SUN-243 Micronodular Asymmetrical Disease and Lack of Rigorous Biochemical Success following Adrenalectomy for Primary Aldosteronism detected by PET-CT Imaging and Post-Operative Confirmatory Testing

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Abstract Disclosure: J. Kearney: None. D. Gillett: None. E. Goodchild: None. H. Cheow: None. M. Krishnamurthy: None. K. Laycock: None. X. Wu: None. M. Gurnell: None. W. Drake: None. M.J. Brown: None. Background: Complete clinical success, defined by PASO criteria, is achieved in only 31% of patients after adrenalectomy for Primary Aldosteronism (PA), compared to 88% biochemical success (1). This discrepancy exists despite convincing pre-operative lateralisation. The PASO criteria for biochemical cure may lack the sensitivity to detect residual disease. Micronodular disease is hypothesised to be the causative pathology in disease relapse/persistence post-operatively. This is reflected in the paradigm shift from the dichotomy of unilateral and bilateral disease to the concept of asymmetrical disease. Radioligand PET-CT imaging parameters could more accurately subclassify patients pre-operatively by enabling identification of previously undetectable contralateral gland disease. Hypotheses: 1-PASO criteria misclassifies some patients with residual autonomous aldosterone secretion post adrenalectomy as complete biochemical success. 2-Radioligand PET-CTs ([11C]metomidate and [18F]CETO) can identify micronodular disease in the contralateral gland, thus more accurately identifying patients best suited to medical therapy. Methods/Results: 1.Patients from the MATCH study with complete PASO biochemical success at 6- and 24-months post-operatively were grouped by clinical outcome, and aldosterone renin ratio (ARR) values compared. A trend towards higher ARR was seen in those with absent vs partial vs complete clinical success. 14/18 patients with KCNJ5 mutation achieved complete clinical success at 6 months vs 3/20 with CACNA1D mutation (and 0 CACNA1D at 2 years). Amongst those with complete biochemical and partial clinical success, mean ARR was higher in CACNA1D vs KCNJ5 genotype (248 vs 82 pmol/L per nmol/L/h). 2.Of 13 patients who scored complete clinical success on PASO, only five achieved a normal Captopril Challenge Test (suppression of aldosterone and rise in renin).3.Total adrenal volume was manually outlined on CT, copied to the PET image and voxel data extracted. 20 patients with complete clinical and biochemical success, so assumed ‘normal’ contralateral gland, were compared to 20 with bilateral disease, (failure to lateralise on AVS/PET-CT). Glands with multifocal/asymmetrical disease are, on average, larger, with greater uptake than normal glands and less variability in voxel SUV values than glands with unilateral APA. Conclusion: •The ARR as a measure of post-operative outcomes may miss some patients with contralateral disease not detected on lateralisation pre-operatively. •Exploratory radiological data demonstrates that whole adrenal voxel analysis measures differ between aldosterone producing adenomas, micronodular disease and normal glands. •Asymmetrical disease is likely more prevalent than previously thought and may be detected by PET-CT pre-operatively and confirmatory testing post-operatively. (1)Wu et al. Nat Med. 2023 Presentation: Sunday, July 13, 2025

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