Use of PET/CT with cosyntropin stimulation to identify and localize adrenal rest tissue following adrenalectomy in a woman with congenital adrenal hyperplasia
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CONTEXT: Adrenalectomy is an experimental treatment option for select patients with congenital adrenal hyperplasia who have failed medical therapy. After adrenalectomy, adrenal rest tissue can remain in extraadrenal locations, cause recurrent hyperandrogenism, and be difficult to localize. OBJECTIVE: The aim of the study was to investigate the usefulness of positron emission tomography/computerized tomography (PET/CT) in identifying adrenal rest tissue. SUBJECT: A female with salt-wasting 21-hydroxylase deficiency who had bilateral adrenalectomy at age 17 yr presented with hyperandrogenism at age 32 yr. Pelvic magnetic resonance imaging and ultrasound imaging were nondiagnostic for the source of androgen production. METHODS AND RESULTS: A baseline F-18 labeled fluoro-2-deoxy-d-glucose (18F-FDG) PET/CT scan showed no active uptake; however, a second scan preceded by a 250-μg cosyntropin injection identified three areas of active uptake near both ovaries. Subsequent ovarian venous sampling showed elevations in 17-hydroxyprogesterone, androstenedione, and 21-deoxycortisol in both ovarian veins compared to a peripheral vein at baseline and more so after cosyntropin administration. At laparoscopy, three well-circumscribed nodules (2.4 × 0.9 × 1.3 cm, 1.2 × 1.5 × 1.5 cm, and 2 × 1.5 × 1 cm) lying lateral to the fallopian tubes adjacent to the broad ligaments were removed. The paraovarian nodules and previously removed adrenal glands had similar histology and immunohistochemistry. Postoperatively, androgen concentrations were undetectable, with no response to cosyntropin stimulation. CONCLUSIONS: Patients with CAH after an adrenalectomy may experience recurrent hyperandrogenism due to adrenal rest tissue. 18F-FDG PET/CT with cosyntropin stimulation accurately identified adrenal rest tissue not visualized with conventional imaging, allowing for successful surgical resection.
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Adrenal rest is most commonly found in the rete testis and has been described in the ovaries and broad ligament.
“Adrenal rest is most commonly found in the rete testis (Figure 3C) and has been described in the ovaries and broad ligament.112,113”
From Congenital adrenal hyperplasia (2017) · cites this paper as [113]
Adrenalectomy may not fully eliminate hyperandrogenemia because adrenal rest tumors can arise in the testes, ovaries, or retroperitoneum.
“Adrenalectomy may not totally remove hyperandrogenemia owing to the potential development of adrenal rest tumors in the testes (330), ovaries (332), or retroperitoneum (333).”
From Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society* Clinical Practice Guideline (2018) · cites this paper as [333]
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References 19 · Cited by 48
- Authors
- Crocker, M. K., Barak, S., Millo, C. M., Beall, S. A., Niyyati, M., Chang, R., Avila, N. A., Van Ryzin, C., Segars, J., Quezado, M., & Merke, D. P.
- Affiliations
- Boston Children's Hospital (US)
- National Institutes of Health (US)
- National Institutes of Health Clinical Center (US)
- Veterans Health Administration (US)
- Corresponding author
- Crocker, Melissa K.
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2012-11
- Volume
- 97
- Issue
- 11
- Pages
- E2084-E2089
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- PMC
- PMC3485588
- OpenAlex
- W2017521694
- Cited by
- 48
- References
- 19
- Citations by year
- 2025: 2 · 2024: 4 · 2023: 3 · 2022: 5 · 2021: 4 · 2020: 2 · 2019: 2 · 2018: 3 · 2017: 5 · 2016: 3 · 2015: 3 · 2014: 7 · 2013: 5
- FWCI
- 1.93
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hormonal Regulation and Hypertension
- Keywords
- congenital adrenal hyperplasia, adrenalectomy, cosyntropin stimulation, 18F-FDG PET/CT, 21-hydroxylase deficiency, salt-wasting CAH, ovarian androgen production
- MeSH terms
- Adrenal Glands, Adrenal Hyperplasia, Congenital, Adrenalectomy, Adult, Cosyntropin, Female, Humans, Tomography, X-Ray Computed, Treatment Outcome, Positron-Emission Tomography, Multimodal Imaging
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