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Chakravarti S, Uyeda JW. Expanding Role of Dual-Energy CT for Genitourinary Tract Assessment in the Emergency Department, From the AJR Special Series on Emergency Radiology. AJR Am J Roentgenol 2023; 221:720-730. [PMID: 37073900 DOI: 10.2214/ajr.22.27864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Among explored applications of dual-energy CT (DECT) in the abdomen and pelvis, the genitourinary (GU) tract represents an area where accumulated evidence has established the role of DECT to provide useful information that may change management. This review discusses established applications of DECT for GU tract assessment in the emergency department (ED) setting, including characterization of renal stones, evaluation of traumatic injuries and hemorrhage, and characterization of incidental renal and adrenal findings. Use of DECT for such applications can reduce the need for additional multiphase CT or MRI examinations and reduce follow-up imaging recommendations. Emerging applications are also highlighted, including use of low-energy virtual monoenergetic images (VMIs) to improve image quality and potentially reduce contrast media doses and use of high-energy VMIs to mitigate renal mass pseudoenhancement. Finally, implementation of DECT into busy ED radiology practices is presented, weighing the trade-off of additional image acquisition, processing time, and interpretation time against potential additional useful clinical information. Automatic generation of DECT-derived images with direct PACS transfer can facilitate radiologists' adoption of DECT in busy ED environments and minimize impact on interpretation times. Using the described approaches, radiologists can apply DECT technology to improve the quality and efficiency of care in the ED.
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Affiliation(s)
| | - Jennifer W Uyeda
- Department of Emergency Radiology, Brigham and Women's Hospital/Harvard Medical School, 75 Francis St, Boston, MA 02115
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2
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Gaisbauer S, Zeugswetter FK, Tichy A, Rowan C, Ludewig E. Assessment of Adrenal Computed Tomography Characteristics in Cats with Nonadrenal Disease. J Am Anim Hosp Assoc 2022; 58:113-120. [PMID: 35576401 DOI: 10.5326/jaaha-ms-7140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/11/2022]
Abstract
Adrenal computed tomography characteristics (aCTc) in healthy cats are known, but reference intervals for diseased cats are lacking. aCTc of cats without evidence of adrenal disease (NAD group) were compared to parameters of cats with possible concurrent adrenal disease (PAD group). The PAD group was assessed for adrenal masses or other morphological deviations using the NAD group as reference. Associations of aCTc with patient variables were explored, and all results were compared with published aCTc of healthy cats. No incidental adrenal masses were identified in the PAD group (n = 92), and only few aCTc differed compared to the NAD group (n = 30). The NAD group showed similar associations of patient variables and aCTc as length (right: 11.5 ± 2.2 mm, left: 11.8 ± 1.7 mm), width (right: 6.4 ± 1.2 mm, left: 5.4 ± 0.8 mm), height (right: 4.5 ± 0.9 mm, left: 4.5 ± 0.8 mm), attenuation (right: 33.1 ± 5.0 Hounsfield units, left: 32.5 ± 5.3 Hounsfield units) and position, but markedly more mineralization (right: 10%, left: 13.3%) than reported in healthy cats. This study provides references of aCTc for diseased cats without evidence of adrenal disease. The result suggests that adrenal incidentalomas seem to be rare in cats.
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Affiliation(s)
- Stefanie Gaisbauer
- From the Department for Companion Animals and Horses, University Clinic for Small Animals (F.K.Z., C.R., E.L., S.G.), Platform Bioinformatics and Biostatistics (A.T.), the University of Veterinary Medicine Vienna, Vienna, Austria
| | - Florian Karl Zeugswetter
- From the Department for Companion Animals and Horses, University Clinic for Small Animals (F.K.Z., C.R., E.L., S.G.), Platform Bioinformatics and Biostatistics (A.T.), the University of Veterinary Medicine Vienna, Vienna, Austria
| | - Alexander Tichy
- From the Department for Companion Animals and Horses, University Clinic for Small Animals (F.K.Z., C.R., E.L., S.G.), Platform Bioinformatics and Biostatistics (A.T.), the University of Veterinary Medicine Vienna, Vienna, Austria
| | - Conor Rowan
- From the Department for Companion Animals and Horses, University Clinic for Small Animals (F.K.Z., C.R., E.L., S.G.), Platform Bioinformatics and Biostatistics (A.T.), the University of Veterinary Medicine Vienna, Vienna, Austria
| | - Eberhard Ludewig
- From the Department for Companion Animals and Horses, University Clinic for Small Animals (F.K.Z., C.R., E.L., S.G.), Platform Bioinformatics and Biostatistics (A.T.), the University of Veterinary Medicine Vienna, Vienna, Austria
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3
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Zekan D, King RS, Hajiran A, Patel A, Deem S, Luchey A. Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size. BMC Urol 2022; 22:73. [PMID: 35501776 PMCID: PMC9063092 DOI: 10.1186/s12894-022-01024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction/background Adrenal incidentalomas (AIs) are masses > 1 cm found incidentally during radiographic imaging. They are present in up to 4.4% of patients undergoing CT scan, and incidence is increasing with usage and sensitivity of cross-sectional imaging. Most result in diagnosis of adrenal cortical adenoma, questioning guidelines recommending removal of all AIs with negative functional workup. This retrospective study analyzes histological outcome based on size of non-functional adrenal masses. Material and methods 10 years of data was analyzed from two academic institutions. Exclusion criteria included patients with positive functional workups, those who underwent adrenalectomy during nephrectomy, < 18 years, and incomplete records. AI radiologic and histologic size, histologic outcome, laterality, imaging modality, gender, and age were collected. T-test was used for comparison of continuous variables, and the two-sided Fisher’s exact or chi-square test were used to determine differences for categorical variables. Univariate analysis of each independent variable was performed using simple logistic regression. Results 73 adrenalectomies met the above inclusion criteria. 60 were detected on CT scan, 12 on MRI, and one on ultrasound. Eight of 73 cases resulted in malignant pathology, 3 of which were adrenocortical carcinoma (ACC). Each ACC measured > 6 cm, with mean radiologic and pathologic sizes of 11.2 cm and 11.3 cm. Both radiologic and pathologic size were significant predictors of malignancy (p = 0.008 and 0.011). Conclusions Our results question the generally-accepted 4 cm cutoff for excision of metabolically-silent AIs. They suggest a 6 cm threshold would suffice to avoid removal of benign lesions while maintaining sensitivity for ACC.
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Affiliation(s)
- David Zekan
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, USA.
| | - Robert Scott King
- Department of Urology, Charleston Area Medical Center, 3100 MacCorkle Ave SE Suite 602, Charleston, WV, 25304, USA
| | - Ali Hajiran
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, USA
| | - Apexa Patel
- Health Education and Research Institute, Charleston Area Medical Center, 3110 MacCorkle Ave SE, Charleston, WV, 25304, USA
| | - Samuel Deem
- Department of Urology, Charleston Area Medical Center, 3100 MacCorkle Ave SE Suite 602, Charleston, WV, 25304, USA
| | - Adam Luchey
- Department of Urology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, 26505, USA
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Cystic adrenal masses: spectrum of multimodality imaging features and pathological correlation. Clin Radiol 2022; 77:479-488. [DOI: 10.1016/j.crad.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
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Viëtor CL, Creemers SG, van Kemenade FJ, van Ginhoven TM, Hofland LJ, Feelders RA. How to Differentiate Benign from Malignant Adrenocortical Tumors? Cancers (Basel) 2021; 13:cancers13174383. [PMID: 34503194 PMCID: PMC8431066 DOI: 10.3390/cancers13174383] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Adrenocortical carcinoma is a rare cancer with a poor prognosis. Adrenal tumors are, however, commonly identified in clinical practice. Discrimination between benign and malignant adrenal tumors is of great importance to determine the appropriate treatment and follow-up strategy. This review summarizes the current diagnostic strategies and challenges to distinguish benign from malignant adrenal lesions. We will focus both on radiological and biochemical assessments, enabling diagnosis of the adrenal lesion preoperatively, and on histopathological and a wide variety of molecular assessments that can be done after surgical removal of the adrenal lesion. Furthermore, new non-invasive strategies such as liquid biopsies, in which blood samples are used to study circulating tumor cells, tumor DNA and microRNA, will be addressed in this review. Abstract Adrenocortical carcinoma (ACC) is a rare cancer with a poor prognosis. Adrenal incidentalomas are, however, commonly identified in clinical practice. Discrimination between benign and malignant adrenal tumors is of great importance considering the large differences in clinical behavior requiring different strategies. Diagnosis of ACC starts with a thorough physical examination, biochemical evaluation, and imaging. Computed tomography is the first-level imaging modality in adrenal tumors, with tumor size and Hounsfield units being important features for determining malignancy. New developments include the use of urine metabolomics, also enabling discrimination of ACC from adenomas preoperatively. Postoperatively, the Weiss score is used for diagnosis of ACC, consisting of nine histopathological criteria. Due to known limitations as interobserver variability and lack of accuracy in borderline cases, much effort has been put into new tools to diagnose ACC. Novel developments vary from immunohistochemical markers and pathological scores, to markers at the level of DNA, methylome, chromosome, or microRNA. Molecular studies have provided insights into the most promising and most frequent alterations in ACC. The use of liquid biopsies for diagnosis of ACC is studied, although in a small number of patients, requiring further investigation. In this review, current diagnostic modalities and challenges in ACC will be addressed.
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Affiliation(s)
- Charlotte L. Viëtor
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, 3015GD Rotterdam, The Netherlands; (C.L.V.); (T.M.v.G.)
| | - Sara G. Creemers
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
| | - Folkert J. van Kemenade
- Department of Pathology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands;
| | - Tessa M. van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, 3015GD Rotterdam, The Netherlands; (C.L.V.); (T.M.v.G.)
| | - Leo J. Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
- Correspondence:
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Virtual Noncontrast Images From Portal Venous Phase Spectral-Detector CT Acquisitions for Adrenal Lesion Characterization. J Comput Assist Tomogr 2021; 45:24-28. [PMID: 32168080 DOI: 10.1097/rct.0000000000000982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to investigate if Hounsfield unit (HU) values from virtual noncontrast (VNC) images derived from portal venous phase spectral-detector computed tomography can help to differentiate adrenal adenomas and metastases. METHODS Spectral-detector computed tomography datasets of 33 patients with presence of adrenal lesions and standard of reference for lesion origin by follow-up/prior examinations or dedicated magnetic resonance imaging were included. Conventional and VNC images were reconstructed from the same scan. Region of interest-based image analysis was performed in adrenal lesions and contralateral healthy adrenal tissue. RESULTS The 33 lesions consisted of 23 adenomas and 10 metastases. Hounsfield unit values of all lesions in VNC images were significantly lower compared with conventional images (18.2 ± 12.6 HU vs 59.6 ± 21.7 HU, P < 0.001). Hounsfield unit values in adenomas were significantly lower in VNC images (11.3 ± 6.5 HU vs 34.1 ± 9.1 HU, P < 0.001). CONCLUSIONS Virtual noncontrast HU values differed significantly between adrenal adenomas and metastases and can therefore be used for improved characterization of incidental adrenal lesions and definition of adrenal adenomas.
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Reginelli A, Vacca G, Belfiore M, Sangiovanni A, Nardone V, Vanzulli A, Grassi R, Cappabianca S. Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review. Gland Surg 2021; 9:2331-2342. [PMID: 33447584 DOI: 10.21037/gs-20-559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.
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Affiliation(s)
- Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Giovanna Vacca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Mariapaola Belfiore
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, Naples, Italy
| | - Angelo Vanzulli
- Department of Radiology, University "La Statale" of Milan, Milan, Italy
| | - Roberto Grassi
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Naples, Italy
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Yalniz C, Morani AC, Waguespack SG, Elsayes KM. Imaging of Adrenal-Related Endocrine Disorders. Radiol Clin North Am 2020; 58:1099-1113. [PMID: 33040851 DOI: 10.1016/j.rcl.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endocrine disorders associated with adrenal pathologies can be caused by insufficient adrenal gland function or excess hormone secretion. Excess hormone secretion may result from adrenal hyperplasia or hormone-secreting (ie, functioning) adrenal masses. Based on the hormone type, functioning adrenal masses can be classified as cortisol-producing tumors, aldosterone producing tumors, and androgen-producing tumors, which originate in the adrenal cortex, as well as catecholamine-producing pheochromocytomas, which originate in the medulla. Nonfunctioning lesions can cause adrenal gland enlargement without causing hormonal imbalance. Evaluation of adrenal-related endocrine disorders requires clinical and biochemical workup associated with imaging evaluation to reach a diagnosis and guide management.
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Affiliation(s)
- Ceren Yalniz
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Ajaykumar C Morani
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
| | - Khaled M Elsayes
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA.
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9
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Elbanan MG, Javadi S, Ganeshan D, Habra MA, Rao Korivi B, Faria SC, Elsayes KM. Adrenal cortical adenoma: current update, imaging features, atypical findings, and mimics. Abdom Radiol (NY) 2020; 45:905-916. [PMID: 31529204 DOI: 10.1007/s00261-019-02215-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Adrenal adenoma is the most common adrenal lesion. Due to its wide prevalence, adrenal adenomas may demonstrate various imaging features. Thus, it is important to identify typical and atypical imaging features of adrenal adenomas and to be able to differentiate atypical adrenal adenomas from potentially malignant lesions. In this article, we will discuss the diagnostic approach, typical and atypical imaging features of adrenal adenomas, as well as other lesions that mimic adrenal adenomas.
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Affiliation(s)
- Mohamed G Elbanan
- Department of Diagnostic Radiology, Yale New Haven Health System, Bridgeport Hospital, Bridgeport, CT, USA
| | - Sanaz Javadi
- Departments of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Dhakshinamoorthy Ganeshan
- Departments of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Brinda Rao Korivi
- Departments of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Silvana C Faria
- Departments of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Khaled M Elsayes
- Departments of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA.
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Bhargava P, Sangster G, Haque K, Garrett J, Donato M, D'Agostino H. A Multimodality Review of Adrenal Tumors. Curr Probl Diagn Radiol 2019; 48:605-615. [DOI: 10.1067/j.cpradiol.2018.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 10/16/2018] [Indexed: 12/15/2022]
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Siraj M, Tolofari S, Yow L, Sinclair A, Javed S, Mukherjee R, Bell R, Lynch N, Counsell A, Pollard A, Lewis P, Adeyoju A. ‘Adrenal incidentalomas’; Rationalising assessment in the urology multi-disciplinary team meeting. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818808893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The combination of an aging population and the continual technological advances in modern imaging techniques have contributed to the increased detection of asymptomatic incidental lesions. The definition of an adrenal ‘incidentaloma’ is an asymptomatic lesion (⩾1 cm) detected on imaging following a suspected alternative primary diagnosis. The majority of these adrenal incidentalomas, may be benign and non-functioning, however, a proportion of these lesions may be either malignant or ‘hyperfunctioning’ (hormone-producing). As such, these incidental and asymptomatic lesions can provide the urologist with a diagnostic dilemma. In this article we aim to review the current literature with reference to common clinical scenarios often encountered as part of the urology multi-disciplinary team meeting. The overall aim is to rationalise and standardise an approach to these often challenging scenarios.
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Affiliation(s)
| | | | - Lina Yow
- Glan Clwyd District General Hospital, UK
| | | | - Saqib Javed
- Royal Liverpool and Broadgreen NHS Foundation Trust, UK
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Liu T, Sun H, Zhang H, Duan J, Hu Y, Xie S. Distinguishing adrenal adenomas from non-adenomas with multidetector CT: evaluation of percentage washout values at a short time delay triphasic enhanced CT. Br J Radiol 2018; 92:20180429. [PMID: 30433826 DOI: 10.1259/bjr.20180429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE: To retrospectively evaluate the diagnostic values of absolute percentage washout ratio (APW) and relative percentage washout ratio (RPW) obtained from a short time delay triphasic enhanced CT in distinguishing adenomas from non-adenomas. METHODS: The study population consisted of 116 patients (58 males and 58 females; mean age, 52 years; age range, 23-89 years) with 116 adrenal masses from 2010 to 2016. Absolute attenuation values in each phase of CT were measured, and then the APW and RPW were calculated. The APW and RPW receiver operating characteristic (ROC) analysis was performed to evaluate the strength of the tests. Sensitivity, specificity, and accuracy were calculated for APW and RPW. RESULTS: Significant differences were observed in APW and RPW values between the adenoma and non-adenoma groups (p < 0.001). Areas under the ROC curve were 0.822 (95% confidence interval: 0.730, 0.914) and 0.913 (95% confidence interval: 0.851, 0.975) for the APW and RPW tests, respectively. The RPW (≥30%) criterion showed the best accuracy (86%), with 85% sensitivity and 90% specificity, followed by the APW (≥32%) criterion, with 81% accuracy, 85% sensitivity, and 69% specificity. CONCLUSION: The APW and RPW values from a short time delay triphasic enhanced CT were efficient and helpful in differentiating adenomas from non-adenomas, and could provide comparable diagnostic results to the previous reported longer delayed dedicated adrenal CT protocols. ADVANCES IN KNOWLEDGE: The washout ratio from a short time delay triphasic enhanced CT could help in differentiating adenomas from non-adenomas without the dedicated adrenal CT.
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Affiliation(s)
- Tongxi Liu
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
| | - Hongliang Sun
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
| | - Haibo Zhang
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
| | - Jianghui Duan
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
| | - Yingying Hu
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
| | - Sheng Xie
- 1 Department of Radiology, China-Japan Friendship Hospital , Beijing , China
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Abstract
Cross-sectional spinal imaging is common, and extraspinal findings are often incidentally identified during interpretation. Although some of these findings may cause symptoms that mimic a spinal disorder, the majority are entirely asymptomatic and incidental. It is essential that the radiologist not only identify those abnormalities that may have clinical significance but also recognize those that are clinically irrelevant and thereby prevent patients from being subjected to further unnecessary, expensive and potentially harmful interventions. This article focuses on those abnormalities that are commonly encountered and provides practical guidance for follow-up and management based on current recommendations.
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Affiliation(s)
- Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 655 W. Baltimore St, Baltimore, MD 21201, USA.
| | - Jessica Record
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 655 W. Baltimore St, Baltimore, MD 21201, USA
| | - Lorenna Vidal
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 655 W. Baltimore St, Baltimore, MD 21201, USA
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Utility of Intermediate-Delay Washout CT Images for Differentiation of Malignant and Benign Adrenal Lesions: A Multivariate Analysis. AJR Am J Roentgenol 2018; 211:W109-W115. [PMID: 29949418 DOI: 10.2214/ajr.17.19103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The objective of this study was to identify features that impact the diagnostic performance of intermediate-delay washout CT for distinguishing malignant from benign adrenal lesions. MATERIALS AND METHODS This retrospective study evaluated 127 pathologically proven adrenal lesions (82 malignant, 45 benign) in 126 patients who had undergone portal venous phase and intermediate-delay washout CT (1-3 minutes after portal venous phase) with or without unenhanced images. Unenhanced images were available for 103 lesions. Quantitatively, lesion CT attenuation on unenhanced (UA) and delayed (DL) images, absolute and relative percentage of enhancement washout (APEW and RPEW, respectively), descriptive CT features (lesion size, margin characteristics, heterogeneity or homogeneity, fat, calcification), patient demographics, and medical history were evaluated for association with lesion status using multiple logistic regression with stepwise model selection. Area under the ROC curve (Az) was calculated from both univariate and multivariate analyses. The predictive diagnostic performance of multivariate evaluations was ascertained through cross-validation. RESULTS Az for DL, APEW, RPEW, and UA was 0.751, 0.795, 0.829, and 0.839, respectively. Multivariate analyses yielded the following significant CT quantitative features and associated Az when combined: RPEW and DL (Az = 0.861) when unenhanced images were not available and APEW and UA (Az = 0.889) when unenhanced images were available. Patient demographics and presence of a prior malignancy were additional significant factors, increasing Az to 0.903 and 0.927, respectively. The combined predictive classifier, without and with UA available, yielded 85.7% and 87.3% accuracies with cross-validation, respectively. CONCLUSION When appropriately combined with other CT features, washout derived from intermediate-delay CT with or without additional clinical data has potential utility in differentiating malignant from benign adrenal lesions.
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16
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Can Imaging Predict Subclinical Cortisol Secretion in Patients With Adrenal Adenomas? A CT Predictive Score. AJR Am J Roentgenol 2017; 209:122-129. [DOI: 10.2214/ajr.16.16965] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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17
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Behbahani S, Mittal S, Patlas MN, Moshiri M, Menias CO, Katz DS. "Incidentalomas" on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations. Abdom Radiol (NY) 2017; 42:1046-1061. [PMID: 27695953 DOI: 10.1007/s00261-016-0914-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on "incidentalomas" discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.
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Affiliation(s)
- Siavash Behbahani
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA.
| | - Sameer Mittal
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA
| | - Michael N Patlas
- Department of Radiology, Hamilton General Hospital, McMaster University, 237 Barton St., East Hamilton, ON, L8L 2X2, Canada
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Christine O Menias
- Department of Radiology, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY, 11501, USA
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18
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Sahdev A. Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists? Br J Radiol 2017; 90:20160627. [PMID: 28181818 PMCID: PMC5605062 DOI: 10.1259/bjr.20160627] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/29/2016] [Accepted: 02/07/2017] [Indexed: 12/29/2022] Open
Abstract
Adrenal incidentalomas are unsuspected, asymptomatic adrenal masses detected on imaging. Most are non-functioning benign adrenocortical adenomas but can represent other benign lesions or lesions requiring therapeutic intervention including adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis. This review summarizes and highlights radiological recommendations within the recently issued guidelines for the management of adrenal incidentalomas from the European Society of Endocrinology Clinical Practice in collaboration with the European Network for Study of Adrenal Tumours. Four pre-defined clinical questions were addressed in the guidelines and two have specific relevance and implications for radiologists: (1) how to assess risk of malignancy on imaging and (2) what follow-up is indicated if an adrenal incidentaloma is not surgically removed? The guidelines also include recommendations for frequently encountered special circumstances, including bilateral incidentalomas, incidentalomas in patients with extra-adrenal malignancy and in the young and elderly patients. This review highlights radiological recommendations within the guidelines and evidence used for formulating the guidelines.
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Affiliation(s)
- Anju Sahdev
- Department of Imaging, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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19
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Connolly MJ, McInnes MDF, El-Khodary M, McGrath TA, Schieda N. Diagnostic accuracy of virtual non-contrast enhanced dual-energy CT for diagnosis of adrenal adenoma: A systematic review and meta-analysis. Eur Radiol 2017; 27:4324-4335. [PMID: 28289937 DOI: 10.1007/s00330-017-4785-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 01/17/2017] [Accepted: 02/16/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To compare the diagnostic accuracy of dual-energy (DE) virtual non-contrast computed tomography (vNCT) to non-contrast CT (NCT) for the diagnosis of adrenal adenomas. METHODS Search of multiple databases and grey literature was performed. Two reviewers independently applied inclusion criteria and extracted data. Risk of bias was assessed using QUADAS-2. Summary estimates of diagnostic accuracy were generated and sources of heterogeneity were assessed. RESULTS Five studies (170 patients; 192 adrenal masses) were included for diagnostic accuracy assessment; all used dual-source dual-energy CT. Pooled sensitivity for adrenal adenoma on vNCT was 54% (95% CI: 47-62%). Pooled sensitivity for NCT was 57% (95% CI: 45-69%). Pooling of specificity was not performed since no false positives were reported. There was a trend for overestimation of HU density on vNCT as compared to NCT which appeared related to contrast timing. Potential sources of bias were seen regarding the index test and reference standard for the included studies. Potential sources of heterogeneity between studies were seen in adenoma prevalence and intravenous contrast timing. CONCLUSIONS vNCT images generated from dual-energy CT demonstrated comparable sensitivity to NCT for the diagnosis of adenomas; however the included studies are heterogeneous and at high risk for some types of bias. KEY POINTS • Similar sensitivity of vNCT to NCT for diagnosis of adenoma • Heterogeneity could be related to vNCT from early (<=60 sec) CECT studies • Could not pool specificity as there were no false positives • Small number of heterogeneous studies at high risk of bias.
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Affiliation(s)
- Michael J Connolly
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Department of Radiology, Room c159 Ottawa Hospital Civic Campus, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, USA
| | - Matthew D F McInnes
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Department of Radiology, Room c159 Ottawa Hospital Civic Campus, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, USA.
| | | | - Trevor A McGrath
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicola Schieda
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa Department of Radiology, Room c159 Ottawa Hospital Civic Campus, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, USA
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20
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Ananthakrishnan L, Rajiah P, Ahn R, Rassouli N, Xi Y, Soesbe TC, Lewis MA, Lenkinski RE, Leyendecker JR, Abbara S. Spectral detector CT-derived virtual non-contrast images: comparison of attenuation values with unenhanced CT. Abdom Radiol (NY) 2017; 42:702-709. [PMID: 28084546 DOI: 10.1007/s00261-016-1036-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To assess virtual non-contrast (VNC) images obtained on a detection-based spectral detector CT scanner and determine how attenuation on VNC images derived from various phases of enhanced CT compare to those obtained from true unenhanced images. METHODS In this HIPAA compliant, IRB approved prospective multi-institutional study, 46 patients underwent pre- and post-contrast imaging on a prototype dual-layer spectral detector CT between October 2013 and November 2015, yielding 84 unenhanced and VNC pairs (25 arterial, 39 portal venous/nephrographic, 20 urographic). Mean attenuation was measured by one of three readers in the liver, spleen, kidneys, psoas muscle, abdominal aorta, and subcutaneous fat. Equivalence testing was used to determine if the mean difference between unenhanced and VNC attenuation was less than 5, 10, or 15 HU. VNC image quality was assessed on a 5 point scale. RESULTS Mean difference between unenhanced and VNC attenuation was <15 HU in 92.6%, <10 HU in 75.2%, and <5 HU in 44.4% of all measurements. Unenhanced and VNC attenuation were equivalent in all tissues except fat using a threshold of <10 HU difference (p < 0.05). No significant variation was seen between phases. In fat, VNC overestimated the HU relative to unenhanced images. VNC image quality was rated as excellent or good in 84% of arterial phase and 85% of nephrographic phase cases, but only 40% of urographic phase. CONCLUSION VNC images derived from novel dual layer spectral detector CT demonstrate attenuation values similar to unenhanced images in all tissues evaluated except for subcutaneous fat. Further study is needed to determine if attenuation thresholds currently used clinically for common pathology should be adjusted, particularly for lesions containing fat.
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21
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Wale DJ, Wong KK, Viglianti BL, Rubello D, Gross MD. Contemporary imaging of incidentally discovered adrenal masses. Biomed Pharmacother 2017; 87:256-262. [PMID: 28063406 DOI: 10.1016/j.biopha.2016.12.090] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/08/2016] [Accepted: 12/22/2016] [Indexed: 12/11/2022] Open
Abstract
Adrenal lesions are routinely encountered incidentally in clinical practice. Although most of these lesions are benign, malignancy needs to be excluded. Therefore, the initial clinical workup is to exclude aggressive characteristics suggesting malignancy and to identify characteristics predictive of the most common benign lesion, an adrenal adenoma. Predicting a benign adenoma using a variety of imaging modalities has been widely studied using unenhanced computed tomography (CT), contrast enhanced CT, and magnetic resonance (MR) imaging. This review article describes the currently used imaging protocols and clinical interpretation criteria of common adrenal lesions. An adenoma can be predicted if a homogenous soft tissue adrenal mass demonstrates low attenuation (upper threshold value of 10 Hounsfield Units) on unenhanced CT, demonstrates an absolute enhancement washout of ≥ 60% and/or relative enhancement washout of ≥ 40% on adrenal washout contrast enhanced CT, or demonstrates signal loss in opposed-phased MR imaging. If an adrenal adenoma cannot be predicted based upon these criteria, the lesion should be evaluated for other imaging characteristics that suggest a specific pathology, such as an adrenal cyst or myelolipoma. Although nonspecific and with limitations, 18F-fluorodeoxyglucose (FDG) PET/CT has a potential role for differentiating benign from malignant lesions based upon the amount of radiopharmaceutical uptake with malignant lesions generally having greater uptake. If clinical and/or hormonal screening suggests a pheochromocytoma, consideration can be given to 18F-dihydroxyphenylalanine (DOPA) or 123I-metaiodobenzylguanidine (MIBG) in addition to CT and MR. Finally, this review proposes a diagnostic work-up strategy for routine use in clinical practice.
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Affiliation(s)
- Daniel J Wale
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI 48109, USA; Department of Nuclear Medicine, Department of Veterans Affairs Health System, Ann Arbor, MI 48105, USA.
| | - Ka Kit Wong
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI 48109, USA
| | - Benjamin L Viglianti
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI 48109, USA; Department of Nuclear Medicine, Department of Veterans Affairs Health System, Ann Arbor, MI 48105, USA
| | - Domenico Rubello
- Radiology, Medical Physics, Santa Maria della Misericordia Hospital, 45100 Rovigo, Italy
| | - Milton D Gross
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI 48109, USA; Department of Nuclear Medicine, Department of Veterans Affairs Health System, Ann Arbor, MI 48105, USA
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22
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Dual-Energy CT of Incidental Findings in the Abdomen: Can We Reduce the Need for Follow-Up Imaging? AJR Am J Roentgenol 2016; 207:W58-W68. [DOI: 10.2214/ajr.16.16087] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Baltzer P, Clauser P, Klatte T, Walz J. Work-up of the Incidental Adrenal Mass. Eur Urol Focus 2015; 1:217-222. [PMID: 28723390 DOI: 10.1016/j.euf.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/07/2015] [Indexed: 12/26/2022]
Abstract
CONTEXT Incidental adrenal masses (or adrenal incidentalomas [AI]) are a common finding during imaging and are present in up to 5% of the computed tomography (CT) scans performed on the general population. The best way to manage these lesions is still under discussion. OBJECTIVE To evaluate recent literature and available guidelines regarding the work-up of AIs. EVIDENCE ACQUISITION We used a medical search engine to identify studies published in the past 5 yr regarding AIs. We also evaluated current guidelines and the most relevant papers published before 2010. EVIDENCE SYNTHESIS Unenhanced and contrast-enhanced CT, with laboratory tests to exclude functional lesions, are the most sensitive and specific methods currently available for the characterisation of adrenal masses. Magnetic resonance imaging, positron emission tomography-CT and fine-needle aspiration biopsy can be used as adjunct diagnostic tools in indeterminate lesions but are rarely indicated. In a relatively high number of indeterminate nodules, follow-up or surgery is suggested, although most of these lesions turn out to be benign. CONCLUSIONS Various imaging modalities, with CT being most important, are available to diagnose malignant and functional lesions in AIs. An improved identification of benign lesions is warranted to reduce the number of unnecessary surgeries and follow-up examinations in patients with benign lesions. PATIENT SUMMARY We performed a review of the literature on and guidelines for the management of incidental adrenal masses. It is possible to detect the presence of lesions that require surgery in the majority of cases. Follow-up is required for lesions that are not treated surgically.
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Affiliation(s)
- Pascal Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Paola Clauser
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Klatte
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Jochen Walz
- Institut Paoli-Calmettes, Service de chirurgie urologique, Marseille, France
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Mariño MA. Incidentalomas: concept, relevance and challenges for medical practice. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2015. [DOI: 10.5712/rbmfc10(35)1053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Incidentaloma (which has not been included as a MeSH term neither in other medical databases or Bioportal) is a neologism used to describe an incidentally discovered mass (or abnormality) in asymptomatic persons. Incidentaloma, or incidental finding, is extremely common now and in most cases harmless, but sometimes it is not possible to exclude the possibility of real damage and in very few cases, some people can get benefit from its discovery. Therefore, most of incidentalomas represent overdiagnosis originated by the massive use of high-resolution diagnostic procedures. In many cases, incidentaloma causes anxiety, consume time and resources, and can even cause further damage to patients’ health as a result of procedures performed in the post-finding follow-up. Thus, it is important to recognize the problem to try to avoid it if possible, and learn strategies to deal with it once we stumbled upon an incidentaloma.
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Herr K, Muglia VF, Koff WJ, Westphalen AC. Imaging of the adrenal gland lesions. Radiol Bras 2015; 47:228-39. [PMID: 25741090 PMCID: PMC4337123 DOI: 10.1590/0100-3984.2013.1762] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 10/03/2013] [Indexed: 12/21/2022] Open
Abstract
With the steep increase in the use of cross-sectional imaging in recent years, the
incidentally detected adrenal lesion, or "incidentaloma", has become an increasingly
common diagnostic problem for the radiologist, and a need for an approach to
classifying these lesions as benign, malignant or indeterminate with imaging has
spurred an explosion of research. While most incidentalomas represent benign disease,
typically an adenoma, the possibility of malignant involvement of the adrenal gland
necessitates a reliance on imaging to inform management decisions. In this article,
we review the literature on adrenal gland imaging, with particular emphasis on
computed tomography, magnetic resonance imaging, and photon-emission tomography, and
discuss how these findings relate to clinical practice. Emerging technologies, such
as contrast-enhanced ultrasonography, dual-energy computed tomography, and magnetic
resonance spectroscopic imaging will also be briefly addressed.
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Affiliation(s)
- Keith Herr
- MD, Assistant Professor, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Valdair F Muglia
- MD, Habiliation, Associate Professor, Department of Internal Medicine - Radiology, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil
| | - Walter José Koff
- MD, Habilitation, Full Professor, Department of Surgery - Urology, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Antonio Carlos Westphalen
- MD, PhD, Associate Professor, Departments of Radiology and Biomedical Imaging and Urology, School of Medicine, University of California, San Francisco, CA, USA
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26
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Willatt J, Chong S, Ruma JA, Kuriakose J. Incidental Adrenal Nodules and Masses: The Imaging Approach. Int J Endocrinol 2015; 2015:410185. [PMID: 26064109 PMCID: PMC4429195 DOI: 10.1155/2015/410185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/12/2015] [Indexed: 12/21/2022] Open
Abstract
Adrenal nodules are detected with increasing frequency. The National Institute of Health (NIH), American College of Radiology (ACR), and the American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons (AACE/AAES) have produced guidelines for the management of incidental adrenal nodules. This review provides a summary of the consensus radiologic approach to these nodules.
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Affiliation(s)
- J. Willatt
- University of Michigan Health System, Ann Arbor, MI 48109, USA
- Veterans Administration Hospital, Ann Arbor, MI 48105, USA
- *J. Willatt:
| | - S. Chong
- University of Michigan Health System, Ann Arbor, MI 48109, USA
- Veterans Administration Hospital, Ann Arbor, MI 48105, USA
| | - J. A. Ruma
- University of Michigan Health System, Ann Arbor, MI 48109, USA
- Veterans Administration Hospital, Ann Arbor, MI 48105, USA
| | - J. Kuriakose
- University of Michigan Health System, Ann Arbor, MI 48109, USA
- Veterans Administration Hospital, Ann Arbor, MI 48105, USA
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Ravenel JG, Rosenzweig KE, Kirsch J, Ginsburg ME, Kanne JP, Kestin LL, Parker JA, Rimner A, Saleh AG, Mohammed TLH. ACR Appropriateness Criteria Non-invasive Clinical Staging of Bronchogenic Carcinoma. J Am Coll Radiol 2014; 11:849-56. [DOI: 10.1016/j.jacr.2014.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 05/28/2014] [Indexed: 11/15/2022]
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Abstract
Incidental adrenal neoplasms are usually nonfunctioning benign adenomas. Once hormonal production has been assessed, the nonsecreting lesions must be evaluated for the possibility of malignancy. This evaluation relies primarily on the radiographic characteristics. This article focuses on the current state of radiologic technology available to accurately assess nonfunctioning adrenal incidentalomas. As this technology advances, a lesion's malignant potential can more accurately be determined, thereby allowing physicians to make more informed treatment recommendations.
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Affiliation(s)
- Peter J Mazzaglia
- Department of General Surgery, The Warren Alpert School of Medicine, Brown University, 593 Eddy Street, APC 4, Providence, RI 02905, USA.
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29
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Wickramarachchi BN, Meyer-Rochow GY, McAnulty K, Conaglen JV, Elston MS. Adherence to adrenal incidentaloma guidelines is influenced by radiology report recommendations. ANZ J Surg 2014; 86:483-6. [PMID: 25060597 DOI: 10.1111/ans.12799] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Approximately 5% of all abdominal computed tomography (CT) and magnetic resonance imaging (MRI) scans reveal an adrenal incidentaloma. Although most adrenal incidentalomas are benign non-functioning adenomas, lesions may be hormonally active and/or malignant. The aim of this study was to determine adherence to recommended international guidelines and potential influencing factors when an adrenal incidentaloma is identified in routine clinical practice. METHODS A retrospective study was performed of all CT and MRI reports from December 2009 to December 2011 using a key phrase search to identify patients with an incidental adrenal lesion. RESULTS A total of 125 patients with incidental adrenal lesions were identified, of which 74 patients were considered appropriate for further endocrine/radiological workup. Of the 74 patients, only 19 (26%) were initially referred to the endocrine service for investigation; 21/74 (28%) had complete biochemical workup and 24/74 (32%) had imaging follow-up arranged. The reporting radiologist provided advice for follow-up in 31/74 (42%), and action was more likely to be taken when this recommendation was given. Follow-up of the patients who had not received investigation was attempted resulting in assessment of a further 23 patients. Of the 44 patients who have undergone full assessment, four patients were found to have clinically significant lesions (one each of: Cushing's syndrome, phaeochromocytoma, Conn's syndrome and plasmacytoma). CONCLUSION This study suggests that the majority of adrenal incidentalomas may not be investigated according to current international guidelines. The recommendations by the reporting radiologist appear to influence whether a patient is referred for further investigation.
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Affiliation(s)
| | - Goswin Y Meyer-Rochow
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand.,Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Kim McAnulty
- Department of Radiology, Waikato Hospital, Hamilton, New Zealand
| | - John V Conaglen
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Marianne S Elston
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand.,Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
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30
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Tang Y, Bharwani N, Micco M, Akker S, Rockall A, Sahdev A. The prevalence of incidentally detected adrenal enlargement on CT. Clin Radiol 2014; 69:e37-42. [DOI: 10.1016/j.crad.2013.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/13/2013] [Accepted: 08/27/2013] [Indexed: 11/16/2022]
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Guerrisi A, Marin D, Baski M, Guerrisi P, Capozza F, Catalano C. Adrenal lesions: spectrum of imaging findings with emphasis on multi-detector computed tomography and magnetic resonance imaging. J Clin Imaging Sci 2013; 3:61. [PMID: 24605256 PMCID: PMC3935261 DOI: 10.4103/2156-7514.124088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 10/28/2013] [Indexed: 11/04/2022] Open
Abstract
The adrenal gland is a common site of a large spectrum of abnormalities like primary tumors, hemorrhage, metastases, and enlargement of the gland from external hormonal stimulation. Most of these lesions represent nonfunctioning adrenal adenomas and thus warrant a conservative management. Multi-detector computed tomography (CT) and magnetic resonance (MR) imaging are still considered highly specific and complementary techniques for the detection and characterization of adrenal abnormalities. Radiologist can establish a definitive diagnosis for most adrenal masses (i.e., carcinoma, hemorrhage) based on imaging alone. Imaging therefore can differentiate malignant lesions from those benign and avoid unnecessary aggressive management of benign lesions. The article gives an overview of the adrenal lesions and their imaging characteristics seen on CT and MR imaging.
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Affiliation(s)
- Antonino Guerrisi
- Department of Radiological Sciences, University of Rome "La Sapienza", Viale Regina Elena 324, Rome, 00161, Italy
| | - Daniele Marin
- Department of Radiology, Duke University Medical Center, Duke North-Room 1417, Erwin Road, Durham, NC 27710, USA
| | - Mahbubeh Baski
- Department of Radiological Sciences, University of Rome "La Sapienza", Viale Regina Elena 324, Rome, 00161, Italy
| | - Pietro Guerrisi
- Department of Radiological Sciences, University of Rome "La Sapienza", Viale Regina Elena 324, Rome, 00161, Italy
| | - Federica Capozza
- Department of Radiological Sciences, University of Rome "La Sapienza", Viale Regina Elena 324, Rome, 00161, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, University of Rome "La Sapienza", Viale Regina Elena 324, Rome, 00161, Italy
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Abstract
Endocrine tumors are hormonally active benign or malignant neoplasms arising within endocrine organs or from specialized cells of the amine precursor uptake and decarboxylation system. The detection rate of these tumors is increasing as a result of sensitive biochemical tests and high-resolution diagnostic imaging. Medical imaging has become a key component in the diagnosis and staging of endocrine malignancies; however, despite the impressive advances in computed tomography (CT) and MRI, detection of small primary tumors and metastases continues to be a challenge. Functional imaging techniques use radiopharmaceuticals targeted at unique tumor cellular processes in order to provide sensitive and highly specific whole-body imaging. Functional imaging allows prediction of the efficacy of radionuclide or receptor-based therapies and surveillance after therapy. Advances in imaging have not been limited to radiopharmaceuticals. Hybrid scanner technology in the form of PET/CT and single photon emission computed tomography (SPECT)/CT, designed to combine functional images with anatomic maps, has further improved the diagnostic accuracy. High-resolution hybrid imaging when deployed with novel PET and SPECT radiopharmaceuticals has the potential to dramatically change, individualize, and optimize imaging plans based on the histological grade, degree of differentiation, and genetic profile of each patient's endocrine neoplasm.
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MDCT in the differentiation of adrenal masses: comparison between different scan delays for the evaluation of intralesional washout. ScientificWorldJournal 2013; 2013:957680. [PMID: 23533368 PMCID: PMC3606796 DOI: 10.1155/2013/957680] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 02/15/2013] [Indexed: 11/17/2022] Open
Abstract
Purpose. To evaluate the accuracy of the washout in the differential diagnosis between adenomas and nonadenomas and to compare the obtained results in delayed CT scans at 5, 10 and 15 minutes. Methods. Fifty patients with adrenal masses were prospectively evaluated. CT scans were performed by using a 320-row MDCT device, before and after injection of contrast material. In 25 cases, delayed scans were performed at 5′ and 10′ (group 1), while in the remaining 25, at 5′ and 15′ (group 2). Absolute and relative wash-out percentage values (APW and RPW) were calculated. Results. Differential diagnosis between adenomas and nonadenomas was obtained in 48/50 (96%) cases, with sensitivity, specificity, and accuracy values of 96%, 95%, and 96%, respectively. In group 1, APW and RPW values were, respectively, 69.8% and 67.2% at 5′ and 75.9% and 73.5% at 10′ for adenomas and 25.1% and 15.8% at 5′ and 33.5% and 20.5% at 10′ for nonadenomas. In group 2, APW and RPW values were 63% and 54.6% at 5′ and 73.8% and 65.5% at 15′ for adenomas and 22% and 12.5% at 5′ and 35.5% and 19.9% at 15′ for nonadenomas. Conclusions. The evaluation of the wash-out values in CT scans performed at 5′, 10′, and 15′ provides comparable diagnostic results. CT scans performed at 5′ are, therefore, to be preferred, since they reduce the examination time and patient discomfort.
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Ojili V, Tirumani SH, Chintapalli KN, Gunabushanam G. Non-Invasive Diagnosis of Abdomino-Pelvic Masses: Role of Multimodality Imaging. J Clin Imaging Sci 2013; 3:6. [PMID: 23607075 PMCID: PMC3625888 DOI: 10.4103/2156-7514.106621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 12/18/2012] [Indexed: 11/04/2022] Open
Abstract
Recent advances in radiology have greatly increased the ability to make highly accurate diagnosis. Biopsy of many commonly seen lesions is no longer performed as the radiological findings are pathognomonic. This gives rise to the concept of ‘virtual biopsy’, a term coined on the lines of other imaging techniques such as virtual colonoscopy. Virtual biopsy is not a new imaging technique but a new concept which refers to the use of existing imaging modalities to evaluate the morphological features of tumors and arriving at a non-invasive diagnosis with a high degree of confidence obviating the need for true biopsy. Elements of virtual biopsy have already been incorporated into some evidence-based guidelines, and it is expected that with further technological advancements, an increasing number of tumors may be diagnosed and managed accordingly. A wider acceptance of virtual biopsy could further reduce the need for invasive biopsies and its attendant costs and risks. In this review article, we use index cases to further emphasize this concept.
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Affiliation(s)
- Vijayanadh Ojili
- Department of Radiology, University of Texas Health Sciences Centre at San Antonio, San Antonio, TX 78229, USA
| | - Sree Harsha Tirumani
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Kedar N. Chintapalli
- Department of Radiology, University of Texas Health Sciences Centre at San Antonio, San Antonio, TX 78229, USA
| | - Gowthaman Gunabushanam
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut, 06520-8042, USA
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36
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Taffel M, Haji-Momenian S, Nikolaidis P, Miller FH. Adrenal imaging: a comprehensive review. Radiol Clin North Am 2012; 50:219-43, v. [PMID: 22498440 DOI: 10.1016/j.rcl.2012.02.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The discovery of an incidental adrenal mass (adrenal incidentaloma) continues to rise with the increasing use of cross-sectional imaging. Although most adrenal lesions are benign and asymptomatic, radiologists should guide evaluation of these lesions, whether benign or malignant. This article reviews the various imaging techniques used to evaluate adrenal masses and their relative strengths and weaknesses. It focuses on the most prevalent adrenal pathologies and their typical imaging characteristics, and concludes with a brief discussion of developing techniques, including diffusion-weighted imaging and dual-energy CT.
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Affiliation(s)
- Myles Taffel
- Department of Radiology, George Washington University Medical Center, Washington, DC, USA.
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Kapoor A, Morris T, Rebello R. Guidelines for the management of the incidentally discovered adrenal mass. Can Urol Assoc J 2011; 5:241-7. [PMID: 21801680 DOI: 10.5489/cuaj.11135] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Anil Kapoor
- Division of Urology, Department of Surgery, McMaster University, Hamilton, ON
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Wong KK, Arabi M, Bou-Assaly W, Marzola MC, Rubello D, Gross MD. Evaluation of incidentally discovered adrenal masses with PET and PET/CT. Eur J Radiol 2011; 81:441-50. [PMID: 21295930 DOI: 10.1016/j.ejrad.2010.12.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/23/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Incidentally discovered adrenal masses are commonly seen with high resolution diagnostic imaging performed for indications other than adrenal disease. Although the majority of these masses are benign and non-secretory, their unexpected discovery prompts further biochemical and often repeated imaging evaluations, sufficient to identify hormonally active adrenal masses and/or primary or metastatic neoplasms to the adrenal(s). In the present paper we investigate the role of PET and PET/CT for the detection of adrenal incidentalomas in comparison with CT and MRI. MATERIALS AND METHODS a systematic revision of the papers published in PubMed/Medline until September 2010 was done. RESULTS The diagnostic imaging approach to incidentally discovered adrenal masses includes computed tomography (CT), magnetic resonance imaging (MRI) and more recently positron emission tomography (PET) with radiopharmaceuticals designed to exploit mechanisms of cellular metabolism, adrenal substrate precursor uptake, or receptor binding. CONCLUSION The functional maps created by PET imaging agents and the anatomic information provided by near-simultaneously acquired, co-registered CT facilitates localization and diagnosis of adrenal dysfunction, distinguishes unilateral from bilateral disease, and aids in characterizing malignant primary and metastatic adrenal disease.
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Affiliation(s)
- Ka Kit Wong
- Department of Nuclear Medicine, Veterans Affairs Hospital, and University of Michigan Health System, Department of Radiology, Division of Nuclear Medicine, Ann Arbor, MI 48105, USA.
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ACR Appropriateness Criteria® Noninvasive Clinical Staging of Bronchogenic Carcinoma. J Thorac Imaging 2010; 25:W107-11. [PMID: 21042062 DOI: 10.1097/rti.0b013e3181f51e7f] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, Brink JA, Baker ME, Federle MP, Foley WD, Francis IR, Herts BR, Israel GM, Krinsky G, Platt JF, Shuman WP, Taylor AJ. Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010; 7:754-73. [DOI: 10.1016/j.jacr.2010.06.013] [Citation(s) in RCA: 512] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 06/07/2010] [Indexed: 02/06/2023]
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Abstract
OBJECTIVE Differentiating neoplastic from nonneoplastic bone marrow changes on imaging can be challenging. MRI provides the most helpful information when using T1-weighted and opposed-phase (chemical shift) sequences. We discuss the MRI assessment of bone marrow in the context of a complex clinical case. CONCLUSION The case shows a false-positive result of opposed-phase imaging of bone marrow, which was a postinflammatory cause resulting in marrow fibrosis that mimicked neoplastic marrow infiltration and necessitated biopsy for definitive diagnosis.
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The incidental indeterminate adrenal mass on CT (> 10 H) in patients without cancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. AJR Am J Roentgenol 2007; 189:1119-23. [PMID: 17954649 DOI: 10.2214/ajr.07.2167] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to determine whether follow-up imaging evaluation is necessary for incidentally discovered indeterminate adrenal lesions (> 10 H) on CT in patients with no known malignancy. MATERIALS AND METHODS A computer search of CT reports from January 2000 to December 2003 identified patients with incidentally detected, indeterminate, but benign-appearing adrenal lesions who had no known malignancy and no clinical suspicion of hyperfunctioning adrenal mass. Patients with adrenal masses diagnostic on the initial CT or heterogeneous masses were excluded. Two hundred ninety patients with 321 lesions met the study criteria. Each lesion was determined to be benign or malignant based on histopathology, characterization with diagnostic imaging studies, or a minimum of 1 year of stability on imaging follow-up or 2 years of stability on clinical follow-up. RESULTS Of the 321 lesions, 318 masses (99.1%) were confirmed to be benign and clinically insignificant. These included three (0.9%) histologically confirmed adenomas, 198 (61.7%) adenomas by imaging characterization, five (1.6%) other benign lesions, 71 (22.1%) masses stable on imaging follow-up, and 41 (12.8%) masses with clinical stability. There were three (0.9%) clinically unsuspected functioning masses: one cortisol-producing adenoma and two pheochromocytomas. There were no metastatic adrenal lesions, even among the 13 patients who subsequently developed malignancy elsewhere. CONCLUSION All of the incidentally detected adrenal masses with a CT attenuation of > 10 H were benign in patients with no known malignancy. Follow-up imaging to characterize an incidental adrenal mass appears to have a limited role in this patient cohort.
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