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Cicala, Maria Verena (2012) Ruolo del cateterismo delle vene surrenaliche nell'iperaldosteronismo primitivo. Impatto di differenti criteri diagnostici nella diagnosi di sottotipo. [Tesi di dottorato]

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Abstract (inglese)

In patients with primary aldosteronism (PA), adrenal vein sampling (AVS) is considered the gold standard to distinguish between unilateral and bilateral autonomous production of aldosterone, while diagnostic imaging tests by CT scan or MRI are useful but often inconclusive for the diagnosis of PA. To date agreement is lacking on the best criteria indicating successful cannulation and lateralization.
The aim of the study was to evaluate the impact of different diagnostic criteria for the successful cannulation and lateralization on subtype diagnosis and to compare the difference of the findings between adrenal CT scan and AVS.
Sixty-six patients with confirmed PA underwent AVS. The different diagnosis of PA subtype reached using AVS data assessed by more permissive (type 1) and strict (type 2) criteria were compared. Al patients performed CT scan before AVS and imaging results were compared with results of AVSs (using both criteria).
Using Type 1 criteria AVSs were successful in 86,3% of patients, while they were successful in only 66,6% using type 2 criteria. Type 1 criteria also led to a higher rate of diagnosis of unilateral PA (80,7% of successful procedures) than type 2 (75% of successful procedures). There was considerable disparity in the diagnosis reached using the 2 different criteria, with a concordance in only 50% of patients. In conclusion more permissive criteria for successful cannulation and lateralization on AVS can lead to incorrect diagnosis and accordingly to inappropriate treatment options.
In the selected group of patients with successful AVS, CT findings correlated with AVSs findings and correctly identified unilateral or bilateral disease in 57,9% of patients using type 1 criteria and in 47,7% using type 2 criteria. Finale diagnosis was based on histological results in 29 patients (43,9 %) which underwent adrenalectomy based on AVSs findings. On the basis of CT findings alone 17,5% of patients from the first group and 31,8% of patients of the second group probably would have been incorrectly bypassed as candidates for adrenalectomy. CT scanning lacks sensitivity and specificity and should, therefore, be followed by AVS, which is the only reliable means of differentiating unilateral from bilateral PA and lateralizing APAs preoperatively. However, there are still controversies to be solved by large prospective studies on the criteria to adopt for defining the most appropriate cut off for both correct cannulation and lateralization.

Abstract (italiano)

Il Cateterismo venoso surrenalico (AVS) è considerato ad oggi il gold standard per distinguere tra una ipersecrezione aldosteronica unilaterale o bilaterale in pazienti affetti da iperaldosteronismo primitivo (PA); mentre procedure di imaging, quali TAC o RMN pur essendo molto utili spesso risultano inconclusive per la diagnosi. Tuttavia manca ancora un accordo su quale criterio diagnostico usare per identificare un corretto incanalamento ed una corretta lateralizzazione al AVS.
Scopo principale del presente studio è di valutare l'impatto di differenti criteri utilizzati per definire il successo di incanulazione e la lateralizzazione nella diagnosi di sottotipo e di analizzare il ruolo del cateterismo delle vene surrenaliche nella diagnosi e nella conseguente scelta di trattamento di iperaldosteronismo primitivo, comparando risultati di imaging ottenuti tramite TAC surrenalica con l'esito dei cateterismi venosi surrenalici.
66 pazienti con diagnosi di PA sono stati sottoposti ad AVS. I risultati ottenuti sono stati interpretati usando due criteri per l'identificazione di incanalamento e di lateralizzazione diversi, uno più permissive (Tipo 1) e l'altro più restrittivo (Tipo 2). Tutti I pazienti hanno eseguito una TAC surrenalica prima del AVS e le immagini sono state confrontate con I risultati ottenuti al cateterismo (usando entrambi criteri).
Usando il criterio tipo 1 il cateterismo è stato eseguito con successo nel 86,3% dei pazienti, mentre ha avuto successo solamente nel 66,6% dei casi usando il criterio di interpretazione tipo 2. Il criterio tipo 1 ha portato ad identificare un numero maggiore di APA (80,7% delle procedure eseguite con successo) rispetto al criterio tipo 2 (75% delle procedure eseguite con successo). Una diagnosi concorde usando I due criteri si è ottenuta solamente nel 50% dei pazienti. In conclusione criteri più permissive per valutare il successo di incanalamento e la lateralizzazione al AVS possono portare a diagnosi incorrette e conseguentemente a scelte terapeutiche inappropriate.
Nel gruppo di pazienti in cui il cateterismo è stato eseguito con successo, la TAC correlava con I risultati del AVS identificando correttamente lesione uni-o bilaterali nel 57,9% dei casi usando il criterio di tipo 1, e nel 47,7% dei casi usando il criterio tipo 2. La diagnosi finale è basata sull’analisi isto-patologica in 29 pazienti ( 43,9%) sottoposti a surrenectomia monolaterale. Sulla base della sola immagine TAC il 17,5% dei pazienti del primo gruppo e il 31,8% del secondo gruppo sarebbe stato sottoposto erroneamente a surrenectomia. La TAC presenta minore sensibilità  e specificità  e dovrebbe precedere un AVS, che rappresenta il metodo più idoneo nell'identificare un PA unilaterale o bilaterale. Tuttavia permangono tuttora delle controversie che dovrebbero essere risolte da studi prospettici a largo spettro per definire I cut-off più appropriate per identificare un corretto incanalamento e corretta lateralizzazione.

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Tipo di EPrint:Tesi di dottorato
Relatore:Mantero, Franco
Dottorato (corsi e scuole):Ciclo 24 > Scuole 24 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > METODOLOGIA CLINICA E SCIENZE ENDOCRINOLOGICHE
Data di deposito della tesi:20 Gennaio 2012
Anno di Pubblicazione:20 Gennaio 2012
Parole chiave (italiano / inglese):iperaldosteronismo primitivo/primary aldosteronism, cateterismo delle vene surrenaliche/adrenal vein sampling, diagnosi di sottotipo/subtype diagnosis
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/13 Endocrinologia
Struttura di riferimento:Dipartimenti > pre 2012 - Dipartimento di Scienze Mediche e Chirurgiche
Codice ID:4407
Depositato il:31 Ott 2012 13:27
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