/water-molecule.gif water fat Chemical Shift Imaging is sensitive for differentiating adenomas from metastases Chong et al. Radiographics 2006; 26:1811-1826 Leah Hawkins, MSIII Gillian Lieberman, MD Moran A, Mobley HLT. H. Pylori: Physiology & Genetics. 2001 Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Classification: What kind of adenoma is this? Functioning Nonfunctioning Cortex- Conn’s, Cushing’s, hyperandrogenism Medulla- Pheochromocytoma Cysts, myelolipomas, previous trauma Therapeutic Interventions Leah Hawkins, MSIII Gillian Lieberman, MD Classifying Adenomas: Size differential provides clues but is a nonspecific indicator of functionality Abdominal MRI T2 Fat Sat Axial cut shows Right Pheochromocytoma Pheochromocyoma -Large, heterogenous adrenal mass with increased signal Atrophied contralateral adrenal Source: Mayo-Smith W W et al. Radiographics 2001;21:995-1012 Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1: Lab data, PMH concerns for PA Our Patient’s lab results showed an elevated aldo:renin ratio. In concert with his history of hypokalemia, this concerns for primary aldosteronism. The gold standard for diagnosis of primary aldosteronism is Adrenal Venous Sampling. Leah Hawkins, MSIII Gillian Lieberman, MD Why Adrenal venous sampling (AVS)? Gold Standard for Diagnosis of PA Nuclear Scintigraphy (NP-59) can also assesses cortical function but is expensive and results are less specific and quantitative. Determines Laterality Kahn, S. Adrenal Vein Sampling. Techniques in Vascular and Interventional Radiology 2010; 13.2: 110-125. Daunt, Nicholas. Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful. Peripheral Vascular Diagnosis and Interventions. RadioGraphics 2005;25:S143-S158 Determines Treatment Options Rossi, G. Prevalence and Diagnosis of Primary Aldosteronism. Current Hypertension Reports 2010; 12:342-348. Leah Hawkins, MSIII Gillian Lieberman, MD Indications for and Risks of AVS Indications Primary Aldosteronism Adenoma vs. Hyperplasia Pheochromocytoma Adrenal Cushing’s Contraindications General Complications Adrenal Hemorrhage/venous perforation Adrenal Infarction Hypertensive crisis Source: Stowasser. University of Queensland, AU. http://www.uq.edu.au/news/?article=11854 Thomson, Kenneth and Given, Mark. Image-guided Interventions, Chapter: Adrenal Venous Sampling. Philadelphia, Pennsylvania: Saunders Elsevier; 2008; Vol 1: Leah Hawkins, MSIII Gillian Lieberman, MD AVS Procedure 1- Planning 2- Vascular Access Inject contrast Sample adrenal veins b/l (baseline measurement) 4- Sampling Via Seldinger technique Sample IVC below, above level of adrenal veins 3- Ensure entry into adrenal vein Venous Imaging via CT or MR venography Inject ACTH Remove samples b/l at 5min, 10min, 15min 5- Interpretation of Results Leah Hawkins, MSIII Gillian Lieberman, MD Pre-procedure Venography Identifies Adrenal Vein Anatomy Right Adrenal Vein Variants Left Adrenal Vascular Supply Source Elsayes K M et al. Radiographics 2004;24:S73-S86 Source: Daunt N Radiographics 2005;25:S143-S158 Leah Hawkins, MSIII Gillian Lieberman, MD Rationale for Pre-AVS Venography Right Adrenal Vein Can arise: 1-Directly off IVC (most commonly) -branches at variable angles 2- Branch of R renal vein 3- Branch of accessory hepatic vein Left adrenal vein of less concern because Larger size Less variable anatomy Arises as branch of Left renal vein 3 1 2 Matsuura Tomonori et al. Radiologic Anatomy of the Right Adrenal Vein: Preliminary Experience with MDCT. American Journal of Radiology. 2008; 191:402–408 Netter, H Atlas of Human Anatomy, 4E: 2006 Leah Hawkins, MSIII Gillian Lieberman, MD Elsevier Netteranatomy.com Companion Patient 2: CT illustrates most common origin of R adrenal vein off IVC Right Adrenal Vein IVC Aorta Source: Daunt, N. Radiographics 2005; 25:S143-S158 Leah Hawkins, MSIII Gillian Lieberman, MD After preprocedure imaging has been interpreted and incorporated into procedural planning (to reduce risk of venous perforation), we achieve access via the Seldinger technique. Leah Hawkins, MSIII Gillian Lieberman, MD AVS Procedure: Step 2 1- Planning 2- Vascular Access Venous Venous Imaging Imaging via via CT CT or or MR MR venography venography Achieve vascular access via the Seldinger technique Sample IVC inferior and superior to level of the adrenal veins 3- Ensure entry into adrenal vein Inject Inject contrast contrast Sample Sample adrenals adrenals b/l b/l (baseline (baseline measurement) measurement) 4- Sampling Inject Inject ACTH ACTH Remove Remove samples samples b/l b/l at at 5min, 5min, 10min, 10min, 15min 15min 5- Interpretation of Results Leah Hawkins, MSIII Gillian Lieberman, MD Vascular Access in Adrenal Vein Sampling Seldinger Technique Micropuncture Femoral vein Pass small guidewire Pass catheter over guidewire Remove wire Hocking, G. Central Venous Acess and Monitoring. Practical Procedures, Issue 12 (2000), 13: 1-6. Leah Hawkins, MSIII Gillian Lieberman, MD Cannulation of Adrenal veins Schematic http://www.ucumberlands.edu/ Leah Hawkins, MSIII Gillian Lieberman, MD AVS Procedure: Step 3 1- Planning Venous Imaging via CT or MR venography 2- Vascular Access Peripheral, Femoral Obtain baseline IVC samples above, below adrenal veins 3- Ensure entry into adrenal vein Leah Hawkins, MSIII Gillian Lieberman, MD Companion Patient 3: Fluoroscopy aids in confirmation of catheter position Contrast injection confirms position in right adrenal vein Source: Melby, J. NEJM 1967; 277:1050-1056 Leah Hawkins, MSIII Gillian Lieberman, MD Mayo-Smith W W et al. Radiographics 2001;21:995-1012 AVS Procedure: Step 4 1- Planning Venous Imaging via CT or MR venography 2- Vascular Access 3- Ensure entry into adrenal vein Inject contrast Sample adrenals b/l (baseline measurement) 4- Sampling Inject ACTH Remove samples b/l at 5min, 10min, 15min 5- Interpretation of Results Leah Hawkins, MSIII Gillian Lieberman, MD Our Patient: Fluoroscopy-Guided AVS 1- Inject ACTH 2- Venous Samples collected at 5, 10, 15min Right adrenal vein arising from tertiary R hepatic vein T10 T11 Level of renal veins T12 L1 Left Adrenal Vein Sampling Source: BIDMC, PACS Courtesy of Dr. Faintuch Leah Hawkins, MSIII Gillian Lieberman, MD AVS Procedure: Step 5 1- Planning Venous Imaging via CT or MR venography 2- Vascular Access 3- Ensure entry into adrenal vein Inject contrast Sample adrenals b/l (baseline measurement) 4- Sampling Inject ACTH Remove samples b/l at 5min, 10min, 15min 5- Interpretation of Results Ensure quality samples Assess laterality Leah Hawkins, MSIII Gillian Lieberman, MD Interpreting AVS Results Quality [cortisol]adrenal vein :[cortisol]peripheral vein >2-3 Laterality [aldo]/[cortisol]dominant :[aldo]/[cortisol]nondominant adrenal vein >4 Daunt, Nicholas. Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful. Peripheral Vascular Diagnosis and Interventions. RadioGraphics 2005;25:S143-S158 Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1’s AVS Results Our patient’s results returned (as they are a send-out lab): Left Adrenal vein produced >20times the aldosterone made by the right adrenal gland! Leah Hawkins, MSIII Gillian Lieberman, MD Outline Patient Presentation Differential Diagnosis Living Anatomy Menu of Radiologic Tests/Imaging Algorithm Diagnostic Interventions Therapeutic Interventions Medical Management Familial Adrenal Hyperplasia glucocorticoids Idiopathic b/l adrenal hyperplasia aldosterone receptor antagonist Adrenalectomy Surgical CT-guided RFA Leah Hawkins, MSIII Gillian Lieberman, MD Elevated, Nonsuppressable Aldo/Plasma Renin Ratio Elevated ratio not suppressed by: 1- IV saline load 2- Fludrocortisone suppression test AVS Lateralization No Lateralization Aldosterone-secreting adenoma Idiopathic b/l adrenal hyperplasia Adrenalectomy Medical Mgmt RFA Surgical Adrenalectomy Leah Hawkins, MSIII Gillian Lieberman, MD Why Radiofrequency Ablation (RFA)? Curative Adrenalectomy cures hypertension in majority of cases of Conn’s Syndrome, improves blood pressure in remainder. Stowasser M. et al. Diagnosis and Management of Primary Aldosteronism. Journal of the Renin-Angiotensin-Aldosterone System. 2001; 2.3: 156-169. Potential for Better Outcomes An outpatient procedure that spares more of the healthy adrenal gland and can be repeated prn. CT-guided RFA promises reduced morbidity, mortality and cost compared to surgical adrenalectomy. Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax. Radiographics 2002; 22:S259-S269. Leah Hawkins, MSIII Gillian Lieberman, MD Indications for, Risks of RFA of Adrenal Adenomas Indications Benign tumors Small malignancies Debulking procedures Contraindications General Risks: Bleeding, pain, infection, CVA/MI, damage to adjacent structures, death, incomplete treatment Leah Hawkins, MSIII Gillian Lieberman, MD Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax. Radiographics 2002; 22:S259-S269. Adrenal RFA Procedure: Step 1 1- Preprocedure Imaging CT estimates position 2- Gain Access Paraspinal Approach Superior Superior to to rib rib (12 (12thth)) Lateral Lateral to to spinous spinous process process of of T12 T12 3- Ablation Deliver pulses in 5min intervals 4- Post-contrast CT Retarget areas of incomplete ablation Leah Hawkins, MSIII Gillian Lieberman, MD Patient 1 CT: Classic Appearance of Adenoma Left Lateral Decubitus C- CT Axial slice at Level of T12 Classic Adenoma CT Findings: Adrenal Adenoma 1- Small (<1cm) 2- Homogenous 3- Hypodense <10HU (lipid-rich) 20-25HU (lipid-poor) Source: BIDMC, PACS Leah Hawkins, MSIII Gillian Lieberman, MD Johnson, P et al. Adrenal Mass Imaging with Multidetector CT: Pathologic Conditions, Pearls, and Pitfalls. Radiographics 2009;29:1333-1351. Patient 1 CT: Measurement estimates probe trajectory Aorta Adrenal Adenoma Left Kidney Pancreas Leah Hawkins, MSIII Gillian Lieberman, MD Source: BIDMC, PACS Adrenal RFA Procedure: Step 2 1- Preprocedure Imaging CT estimates position 2- Gain Access Paraspinal Approach 3- Ablation Superior to rib (12th) Lateral to spinous process of T12 Deliver pulses in 5min intervals 4- Post-contrast CT Retarget areas of incomplete ablation Leah Hawkins, MSIII Gillian Lieberman, MD Source: Netter, H Atlas of Human Anatomy, 4E: 2006 Elsevier Netteranatomy.com Patient 1: CT-fluoro from RFA Procedure Pre-ablation Grounding pads on chest (ground electric field) Local anesthesia, advance probe CT-fluoro allows for 3-D confirmation of probe placement (Axially, Craniocaudally) Ablation 1- Begin longitudinally in deepest portion of tumor 2- Ablate in 5min intervals (to 60-65ºC) 3- Reposition in new plane 4- Repeat until ablation cylinders overlap Source: BIDMC, PACS Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax. Radiographics 2002; 22:S259-S269. Leah Hawkins, MSIII Gillian Lieberman, MD RFA Electrode: General Information RF electrode Insulated shaft, uninsulated tip Internal 200-watt generator Internally cooled with perfusion pump (10ºC-20ºC) Circulates ice water at 80mL/min *if tumor >4cm, can use “cluster” RFA electrode (3 electrodes spaced 5mm apart) Leah Hawkins, MSIII Gillian Lieberman, MD Dupuy D E et al. Radiographics 2002;22:S259-S269 Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax. Radiographics 2002; 22:S259-S269. Adrenal RFA Procedure: Step 4 1- Preprocedure Imaging CT estimates position 2- Gain Access Paraspinal Approach Superior Superior to to rib rib (12 (12thth)) Lateral Lateral to to spinous spinous process process of of T12 T12 3- Ablation Deliver pulses in 5min intervals 4- Post-ablation CT with contrast Coagulation necrosis = evidence of ablation Retarget areas of incomplete ablation Leah Hawkins, MSIII Gillian Lieberman, MD Our Patient: Follow-up He recovered well from RFA but represented over 1 year later with increasing hypertension. Repeat AVS Left aldo-secreting adenoma Repeat RFA 6mm lesion was ablated f/u on ½ as many anti-hypertensive meds Leah Hawkins, MSIII Gillian Lieberman, MD Take Home Points 1- Refractory HTN = Knee-Jerk Renal US -PA = most common cause of Secondary HTN http://www.conn-register.de 2- Normal Adrenals-wispy, Y-shaped Unicorns -If an incidentaloma is large, heterogenous or hyperdense (HU >20-25), consider 3-phase (delayed contrast) CT or MR shift imaging 3- IR’s role in the diagnosis and treatment of PA AVS gold standard for diagnosis RFA new treatment option with proposed better outcomes Leah Hawkins, MSIII Gillian Lieberman, MD Elevated, Nonsuppressable Aldo/Plasma Renin Ratio Elevated ratio not suppressed by: 1- IV saline load 2- Fludrocortisone suppression test AVS Lateralization No Lateralization Aldosterone-secreting adenoma Idiopathic b/l adrenal hyperplasia Adrenalectomy Medical Mgmt RFA Surgical Adrenalectomy Leah Hawkins, MSIII Gillian Lieberman, MD Acknowledgements •Dr. Sal Faintuch •Dr. James Knutson •Dr. Ammar Sarwar •Dr. Gill Lieberman •Emily Hanson •Dr. Mai-Lan Ho •Beth Israel Deaconess Radiology Dept •HMS III Classmates: Sun Mi Yoo, Ben Oldfield, Vishwan Pamarthi Leah Hawkins, MSIII Gillian Lieberman, MD References Chong S et al. Integrated PET-CT for the Characterization of Adrenal Gland Lesions in Cancer Patients: Diagnostic Efficacy and Interpretation Pitfalls. Radiographics 2006; 26:1811-1826. Daunt, Nicholas. Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful. Peripheral Vascular Diagnosis and Interventions. RadioGraphics 2005;25:S143-S158 Drake et al. Gray’s Anatomy for Students. Elservier, 2007:320-328. Dunnick NR. Adrenal Imaging: current status. AJR Am J Roentgenol 1990; 154:927-936. Dupuy D. et al. Clinical Applications of Radio-Frequency Ablation in the Thorax. Radiographics 2002; 22:S259-S269. Elsayes K et al. Adrenal Masses: MR Imaging Features with Pathologic Correlation. Radiographics 2004; 24:S73-S86. Green Planet Solar Energy.com <http://www.green-planet-solar-energy.com/images/water-molecule.gif> Accessed 12.10.2010 Healthpictures.com. http://healthpictures.com/images/Pheochromocytoma.jpg Accessed 12.9.2010. Hocking, G. Central Venous Acess and Monitoring. Practical Procedures, Issue 12 (2000), 13: 1-6.Source: Netter, H Atlas of Human Anatomy, 4E: 2006 Elsevier Netteranatomy.com Johnson. Pamela T, Horton, Karen M. Adrenal Mass Imaging with Multidetector CT: Pathologic Conditions, Pearls, and Pitfalls. Radiographics 2009;29:1333-1351. Kahn, S. Adrenal Vein Sampling. Techniques in Vascular and Interventional Radiology 2010; 13.2: 110-125. Kaplan, Norman M. Rose, Burton D. Who Should be screened for renovascular or orhter causes of secondary hypertension? Up To Date. 2010; 18.3. http://www.uptodate.com/online/content/topic.do?topicKey=hyperten/4350&selectedTitle=1%7E150&> Accessed December 11, 2010. Leah Hawkins, MSIII Gillian Lieberman, MD References, 2 Magill SB, Raff H, Shaker JL, et al. Comparison of adrenal vein sampling and computed tomography in the differentiation of primary aldosteronism. J Clin Endocrinol Metab 2001;86:1066-1071 Mayo-Smith et al. State-of-the-Art Adrenal Imaging. Radiographics 2001;21:995-1012 Matsuura Tomonori et al. Radiologic Anatomy of the Right Adrenal Vein: Preliminary Experience with MDCT. American Journal of Radiology. 2008; 191:402–408 Melby, J. Diagnosis and Localization of Aldosteron-Producing Adenomas by Adrenal-Vein Catheterization. NEJM 1967; 277:1050-1056. Moran A. Chapter 8- Molecular Structure, Biosynthesis and Pathogenic Roles of Lipopolysaccharides. Helicobacter pylori: Physiology and Genetics. Mobley HLT, Mendz GL, Hazell SL, editors. Washington (DC): ASM Press; 2001. http://www.ncbi.nlm.nih.gov/books/NBK2453/ Accessed 12.12.2010 Netter H, Atlas of Human Anatamy 4E: 2006, Elsevier. NetterAnatomy.com Accessed 12.12.2010 Novelline, Robert A. Fundamentals of Radiology. The Adrenal Glands.: 348-351. Imaging the Abdomen: 210-243. Park BK, Kim B, Ko K, Jeong SY, Kwon GY. Adrenal Masses falsely diagnosed as adenomas on unenhanced and delayed contrast-enhanced computed tomography: pathologic correlation. Eur Radiol 2006;16(3):642-647. Prasad S et al. Renovascular Hypertension, ACR Appropriateness Criteria. American College of Radiology; 2009; 1-8. accessed 12.9.2010 Rossi, G. Prevalence and Diagnosis of Primary Aldosteronism. Current Hypertension Reports 2010; 12:342-348. Semin Chong et al. Integrated PET-CT for the Characterization of Adrenal Gland Lesions in Cancer Patients: Diagnostic Efficacy and Interpretation PitfallsRadiographics November-December 2006 26:1811-1824; doi:10.1148/rg.266065057 Leah Hawkins, MSIII Gillian Lieberman, MD References, 3 Stowasser M. et al. Diagnosis and Management of Primary Aldosteronism. Journal of the Renin-Angiotensin-Aldosterone System. 2001; 2.3: 156-169 Stowasser. Image from “UQ Researchers Identify Thousands with Curable High Blood Pressure”.University of Queensland, AU. Image: http://www.uq.edu.au/news/images/media/Hypertension2.jpg. Article: http://www.uq.edu.au/news/?article=11854 Thomson, Kenneth and Given, Mark for Mauro, Matthew A et al. Image-guided Interventions, Volume 1 Chapter: Adrenal Venous Sampling. Philadelphia, Pennsylvania: Saunders Elsevier; 2008. Accessed 12.12.2010 Veglio F et al. Recent Advances in diagnosis and treatment of primary aldosteronism. Minerva Med. 2003 Aug; 94(4): 259-265. Vincent JM, Morrison ID, Armstrong P, Reznek RH. The Size of Normal Adrenal Glands on Computed Tomography. Clin Radiol. 1994 Jul;49(7):453-5. Williams, GJ et al. Comparative accuracy of renal duplex sonographic parameters in the diagnosis of renal artery stenosis: paired and unpaired analysis. AJR. AM J Roentgenol 2007; 188:798. Wikipedia. Adrenal Core, “Autismpedia” http://www.autismpedia.org/wiki/index.php?title=Image:Adrenal-core.gif Accessed 12.12.2010 Leah Hawkins, MSIII Gillian Lieberman, MD