Dylan Lewis

A 13-Steroid Serum Panel Based on LC-MS/MS: Use in Detection of Adrenocortical Carcinoma

BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignancy, with an annual incidence of 1 or 2 cases per million. Biochemical diagnosis is challenging because up to two-thirds of the carcinomas are biochemically silent, resulting from de facto enzyme deficiencies in steroid hormone biosynthesis. Urine steroid profiling by GC-MS is an effective diagnostic test for ACC because of its capacity to detect and quantify the increased metabolites of steroid pathway synthetic intermediates. Corresponding serum assays for most steroid pathway intermediates are usually unavailable because of low demand or lack of immunoassay specificity. Serum steroid analysis by LC-MS/MS is increasingly replacing immunoassay, in particular for steroids most subject to cross-reaction. METHODS We developed an LC-MS/MS method for the measurement of serum androstenedione, corticosterone, cortisol, cortisone, 11-deoxycorticosterone, 11-deoxycortisol, 21-deoxycortisol, dehydroepiandrosterone sulfate, pregnenolone, 17-hydroxypregnenolone, progesterone, 17-hydroxyprogesterone, and testosterone. Assay value in discriminating ACC from other adrenal lesions (phaeochromocytoma/paraganglioma, cortisol-producing adenoma, and lesions demonstrating no hormonal excess) was then investigated. RESULTS In ACC cases, between 4 and 7 steroids were increased (median = 6), and in the non-ACC groups, up to 2 steroids were increased. 11-Deoxycortisol was markedly increased in all cases of ACC. All steroids except testosterone in males and corticosterone and cortisone in both sexes were of use in discriminating ACC from non-ACC adrenal lesions. CONCLUSIONS Serum steroid paneling by LC-MS/MS is useful for diagnosing ACC by combining the measurement of steroid hormones and their precursors in a single analysis.

Success in adrenal venous sampling between two protocols: experience at a tertiary centre

Adrenal venous sampling (AVS) is currently the best available confirmatory test for lateralising aldosterone production in proven primary aldosteronism (PA).1 AVS is an invasive procedure, which carries a small risk of complications, but requires skilled radiologist to obtain biochemically selective samples.2 The technical success rate of AVS has been cited up to 96% in specialised centres,3 whereas unsuccessful AVS is primarily due to failure in cannulating the right adrenal vein, because of its challenging anatomy. Furthermore, in spite of ‘radiologically successful’ cannulation of both adrenal veins, the samples obtained can still be non-diagnostic due to dilution and lack of selectivity. Following a revision of our AVS protocol (both radiological and biochemical) in 2012, we assessed its impact on the success rate of the procedure. We carried out a retrospective review of all AVS performed in the interventional radiology department since 2008. Prior to 2012 (pre-2012 protocol), three interventional radiologist (IR) performed AVS in randomly allotted slots without cosyntropin stimulation using a size 5 French (Fr) SIM2 Glidecath (Terumo, Somerset, New Jersey) as the preferred catheter for cannulation. As per the revised protocol (post-2012 protocol), two IR (combined experience of >24 years) were designated to perform all AVS procedures and patients were booked as the first case in the morning list. All received cosyntropin bolus intravenously (250 μg in 5 mL of 0.9% saline) an …