Is CXCR4-targeted (68)Ga-pentixafor PET/CT a reliable AVS-free modality for surgical decision-making and prognostic prediction in primary aldosteronism with bilateral adrenal lesions?

BACKGROUND: For patients diagnosed with primary aldosteronism (PA) accompanied by bilateral adrenal lesions, identifying optimal candidates for surgical intervention remains a significant clinical challenge. Although adrenal venous sampling (AVS) is currently the gold standard for lateralizing aldosterone hypersecretion, its technical complexity, invasiveness, and interpretive difficulties restrict its widespread adoption. In this study, we aimed to investigate the clinical application of (68)Ga-pentixafor positron emission tomography/computed tomography (PET/CT) as a non-invasive imaging modality in AVS-free surgical decision-making for PA patients with bilateral adrenal lesions. RESULTS: Among the 51 patients who underwent (68)Ga-pentixafor PET/CT, 36 patients had adrenalectomy, with the surgical side determined by PET/CT lateralization. The postoperative complete biochemical and clinical success rates for these patients were 91.67% and 100%, respectively. Additionally, receiver operating characteristic curve analysis indicated that PET/CT results were favorable predictors of postoperative outcomes in surgical patients. Postoperative pathological evaluation of (68)Ga-pentixafor PET/CT-guided surgical patients revealed that 86.11% had adrenocortical adenomas with positive CYP11B2 and CXCR4 expression. CONCLUSION: CXCR4-targeted (68)Ga-pentixafor PET/CT can be effectively utilized in surgery decision-making for PA patients with bilateral adrenal lesions, offering a potential alternative to AVS and maybe applied to predict postoperative biochemical and clinical success. TRIAL REGISTRATION: (68)Ga-Pentixafor PET/CT for Guiding Surgical Treatment of Primary Aldosteronism With Bilateral Adrenal Lesions; Trial registration number: NCT06247566; Date of registration: 2021-11-01; URL of trial registry record: https://clinicaltrials.gov/study/NCT06247566 .