Correspondence

The Incidentally Discovered Adrenal Mass

N Engl J Med 2007; 356:2005-2006May 10, 2007

Article

To the Editor:

The Clinical Practice article by Young (Feb. 8 issue),1 on the incidentally discovered adrenal mass, provides a personal view of how to approach this clinical problem, but it does not mention relevant guidelines from a recent international symposium.2,3 An important recommendation endorsed at the meeting was that initial testing for pheochromocytoma include the measurement of fractionated metanephrines in plasma, urine, or both. This recommendation recognizes that a missed diagnosis (due to inadequate sensitivity) can have catastrophic consequences for the patient. Young emphasizes specificity and in this respect suggests that urinary measurement is preferable to plasma measurement. However, Lenders et al.4 reported a specificity of 69% for urinary fractionated metanephrines and 89% for plasma metanephrines. Apart from that report and another by Unger et al.,5 which also showed better diagnostic accuracy with the use of the plasma test than the urine test, there are no reliable head-to-head comparisons of these two tests of fractionated metanephrines. Furthermore, urinary dopamine is derived mainly from renal extraction and decarboxylation of circulating levodopa and is not a reliable marker for dopamine-producing tumors.2

Karel Pacak, M.D., Ph.D.
Graeme Eisenhofer, Ph.D.
National Institutes of Health, Bethesda, MD 20892
karel@mail.nih.gov

Ashley Grossman, M.D., F.R.C.P.
Barts and the London, London E1 2AD, United Kingdom

5 References

1. 1

   Young WF Jr. The incidentally discovered adrenal mass. N Engl J Med 2007;356:601-610
   Full Text | Web of Science | Medline

2. 2

   Grossman A, Pacak K, Sawka A, et al. Biochemical diagnosis and localization of pheochromocytoma: can we reach a consensus? Ann N Y Acad Sci 2006;1073:332-347
   CrossRef | Web of Science | Medline

3. 3

   Pacak K, Eisenhofer G, Ahlman H, et al. Pheochromocytoma: recommendations for clinical practice from the First International Symposium. Nat Clin Pract Endocrinol Metab 2007;3:92-102
   CrossRef | Web of Science | Medline

4. 4

   Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002;287:1427-1434
   CrossRef | Web of Science | Medline

5. 5

   Unger N, Pitt C, Schmidt IL, et al. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. Eur J Endocrinol 2006;154:409-417
   CrossRef | Web of Science | Medline

To the Editor:

Primary aldosteronism due to an aldosterone-producing adenoma and resulting in surgically reversible hypertension is extremely rare. Defined by a ratio of the plasma aldosterone concentration to plasma renin activity of more than 20, primary aldosteronism in the absence of an aldosterone-producing tumor is considered to be idiopathic. Even during treatment with diuretics, the pattern of extreme suppression of plasma renin activity to undetectable levels (i.e., <0.1 ng per milliliter per hour) in the presence of a plasma aldosterone concentration of 10 to 20 ng per deciliter (i.e., a ratio of 100 to 200) is not unusual in black persons with hypertension, and in our experience, this pattern appears to be more prevalent among blacks from the Caribbean region and recent immigrants from Western Africa than among other black patients. Such patients tend to have a “resistant” hypertension, with or without a susceptibility to hypokalemia, and typically have a good response to the addition of spironolactone or amiloride.

In clinics serving such populations, following Young's recommendations, especially in the case of older patients who have an increased coincidence of silent adrenal nodules, could lead to unnecessary invasive diagnostic procedures such as adrenal venous sampling. Therefore, clinical considerations, not just hormonal data, should guide the choice of further interventions.

Irene Gavras, M.D.
Boston University School of Medicine, Boston, MA 02118
igavras@bu.edu

Citing Articles (3)

Citing Articles

1. 1

   Yujiang Fang. (2011) Editorial Comment from Dr Fang to Increased expression of CYP17 and CYP11B1 in subclinical Cushing's syndrome due to adrenal adenomas. International Journal of Urology 18:10, 697-699
   CrossRef

2. 2

   Yujiang Fang, Lei Zhao, Meifu Zang, Songsen Chen, Feng Yan, Xu Di, Alicia Duren. (2010) A Dispensable Role for P450scc in the Overproduction of Aldosterone in Aldosterone-Producing Adenoma and Idiopathic Hyperaldosteronism in Patients with Primary Aldosteronism. Pathology & Oncology Research 16:4, 589-592
   CrossRef

3. 3

   Douglas J Turner, Judiann Miskulin. (2009) Management of adrenal lesions. Current Opinion in Oncology 21:1, 34-40
   CrossRef