Is ovarian and adrenal venous catheterization and sampling helpful in the investigation of hyperandrogenic women?
Is ovarian and adrenal venous catheterization and sampling helpful in the investigation of hyperandrogenic women?
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DOI：
10.1046/j.1365-2265.2003.01792.x
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发表时间：
2003-07-01
影响因子：
3.2
通讯作者：
Grossman, AB
中科院分区：
文献类型：
--
作者：
Kaltsas, GA;Mukherjee, JJ;Grossman, AB
目的评价我们对低剂量地塞米松抑制试验(LDDST)后雄激素升高不能抑制的高雄激素妇女进行卵巢和肾上腺静脉插管和取样的做法。我们考虑了插管的技术成功率，除了标准的生化测试和成像结果之外还获得了额外的信息，以及采样对管理决策的影响。设计回顾分析1980-1996年间在伦敦圣巴塞洛缪医院进行的所有卵巢和肾上腺静脉插管的结果。对于LDDST后未能将其升高的睾酮(T)、雄烯二酮(A4)和/或脱氢表雄酮-硫酸盐(DHEAS)水平抑制到正常范围或低于基准值50%的患者，进一步进行肾上腺CT、卵巢超声以及卵巢和肾上腺静脉插管和取样。总的插管成功率：四条静脉插管成功率为27%，三条静脉插管成功率为65%，两条静脉插管成功率为87%。其中右肾上腺静脉(RAV)50%，右卵巢静脉(ROV)42%，左肾上腺静脉(LAV)87%，左卵巢静脉(LOV)73%。影像检查(肾上腺CT和卵巢超声)发现肿瘤8例，肾上腺肿瘤3例，卵巢肿瘤5例，其中7例接受手术治疗。在这些患者中，有6例的临床表现提示肿瘤的存在；此外，结合影像发现，所有8例患者都发现了可疑的肾上腺和卵巢肿块。5名卵巢肿瘤患者的血清睾酮水平为4.5nmol/L。另外8名患者根据诊断和治疗的综合指征进行了剖腹手术；其中2名患者的导尿结果提示是卵巢肿瘤。这8例患者均为多囊卵巢综合征(PCOS)，未发现隐匿性卵巢肿瘤。所有非肿瘤性高雄激素血症患者的基础睾酮水平均未超过7nmol/L(中位数4.4nmol/L，范围2.5~7nmol/L)。结论对于有高雄激素血症症状和体征的女性，即使不能将升高的雄激素水平抑制到正式的48h LDDST，也不应常规进行卵巢和肾上腺静脉插管和取样。所有出现高雄激素症和雄激素水平升高的症状和体征，以及高度怀疑是雄激素分泌肿瘤的患者，都应该进行肾上腺CT和卵巢超声成像来检测这种肿瘤。静脉插管和取样应保留给仍有不确定性的患者，因为仅在本系列中使用的生化和影像检查不能排除卵巢小肿瘤的存在。它的使用应仅限于在这一领域具有专门知识的单位。
OBJECTIVE To audit our practice of performing ovarian and adrenal venous catheterization and sampling in hyperandrogenic women who fail to suppress their elevated androgen levels following a 48-h low-dose dexamethasone suppression test (LDDST). We considered the technical success rate of catheterization, the extra information obtained in addition to the standard biochemical tests and imaging findings, and the impact of sampling on management decisions.DESIGN A retrospective analysis of the results of all ovarian and adrenal venous catheterizations performed at St Bartholomew's Hospital, London, in the years 1980-1996.PATIENTS AND METHODS Baseline ovarian and adrenal androgens were measured in all women presenting with symptoms and signs of hyperandrogenism. Those patients who failed to suppress their elevated testosterone (T), androstenedione (A4) and/or dehydroepiandrosterone-sulphate (DHEAS) levels following a LDDST to within the normal range or to less than 50% of the baseline value were investigated further with adrenal computed tomography (CT), ovarian ultrasound, and ovarian and adrenal venous catheterization and sampling.RESULTS Results were available in 38 patients. The overall catheterization success rate was: all four veins in 27%, three veins in 65%, two veins in 87%. The success rate for each individual vein was: right adrenal vein (RAV) 50%, right ovarian vein (ROV) 42%, left adrenal vein (LAV) 87% and left ovarian vein (LOV) 73%. Eight patients were found to have tumours by means of imaging (adrenal CT and ovarian ultrasound), three adrenal and five ovarian, seven of which underwent operation. In six of these patients the clinical presentation was suggestive of the presence of a tumour; in addition, the combination of imaging findings allowed the detection of suspicious adrenal and ovarian masses in all eight cases. The five patients with ovarian tumours had serum testosterone levels > 4.5 nmol/l. In a further eight patients, laparotomy was performed based on a combination of diagnostic and therapeutic indications; in two of these patients the catheterization results were suggestive of an ovarian tumour. All these eight patients were shown histologically to have polycystic ovarian syndrome (PCOS), and no occult ovarian tumour was identified. None of the patients with nontumourous hyperandrogenism had a baseline testosterone level in excess of 7 nmol/l (median 4.4 nmol/l, range 2.5-7 nmol/l).CONCLUSIONS Our results suggest that ovarian and adrenal venous catheterization and sampling should not be performed routinely in women presenting with symptoms and signs of hyperandrogenism, even if they fail to suppress their elevated androgen levels to a formal 48-h LDDST. All patients presenting with symptoms and signs of hyperandrogenism and elevated androgen levels, and where the suspicion of an androgen-secreting tumour is high, should have adrenal CT and ovarian ultrasound imaging to detect such a tumour. Venous catheterization and sampling should be reserved for patients in whom uncertainty remains, as the presence of a small ovarian tumour cannot be excluded on biochemical and imaging studies used in this series alone. Its use should be restricted to units with expertise in this area.