Adrenal venous sampling identifies surgical candidates missed by imaging in ACTH-independent autonomous cortisol secretion, analysis suggests
Presenter: Tetsuya Kawahara, MD, PhD, Shinkomonji Hospital, Kitakyushu, Japan
Adrenal venous sampling improves functional lateralization in adrenocorticotropic hormone-independent autonomous cortisol secretion with non-decisive imaging. Presented April 23, 2026.
Measuring and comparing cortisol levels in blood drawn directly from each adrenal vein—adrenal venous sampling—identified unilateral cortisol excess with greater sensitivity than contrast-enhanced computed tomography (CT) or adosterol scintigraphy in patients with adrenocorticotropic hormone (ACTH)-independent autonomous cortisol secretion, according to a retrospective analysis presented at AACE 2026.
The single-center study of 66 patients combined contrast-enhanced CT, adosterol scintigraphy, and adrenal venous sampling performed under low-dose dexamethasone suppression without exogenous ACTH stimulation, using Bayesian latent class analysis with postoperative outcomes as partially observed reference data to estimate diagnostic performance.
Adrenal venous sampling for aldosterone is the gold standard for detecting lateralization in primary aldosteronism, but its role in cortisol-producing syndromes is less settled, and its adoption lags outside specialized centers, according to the study authors.
“Outside specialized adrenal centers, adrenal venous sampling for cortisol-producing disorders remains relatively uncommon and is not routinely performed in many institutions,” Dr. Kawahara said in an interview. “Its use is largely limited to centers with specific expertise in it.”
That practice gap is potentially clinically important. Dr. Kawahara said patients with unilateral disease who are misclassified by imaging may be denied curative adrenalectomy and remain exposed to chronic cortisol excess, which can drive ongoing cardiometabolic complications and unnecessary long-term medical management.
Diagnostic performance
Sensitivity for detecting unilateral cortisol excess reached 0.958 with adrenal venous sampling, compared with 0.741 for CT (P = .048) and 0.728 for scintigraphy (P = .045). Specificity was comparable across the three modalities (0.785 for adrenal venous sampling, 0.633 for CT, and 0.771 for scintigraphy).
Neither the absolute size of adrenal tumors on CT nor the degree of asymmetry between them reliably predicted which side was functionally dominant, according to the authors.
“Our findings suggest that anatomical features such as tumor size or asymmetry should not be relied upon alone to guide surgical decisions,” Dr. Kawahara said. “Functional assessment is essential, particularly when imaging findings are bilateral or inconclusive.”
Impact when imaging is nondecisive
Among the 21 patients with bilateral or nondecisive CT findings, adrenal venous sampling identified unilateral disease in 11 (52%). Postoperative remission confirmed true unilateral cortisol excess in 9 of those 11 patients (82%).
In outcome-based analyses, a lateralization index cutoff of 2.5 provided an optimal diagnostic balance between sensitivity and specificity, with values of 0.867 and 1.000 for cortisol-based indices and 0.889 and 1.000 for metanephrine-corrected indices, respectively.
“The key message is that adrenal venous sampling can uncover clinically meaningful unilateral disease even when CT is nondecisive, translating into a high likelihood of postoperative remission,” Dr. Kawahara said. “Therefore, adrenal venous sampling should be considered in selected patients to avoid missed opportunities for curative surgery.”
Authors concluded that adrenal venous sampling, performed under low-dose dexamethasone suppression without ACTH stimulation, offered better diagnostic accuracy compared with CT and adosterol scintigraphy for functional lateralization in ACTH-independent autonomous cortisol secretion.
These findings highlighted a “clinically meaningful discordance” between morphological imaging and functional assessment, which emphasized the importance of adrenal venous sampling in patients with bilateral or nondecisive imaging, they wrote in their abstract.
The lateralization index threshold of 2.5 aligned with postoperative outcomes, they said, and may lead to more reliable surgical decision-making in practice.
Better identification of appropriate candidates for unilateral adrenalectomy could also spare patients with bilateral disease from unnecessary surgical procedures, the authors added.
Disclosures
Dr. Kawahara reported no disclosures.
References
Kawahara T, Toda M, Kanagawa M, Toyama N, Kawahara C, Inazu T. Adrenal venous sampling improves functional lateralization in adrenocorticotropic hormone-independent autonomous cortisol secretion with non-decisive imaging. Endocrine Pract 2026; 32(suppl). https://doi.org/10.1016/j.eprac.2026.03.014