The impact of autonomous cortisol secretion (ACS) on adrenal venous sampling (AVS) in patients with primary aldosteronism (PA) remains uncertain. This study aimed to evaluate the effects of ACS on success and lateralization of AVS. From the Japan Primary Aldosteronism Study-II, 872 PA patients with adrenal nodular lesions on computed tomography (CT) who underwent a 1-mg dexamethasone suppression test (DST) were included. ACS was defined as a post-DST cortisol level ≥1.8 μg/dL. AVS success was assessed using selectivity index (cutoff value 2 without, 5 with ACTH-stimulation), and lateralization was determined using lateralization index (cutoff value 2 without, 4 with ACTH-stimulation). Among 872 patients, 283 (32.4%) had ACS. After ACTH-stimulation, AVS success rate was significantly lower in ACS group than in non-ACS group (84.8% vs. 91.0%, p < 0.01), while no significant difference was observed before ACTH-stimulation. Among 524 patients with successful AVS both before and after ACTH-stimulation, 161 (30.7%) had ACS. The proportion of unilateral results did not differ significantly between ACS and non-ACS groups either with or without ACTH. Concordance between AVS and CT laterality was significantly lower in ACS group only without ACTH-stimulation (44.1% vs. 61.7%, p < 0.01). In patients with post-DST cortisol ≥5 μg/dL, reverse AVS-CT laterality was significantly more frequent than in those with cortisol <1.8 μg/dL both with and without ACTH-stimulation. In conclusion, ACS was associated with a lower AVS success rate with ACTH-stimulation, had no impact on rate of unilateral results, but reduced AVS-CT concordance, especially in patients with higher post-DST cortisol levels.
Pheochromocytoma (PCC) and sympathetic paraganglioma (PGL), together PPGL are rare tumors of the adrenal medulla and extra-adrenal paraganglion, and 10–15% of PCC and 30–50% of PGL metastases. Histopathological analysis of metastatic PPGL has not been well defined. We analyzed 35 metastatic PPGLs based on clinicopathological data and the grading of adrenal pheochromocytoma and paraganglioma (GAPP) which is one of the tools for evaluating malignancy. We added succinate dehydrogenase type B (SDHB) immunohistochemistry with partly SDHB gene analysis and compared them to the patient prognosis. The mean age of patients was 34-year-old (range: 17–81). Mean tumor size was 8.6 cm. Synchronous metastasis was 18 (51.4%) cases, and metachronous metastasis occurred in 17 cases from 1 to 19 years (mean duration: 5 years) after first operation. Catecholamine types were 8 epinephrine, 16 norepinephrine, 6 norepinephrine plus dopamine, and 5 nonfunctional. Loss of SDHB-immunohistochemistry was observed in 43%. Ki67 labeling index was 11% in synchronous and 7% in metachronous metastasis (P < 0.05). Mean Ki67 was 6.0 in all and 14% in expired patients. GAPP score was 6 in all and 8.5 in expired patients. GAPP risk stratification was high in 47%, intermediate in 41%, and low in 12% in all patients, and high in 73%, intermediate in 27%, and low in 0% in expired patients. In conclusion, metastasis occurred in any type of PPGL. SDHB mutation was not confirmed as a major prognostic parameter in metastatic PPGL. Both higher Ki67 labeling index and higher GAPP score were histological indicators for poor prognosis.
Unilateral primary aldosteronism (UPA) is characterized by a severe clinical phenotype and can be cured by adrenalectomy. Establishing accurate cutoff values that indicate the need for adrenal venous sampling (AVS) is crucial. Therefore, we aimed to identify appropriate cutoff values for screening and confirmatory testing to predict UPA by LC-MS/MS-equivalent plasma aldosterone concentration (PAC) using chemiluminescent enzyme immunoassay (CLEIA). A retrospective cohort analysis was conducted as part of the JPAS-II study of 443 patients diagnosed with PA using CLEIA-measured PAC, of whom 179 were confirmed by AVS as having UPA. The screening aldosterone-to-renin ratio (sARR), screening PAC, post-captopril challenge test (CCT) aldosterone-to-renin ratio (ARR), post-CCT PAC, and post-saline infusion test (SIT) PAC were significantly higher in patients with UPA than in those with bilateral PA (p < 0.05). Receiver operator characteristic curve analysis yielded an sARR cutoff value of >183 pg/mL/ng/mL/h (sensitivity of 0.95). The post-CCT ARR (AUC: 0.824 ± 0.022) and post-CCT PAC (AUC: 0.845 ± 0.021) were superior predictors of UPA to post-SIT PAC (AUC: 0.782 ± 0.037). When the cutoff values were designed to maximize sensitivity without a significant reduction in specificity, cutoff values for post-CCT ARR of >153 pg/mL/ng/mL/h (sensitivity: 0.85, specificity: 0.55) and for post-SIT PAC of >48 pg/mL (sensitivity: 0.80, specificity: 0.61) were obtained. Importantly, these cutoff values contributed to a diagnosis of UPA when the presence of hypokalemia or adrenal tumor was also considered. In conclusion, LC-MS/MS-equivalent CLEIA-measured cutoff values for post-CCT ARR of >153 pg/mL/ng/mL/h and for post-SIT PAC of >48 pg/mL are considered to indicate AVS. Study registration number: UMIN ID: 000046631.
Cervical laminoplasty is a well-established surgical approach for managing various cervical spine pathologies, including cervical spondylotic myelopathy, spinal canal stenosis, and ossification of the posterior longitudinal ligament. Among the available laminoplasty techniques, the use of Hydroxyapatite spacers secured with screws is common for maintaining the expanded interlaminar space. However, one potential complication is screw back-out, which, although recognized, has rarely been documented in the literature. We present a rare case of delayed screw migration culminating in skin perforation in a 76-year-old woman who underwent cervical laminoplasty for cervical spondylotic myelopathy. During the index procedure, Hydroxyapatite spacers were placed and secured with screws into the lamina. Seven years postoperatively, gradual subcutaneous migration of the screw from the lamina of the fourth cervical vertebra was observed, ultimately resulting in complete skin penetration 9 years after the initial surgery. The patient underwent surgical removal of the protruding screw along with surrounding granulation tissue. The surgical site was thoroughly irrigated with copious saline, and the wound was closed primarily with sutures. Postoperative recovery was uneventful. Stitches were removed on day 11 after confirming complete wound healing. This case underscores an exceptionally rare but clinically significant late complication of cervical laminoplasty with Hydroxyapatite spacers -complete screw extrusion through the skin. To our knowledge, this is the first documented case of its kind. The prolonged asymptomatic nature of screw migration in this patient highlights the importance of long-term surveillance following laminoplasty, even in the absence of clinical symptoms, to detect hardware-related complications at an early stage.
BACKGROUND:Pressure wire-based fractional flow reserve (FFR) is the reference standard for physiologic lesion assessment but remains underutilized owing to the need for hyperemia, procedural complexity, and wire-related risks. Angiography-derived FFR provides a wire- and hyperemia-free assessment derived from routine angiography; however, its clinical impact in guiding treatment remains uncertain. OBJECTIVES:This study aimed to determine whether angiography-derived FFR is noninferior to pressure wire-based FFR in guiding revascularization decisions among patients with stable coronary artery disease. METHODS:PROVISION (Prospective randomized trial of clinical outcomes of angiography-based fractional flow reserve guidance versus wire-based fractional flow reserve guidance) was a prospective, multicenter, randomized study. Participants were randomized 1:1 to angiography-derived FFR-guided or pressure wire-based FFR-guided revascularization. The primary endpoint was the noninferiority of angiography-derived FFR in terms of revascularization rate, defined as the proportion of patients undergoing percutaneous coronary intervention or coronary artery bypass grafting based on physiologic assessment. Secondary endpoints included the 1-year incidence of major adverse cardiac events (cardiac death, any myocardial infarction, or ischemia-driven target vessel revascularization). RESULTS:Overall, 401 patients (483 vessels) were enrolled at 13 Japanese centers. Revascularization was performed in 41.4% of patients in the angiography-derived FFR group and 37.9% in the pressure wire-based FFR group (absolute difference: 3.5%; 95% CI: -6.0 to 13.1; P for noninferiority = 0.049). At 1 year, major adverse cardiovascular events occurred in 8.4% and 10.1% of patients, respectively (HR: 0.84; 95% CI: 0.44-1.60; P = 0.591). CONCLUSIONS:Angiography-derived FFR-guided revascularization was noninferior to pressure wire-based FFR-guided strategy for determining revascularization in patients with stable coronary artery disease. This finding suggests that angiography-derived FFR may serve as a practical, wire-free alternative for physiologic guidance of coronary revascularization, warranting confirmation in larger outcome-driven trials. (PROVISION; UMIN000049230).
