Needle biopsy of incidentally discovered adrenal masses is rarely informative and potentially hazardous

Cinematic rendering of primary adrenal lymphoma

Primary adrenal lymphoma (PAL) is a particularly rare subset of malignant adrenal neoplasms, accounting for ∼1% of all non-Hodgkin's lymphomas. Reported outcomes of PAL, though limited, are dismal, with a 12-month survival rate of ∼20%. PAL is treated with polychemotherapy and early tissue diagnosis to allow initiation of chemotherapy is associated with improved outcomes. Early and accurate radiological diagnosis of PAL is therefore essential in improving outcomes through informing decisions to biopsy and thereby facilitating timely initiation of chemotherapy. To date, however, imaging features of PAL have not been conclusively defined, and a range of divergent imaging appearances have been reported. Cinematic rendering (CR) is a 3D post-processing technique that simulates the propagation and interaction of photons as they pass through the imaged volume. This results in the generation of more photorealistic images that may allow for more comprehensive visualization, description and interpretation of anatomical structures. This manuscript presents the first characterization of the various CR appearances of PAL in the reported literature and provides commentary on the clinical opportunities afforded by CR in the workup of these heterogenous tumors.

Clinical Progression of a Paraganglioma Over Many Years in a Man With Congenital Heart Disease

Background

Documented symptomatic progression of a paraganglioma (PGL) over many years is unusual. Our objective is to report a young man with such an occurrence.

Case Report

A 27-year-old male presented with headache, sweating, and palpitation. He had a history of cyanotic congenital heart disease. Five years before presentation, he had 24-hour urine metanephrines 43 mcg/d (25-222), vanillylmandelic acid 3 mg/d (<6), and homovanillic acid 2.4 mg/d (1.6-7.5) levels and a 3.13 cm mass in the upper aortocaval space. Subsequent imaging showed slow growth of the mass. On admission, his blood pressure was 197/134 mm Hg, heart rate was 163 beats per minute, respiratory rate was 25 per minute, and oxygen saturation was 76% on room air. His 24-hour urine normetanephrine level was 2644 mcg/d (81-667) while metanephrine was 405 mcg/d (55-320). Plasma free metanephrine level was 0.92 nmol/L (0-0.49) and normetanephrine was 11.85 nmol/L (0-0.89). DOTATATE positron emission tomography-computed tomography revealed a 4.3 × 3.1 × 4.9 cm mass with activity in the right upper aortocaval space. He was treated with Prazosin. Two months later, he underwent resection of the mass. Pathology diagnosed a 4.9 cm PGL. He had improvement in metanephrine levels.

Discussion

PGL is diagnosed by documenting excess catecholamines and identifying a lesion on imaging. False negative laboratory testing is rare but can occur. Patients with cyanotic congenital heart disease have a greater risk of developing PGL.

Conclusion

It is crucial to evaluate a patient for PGL if clinical conditions suggest catecholamine excess, especially if a retroperitoneal tumor has grown or the patient has risk factors.

Approach to Fine Needle Aspiration of Adrenal Gland Lesions

Adrenal gland lesions are present in 1% to 5% of patients and are most commonly identified incidentally on abdominal imaging. Fine needle aspiration (FNA) cytology plays an important role in the initial workup of adrenal gland nodules, especially in patients with a known history of malignancy. The most common reason for adrenal gland FNA is to differentiate benign adrenal lesions, such as adrenal cortical adenoma, from metastatic malignancy. However, there is a significant cytomorphologic overlap between primary and metastatic adrenal neoplasms. This review focuses on the current state of adrenal gland FNA cytology, with an emphasis on distinguishing adrenocortical adenoma from carcinoma and adrenal cortical neoplasms from metastatic malignancies. The role of immunohistochemistry in specifically diagnosing adrenal neoplasms is discussed. Proposed diagnostic classification systems for adrenal gland FNA cytology are also described.

Presentation, Management, and Outcomes of Urinary Bladder Paraganglioma: Results From a Multicenter Study

CONTEXT

Urinary bladder paraganglioma (UBPGL) is rare.

OBJECTIVE

We aimed to characterize the presentation and outcomes of patients diagnosed with UBPGL.

METHODS

We conducted a multicenter study of consecutive patients with pathologically confirmed UBPGL evaluated between 1971 and 2021. Outcomes included repeat bladder surgery, metastases, and disease-specific mortality.

RESULTS

Patients (n=110 total; n=56 [51%] women) were diagnosed with UBPGL at a median age of 50 years (interquartile range [IQR], 36-61 years). Median tumor size was 2 cm (IQR, 1-4 cm). UBPGL was diagnosed prior to biopsy in only 37 (34%), and only 69 (63%) patients had evaluation for catecholamine excess. In addition to the initial bladder surgery, 26 (25%) required multiple therapies, including repeat surgery in 10 (9%). Synchronous metastases were present in 9 (8%) patients, and 24 (22%) other patients with UBPGL developed metachronous metastases at a median of 4 years (IQR, 2-10 years) after the initial diagnosis. Development of metachronous metastases was associated with younger age (hazard ratio [HR] 0.97; 95% CI, 0.94-0.99), UBPGL size (HR 1.69; 95% CI, 1.31-2.17), and a higher degree of catecholamine excess (HR 5.48; 95% CI, 1.40-21.39). Disease-specific mortality was higher in patients with synchronous metastases (HR 20.80; 95% CI, 1.30-332.91). Choice of initial surgery, genetic association, sex, or presence of muscular involvement on pathology were not associated with development of metastases or mortality.

CONCLUSIONS

Only a minority of patients were diagnosed before biopsy/surgery, reflecting need for better diagnostic strategies. All patients with UBPGL should have lifelong monitoring for development of recurrence and metastases.

Efficacy of PET-CT in the prediction of metastatic adrenal masses that are detected on follow-up of the patients with prior nonadrenal malignancy: A nationwide multicenter case-control study

Metastasis is the second most common type of adrenal gland mass. In patients undergoing follow-up for nonadrenal malignancy, adrenalectomy is performed when metastasis to adrenal gland is suspected on the basis of positron emission tomography-computed tomography (PET-CT) imaging. This study investigated the efficacy of PET-CT in the discrimination of metastatic lesions from nonmetastatic lesions in the adrenal glands. In this multicentric study, data was collected from enrolled centers. Forty-one patients who underwent surgery for suspected adrenal metastases were evaluated retrospectively. The following data types were collected: demographic, primary tumor, maximum standardized uptake value of adrenal mass (a-SUVx) and detectability in computed tomography and/or magnetic resonance imaging, and specimen size and histopathology. Six patients were excluded due to unavailability of PET-CT reports and 4 for being primary adrenal malignancy. The rest were divided into 2 groups (metastatic: n = 17, 55% and nonmetastatic: n = 14, 45%) according to histopathology reports. There was no statistical difference between the analyzed values, except the a-SUVx (P < .05). The a-SUVx cutoff value was defined as 5.50 by receiver operating characteristic curves and compared with literature. There was no statistical difference when each group was divided as low and high (P > .05). It was found that PET-CT was able to discriminate metastatic lesions from primary benign lesions (P = .022). PET-CT can discriminate primary benign lesions and metastatic lesions by cutoff 5.5 value for a-SUVx.

Giant Adrenal Pseudocysts: An Enigma for Surgeons

Adrenal pseudocysts are cystic lesions arising within the adrenal gland enclosed by a fibrous connective tissue wall that lacks lining cells. They can attain a huge size and pose a diagnostic challenge with a broad range of differentials including benign and malignant neoplasms. There are only a few small case series and case reports describing these lesions. We report a series of five patients who presented with “indeterminate” abdominal cystic lesions and were later on found to have adrenal pseudocyst. Four out of five patients presented with non-specific abdominal symptoms, and one patient presented with symptoms suggestive of a functional adrenal tumor. The size of these tumors ranged from 6 to 30 cm. They had variable radiological features and in two cases even a percutaneous biopsy could not establish the diagnosis. In four of these “indeterminate” abdominal masses, an adrenal origin was not suspected preoperatively. Surgical excision provided a resolution of symptoms, ruled out malignancy, and clinched the diagnosis.

Adrenocortical Tumors and Pheochromocytoma/Paraganglioma Initially Mistaken as Neuroblastoma-Experiences From the GPOH-MET Registry

In children and adolescents, neuroblastoma (NBL), pheochromocytoma (PCC), and adrenocortical tumors (ACT) can arise from the adrenal gland. It may be difficult to distinguish between these three entities including associated extra-adrenal tumors (paraganglioma, PGL). Precise discrimination, however, is of crucial importance for management. Biopsy in ACT or PCC is potentially harmful and should be avoided whenever possible. We herein report data on 10 children and adolescents with ACT and five with PCC/PGL, previously mistaken as NBL. Two patients with adrenocortical carcinoma died due to disease progression. Two (2/9, missing data in one patient) patients with a final diagnosis of ACT clearly presented with obvious clinical signs and symptoms of steroid hormone excess, while seven patients did not. Blood analyses indicated increased levels of steroid hormones in one additional patient; however, urinary steroid metabolome analysis was not performed in any patient. Two (2/10) patients underwent tumor biopsy, and in two others tumor rupture occurred intraoperatively. In 6/10 patients, ACT diagnosis was only established by a reference pediatric pathology laboratory. Four (4/5) patients with a final diagnosis of PCC/PGL presented with clinical signs and symptoms of catecholamine excess. Urine tests indicated possible catecholamine excess in two patients, while no testing was carried out in three patients. Measurements of plasma metanephrines were not performed in any patient. None of the five patients with PCC/PGL received adrenergic blockers before surgery. In four patients, PCC/PGL diagnosis was established by a local pathologist, and in one patient diagnosis was revised to PGL by a pediatric reference pathologist. Genetic testing, performed in three out of five patients with PCC/PGL, indicated pathogenic variants of PCC/PGL susceptibility genes. The differential diagnosis of adrenal neoplasias and associated extra-adrenal tumors in children and adolescents may be challenging, necessitating interdisciplinary and multidisciplinary efforts. In ambiguous and/or hormonally inactive cases through comprehensive biochemical testing, microscopical complete tumor resection by an experienced surgeon is vital to preventing poor outcome in children and adolescents with ACT and/or PCC/PGL. Finally, specimens need to be assessed by an experienced pediatric pathologist to establish diagnosis.

Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma

Catecholamine-producing tumors of childhood include most notably neuroblastoma, but also pheochromocytoma and paraganglioma (PPGL). Diagnosis of the former depends largely on biopsy-dependent histopathology, but this is contraindicated in PPGL where diagnosis depends crucially on biochemical tests of catecholamine excess. Such tests retain some importance in neuroblastoma though continue to largely rely on measurements of homovanillic acid (HVA) and vanillylmandelic acid (VMA), which are no longer recommended for PPGL. For PPGL, urinary or plasma metanephrines are the recommended most accurate tests. Addition of methoxytyramine to the plasma panel is particularly useful to identify dopamine-producing tumors and combined with normetanephrine also shows superior diagnostic performance over HVA and VMA for neuroblastoma. While use of metanephrines and methoxytyramine for diagnosis of PPGL in adults is established, there are numerous pitfalls for use of these tests in children. The establishment of pediatric reference intervals is particularly difficult and complicated by dynamic changes in metabolites during childhood, especially in infants for both plasma and urinary measurements, and extending to adolescence for urinary measurements. Interpretation of test results is further complicated in children by difficulties in following recommended preanalytical precautions. Due to this, the slow growing nature of PPGL and neglected consideration of the tumors in childhood the true pediatric prevalence of PPGL is likely underappreciated. Earlier identification of disease, as facilitated by surveillance programs, may uncover the true prevalence and improve therapeutic outcomes of childhood PPGL. For neuroblastoma there remain considerable obstacles in moving from entrenched to more accurate tests of catecholamine excess.

Incidental Adrenal Mass in a Patient With Surgically Treated Lung Adenocarcinoma

Adrenal metastases are not uncommon in patients with widespread metastatic lung cancer. Isolated metachronous adrenal metastases in cases of surgically treated lung cancer without long-term evidence of disease are rare and may pose a diagnostic and treatment dilemma. The current literature suggests that in such cases, adrenalectomy provides better median and overall survival rates. This case presents an incidentally discovered isolated adrenal mass in a patient with a past medical history of lung adenocarcinoma that was surgically removed three years before metastasis discovery. The patient successfully underwent adrenalectomy and was disease-free with no apparent complications at her three-month follow-up visit. The case highlights the importance of long-term radiographic surveillance after surgical resection of lung adenocarcinoma for the prompt diagnosis and timely treatment of metachronous metastases.

Challenges in Paragangliomas and Pheochromocytomas: from Histology to Molecular Immunohistochemistry

Abdominal paragangliomas and pheochromocytomas (PPGLs) are rare neuroendocrine tumors of the infradiaphragmatic paraganglia and adrenal medulla, respectively. Although few pathologists outside of endocrine tertiary centers will ever diagnose such a lesion, the tumors are well known through the medical community-possible due to a combination of the sheer rarity, their often-spectacular presentation due to excess catecholamine secretion as well as their unrivaled coupling to constitutional susceptibility gene mutations and hereditary syndromes. All PPGLs are thought to harbor malignant potential, and therefore pose several challenges to the practicing pathologist. Specifically, a responsible diagnostician should recognize both the capacity and limitations of histological, immunohistochemical, and molecular algorithms to pinpoint high risk for future metastatic disease. This focused review aims to provide the surgical pathologist with a condensed update regarding the current strategies available in order to deliver an accurate prognostication of these enigmatic lesions.

Adrenal schwannoma: A case report of an unusual incidentaloma

Introduction and importance

Adrenal schwannomas are extremely rare tumors often misdiagnosed. The patients are usually asymptomatic while some present with non-specific abdominal pain. Only a few cases are reported to date.

Case presentation

We here present a case of a 55-year-old Nepalese man presented with nonspecific abdominal pain at our Outpatient Department (OPD) found to have mass on ultrasonography of abdomen. On further investigation with Contrast Enhanced Computerized Tomography (CECT) of the abdomen and pelvis, a well-defined heterogeneous adrenal mass of size (7.8 ∗ 8.3 ∗ 6) cm with foci of calcification was seen in the left retroperitoneum. The intraoperative finding of adrenal mass and histopathology of resected mass was suggestive of schwannoma arising from the adrenal gland which was further confirmed by immunohistochemistry.

Clinical discussion

Adrenal schwannoma can mimic tumors like pheochromocytoma, adrenal adenoma, cortical carcinoma, neuroblastoma, and other masses. Only 1–3% of schwannomas are retroperitoneal. Radiological findings of this tumor are non-suggestive. The histological section shows spindle cells with Antoni A and Antoni B regions while positive staining of S-100 protein in Immunohistochemistry.

Conclusion

The diagnosis of adrenal schwannoma in the retroperitoneum is often challenging. The treatment of choice is surgical resection with a good prognosis.

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Adrenal schwannomas are extremely rare tumors.

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These tumors are mostly found incidentally and often asymptomatic.

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Complete surgical resection of the tumor is a must for good prognosis.

Metastatic Pheochromocytomas and Abdominal Paragangliomas

CONTEXT

Pheochromocytomas and paragangliomas (PPGLs) are believed to harbor malignant potential; about 10% to 15% of pheochromocytomas and up to 50% of abdominal paragangliomas will exhibit metastatic behavior.

EVIDENCE ACQUISITION

Extensive searches in the PubMed database with various combinations of the key words pheochromocytoma, paraganglioma, metastatic, malignant, diagnosis, pathology, genetic, and treatment were the basis for the present review.

DATA SYNTHESIS

To pinpoint metastatic potential in PPGLs is difficult, but nevertheless crucial for the individual patient to receive tailor-made follow-up and adjuvant treatment following primary surgery. A combination of histological workup and molecular predictive markers can possibly aid the clinicians in this aspect. Most patients with PPGLs have localized disease and may be cured by surgery. Plasma metanephrines are the main biochemical tests. Genetic testing is important, both for counseling and prognostic estimation. Apart from computed tomography and magnetic resonance imaging, molecular imaging using 68Ga-DOTATOC/DOTATATE should be performed. 123I-MIBG scintigraphy may be performed to determine whether 131I-MIBG therapy is a possible option. As first-line treatment in patients with metastatic disease, 177Lu-DOTATATE or 131I-MIBG is recommended, depending on which shows best expression. In patients with very low proliferative activity, watch-and-wait or primary treatment with long-acting somatostatin analogues may be considered. As second-line treatment, or first-line in patients with high proliferative rate, chemotherapy with temozolomide or cyclophosphamide + vincristine + dacarbazine is the therapy of choice. Other therapies, including sunitinib, cabozantinib, everolimus, and PD-1/PDL-1 inhibitors, have shown modest effect.

CONCLUSIONS

Metastatic PPGLs need individualized management and should always be discussed in specialized and interdisciplinary tumor boards. Further studies and newer treatment modalities are urgently needed.

Adrenal schwannoma in a female patient; A rare benign neoplasm: Case report and literature review

INTRODUCTION

Schwannomas are rare, slow-growing, usually benign tumors that originate from myelin-producing Schwann cells. Adrenal schwannomas are an exceptionally rare subset of these tumors, with few cases reported in the literature.

PRESENTATION OF CASE

We present the case of a 44-year old female patient being evaluated for chronic abdominal pain at the outpatient clinic. Clinical and laboratory workup was unremarkable. An abdominal CT scan was performed, revealing a left suprarenal solid mass (5 × 6 cm). Surgical resection of the adrenal gland was performed, given the patient's symptoms, the size of the tumor, and its malignant potential. The patient completed the postoperative period satisfactorily, and her symptoms improved. Histopathological findings were compatible with a benign adrenal schwannoma.

DISCUSSION

Schwannomas generally appear in the head, neck and extremities, with the vestibulocochlear nerve being the most frequently involved site. Retroperitoneal schwannomas account for 1-5% of retroperitoneal masses and comprise only 1-3% of all schwannomas. Their incidence increases with age, from 4% in the general population, reaching 7% in patients over 70 years of age.

CONCLUSION

Adrenal incidentalomas represent a diagnostic challenge. Because of the malignant potential of large (> 4 cm) adrenal masses and the lack of characteristic findings using conventional imaging techniques and laboratory diagnostic tools, surgical excision with histopathology and immunohistochemistry analysis are required for definitive diagnosis and optimal management.

Data set for the reporting of pheochromocytoma and paraganglioma: explanations and recommendations of the guidelines from the International Collaboration on Cancer Reporting

BACKGROUND AND OBJECTIVES

The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit to develop evidence-based, internationally agreed-upon standardized data sets for each anatomic site, to be used throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to improved patient management and enhanced epidemiological research.

METHODS

Pheochromocytoma and paraganglioma are uncommon and are frequently overlooked in registry data sets. Malignant criteria have previously been defined only when there was metastatic disease.

RESULTS

With recent recognition of a significant inheritance association and the development of risk stratification tools, this data set was created in order to obtain more meaningful outcomes and management data, using similar criteria across the global pathology community. Issues related to key core and non-core elements, especially clinical hormonal status, familial history, tumor focality, proliferative fraction, adverse or risk stratification features, and ancillary techniques, are discussed in the context of daily application to these types of specimens.

CONCLUSIONS

The ICCR data set, developed by an international panel of endocrine organ specialists, establishes a pathology-standardized reporting guide for pheochromocytoma and paraganglioma.

Surgery for adrenocortical carcinoma: When and how?

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.

A laparoscopic treatment of a suspicious adrenal mass revealing an unsual cause of adrenal incidentaloma

Schwannomas are rare tumors, usually benign, originating from the Schwann sheath of the peripheral or cranial nerves. They are an extremely uncommon cause of adrenal incidentaloma. It is difficult to diagnose adrenal schwannoma preoperatively by imaging alone due of their aspect suspect on it. We report a case of adrenal mass discovered incidentally in a 41 years old patient who presented an atypical abdominal pain. Biological assessment was unremarkable, and imaging studies did not show strict imaging criteria for a typical adenoma. A surgical excision of the adrenal incidentaloma was decided. Histopathological examination and immunohistochemical staining of the excised specimen revealed a benign schwannoma.

‘Adrenal incidentalomas’; Rationalising assessment in the urology multi-disciplinary team meeting

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.

Minimally Invasive Surgery for Primary and Metastatic Adrenal Malignancy

Since the first description of laparoscopic adrenalectomy (LA) for pheochromocytoma and Cushing syndrome in 1992, the utilization of and indications for a minimally invasive approach to the adrenal gland have vastly expanded. Although minimally invasive adrenalectomy has been established as the preferred approach for patients with benign tumors of the adrenal gland, minimally invasive adrenalectomy for cancer remains controversial. In this article, the authors review the indications for minimally invasive adrenalectomy for adrenal nodules suspicious for, or established to represent, a primary malignancy or a site of metastatic cancer.

Interventional radiology of the adrenal glands: current status

As more and more adrenal neoplasms are found incidentally or symptomatically, the need for interventional procedures has being increasing. In recent years these procedures registered continued steady expansion. Interventional radiology of the adrenal glands comprises angiographic and percutaneous procedures. They may be applied both in benign and in malignant pathologies. The present review reports the current status of indications, techniques results and complications of the image-guided procedures.

Effectiveness and safety of CT-guided percutaneous radiofrequency ablation of adrenal metastases

OBJECTIVE

The imaging-guided percutaneous radiofrequency (RF) ablation of adrenal metastases is a relatively new treatment procedure, compared to the more widespread application of the technique for the treatment of liver and renal cancers. The present study aims to evaluate the safety and efficacy of the CT-guided percutaneous RF ablation of adrenal metastases in a cohort of patients.

METHODS

33 patients with 38 adrenal metastases who received percutaneous CT-guided RF ablation between 2012 to 2015 were retrospectively reviewed. The average diameter of the treated adrenal metastases was 3.0 ± 1.6 cm. The treatment outcomes, including presence of residual tumours, technical success rate, recurrence rate, and complications, were evaluated. Patients were followed up for every 3 months to monitor the progression of the disease.

RESULTS

Postoperative CT images showed the lack of tumour enhancement in 30 tumours (30/38 tumours, technical success rate = 78.9%), and residual disease was found in 7 tumours (7/37 tumours, 18.9%). The rate of residual disease was significantly lower in the group with tumour size <3 cm than the group with tumour size ≥3 cm (p = 0.025). The severe complication rate was 4.3%, and the mild complication rate was 48%, with intraoperative hypertensive crisis as the most frequently observed complication (27.3%). The follow-up data showed that 76.3% of patients had recurrence-free survival in 27.4 months.

CONCLUSION

The current study demonstrated that radiofrequency ablation is a relatively safe and effective treatment for controlling adrenal metastases, especially for patients with tumour size <3 cm. Advances in knowledge: Surgical resection of the adrenal metastases was advocated as one of the treatment options for patients. The present study showed that radiofrequency ablation is a relatively safe and effective treatment for controlling adrenal metastases.

Clinical Guidelines for the Management of Adrenal Incidentaloma

An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.

C-arm cone-beam computed tomography with stereotactic needle guidance for percutaneous adrenal biopsy: initial experience

Background Metastasis to the adrenal glands is frequent in patients with various cancers and adrenal gland biopsy is routinely performed using ultrasound or computed tomographic (CT) guidance. However, this method is technically challenging, especially in the case of small masses. Purpose To determine whether the new real-time stereotactic needle guidance technique C-arm cone-beam CT (CBCT) allows safe and accurate biopsy of adrenal gland masses, especially those in hard-to-reach anatomical locations. Material and Methods CBCT guidance was used to perform 60 stereotactic biopsy procedures of lesions that were inaccessible with ultrasound or CT guidance. The needle path was carefully planned and calculated on the CBCT virtual navigation guidance system, which acquired 3D CT-like cross-sectional images. The adrenal biopsy procedures were performed with fluoroscopic feedback. Technical success rate, sensitivity, specificity, accuracy, and complications were investigated. Results The technical success rate of adrenal biopsy under CBCT virtual navigation was 100%, with a mean total procedure time of 14.6 ± 3.6 min. Of the 60 lesions, 46 were malignant, 11 were benign, and three were non-diagnostic. The three non-diagnostic lesions proved to be malignant. Thus, the sensitivity, specificity, and accuracy were 93.8%, 100%, and 95.0%, respectively. Minor bleeding occurred in two (3.3%) cases. Conclusion CBCT guidance allows safe and accurate biopsy of adrenal gland masses and may be especially useful for hard-to-reach anatomical locations.

Work up of incidental adrenal mass: state of the art

Due to the increasing use of radiological investigations, the detection of incidental adrenal masses has become even more frequent. Therefore, it is crucial to identify the nature of the adrenal mass in order to decide the type of treatment that should be undertaken. Toward this goal, biochemical tests are useful in order to assess catecholamines levels for the presence of a pheochromocytoma or cortisol excess in case of Cushing's syndrome. Furthermore, the dexamethasone suppression test and late-night salivary cortisol may be useful in measuring plasma cortisol, respectively, in the blood and urine. Hyperaldosteronism could be suspected in the presence of arterial hypertension. With regard to imaging modalities, the contrast washout and Hounsfield units estimation might play a role as indicators on computed tomography. In terms of treatment, a surgical approach is most suitable for a hyperfunctioning adrenal mass irrespective of size, and for nonfunctioning masses >4 cm. For indeterminate smaller lesions, with washout >50%, <10 Hounsfield Unit, nonfunctioning, benign-appearing, undergoing a follow-up in regular intervals is more appropriate in order to estimate mass growth. This paper summarizes recent findings on the management of incidental adrenal masses, with a special focus on the use of imaging, surgical management and follow-up modalities in improving patient outcomes.

Procedural and clinical outcomes of percutaneous adrenal biopsy in a high-risk population for adrenal malignancy

OBJECTIVE

The role of percutaneous adrenal biopsy in a high-risk population for adrenal malignancy has not been fully investigated. Our aim was to describe the clinical presentation leading to the adrenal biopsy and evaluate the diagnostic performance, complications and non diagnostic rate of adrenal biopsy.

DESIGN

Single-centre, retrospective cohort study.

PATIENTS AND MEASUREMENTS

Medical records of patients who underwent adrenal biopsy between 1994 and 2014 were reviewed. Adrenal biopsy outcome was compared to a predefined reference standard.

RESULTS

Biopsy was performed in 418 patients [62% men, median age 69 years (range, 15-91)] on 419 adrenal lesions, median size 3·1 cm (range, 0·6-24). The main indication for adrenal mass biopsy was (349/419, 83%) suspected adrenal metastasis from a known or suspected extra-adrenal primary source. Only 116 of 419, 28% of cases had prebiopsy biochemical testing for pheochromocytoma. Biopsy-related complications occurred in 4% of the patients. Histology revealed a metastasis in 231 of 419 (55%), benign adrenal tissue in 137 of 419 (33%), adrenocortical carcinoma in eight of 419 (2%), other lesions in 23 of 419 (5%) including seven cases of pheochromocytoma and six cases of infectious process. Biopsy was nondiagnostic in 20 of 419 (5%). All adrenal masses with unenhanced radiodensity ≤10 HU (42/137, 31%) proved to be benign adrenal adenomas. Adrenal biopsy diagnosed malignancy with a sensitivity of 88·5%, specificity of 91·5%, positive predictive value of 93·4% and negative predictive value of 85·5%.

CONCLUSION

When used in the appropriate clinical setting, adrenal biopsy is a powerful tool in the diagnostic algorithm of the evaluation of adrenal masses with features suspicious for malignancy. Efforts to increase awareness to perform biochemical testing for pheochromocytoma prior to adrenal biopsy are needed.

DIAGNOSIS OF ENDOCRINE DISEASE: The diagnostic performance of adrenal biopsy: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review of published literature on adrenal biopsy and to assess its performance in diagnosing adrenal malignancy.

METHODS

Medline In-Process and Other Non-Indexed Citations, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trial were searched from inception to February 2016. Reviewers extracted data and assessed methodological quality in duplicate.

RESULTS

We included 32 observational studies reporting on 2174 patients (39.4% women, mean age 59.8 years) undergoing 2190 adrenal mass biopsy procedures. Pathology was described in 1621/2190 adrenal lesions (689 metastases, 68 adrenocortical carcinomas, 64 other malignancies, 464 adenomas, 226 other benign, 36 pheochromocytomas, and 74 others). The pooled non-diagnostic rate (30 studies, 2013 adrenal biopsies) was 8.7% (95%CI: 6-11%). The pooled complication rate (25 studies, 1339 biopsies) was 2.5% (95%CI: 1.5-3.4%). Studies were at a moderate risk for bias. Most limitations related to patient selection, assessment of outcome, and adequacy of follow-up. Only eight studies (240 patients) could be included in the diagnostic performance analysis with a sensitivity and specificity of 87 and 100% for malignancy, 70 and 98% for adrenocortical carcinoma, and 87 and 96% for metastasis respectively.

CONCLUSIONS

Evidence based on small sample size and moderate risk of bias suggests that adrenal biopsy appears to be most useful in the diagnosis of adrenal metastasis in patients with a history of extra-adrenal malignancy. Adrenal biopsy should only be performed if the expected findings are likely to alter the management of the individual patient and after biochemical exclusion of catecholamine-producing tumors to help prevent potentially life-threatening complications.

Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.

Management of the Incidental Adrenal Mass

CONTEXT

Incidentally discovered adrenal masses are becoming more common in clinical practice.

OBJECTIVE

To review the management of the incidental adrenal mass, including initial evaluation, surveillance, medical therapy, and surgical therapy.

EVIDENCE ACQUISITION

A literature search of English-language publications that included the keywords adrenal incidentaloma and incidental adrenal mass was performed through July 2015 using PubMed. Relevant original articles and guidelines on the management of the incidental adrenal mass were ultimately selected for analysis, with the consensus of all authors.

EVIDENCE SYNTHESIS

Data from the manuscripts included in this review were synthesized, and findings were categorized into metabolic evaluation, imaging, biopsy, surgical considerations, and follow-up recommendations.

CONCLUSIONS

Ideally, management of patients with adrenal incidentalomas should involve a multidisciplinary approach with experienced surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.

PATIENT SUMMARY

Management of patients with adrenal incidentalomas should involve a multidisciplinary approach with surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.

Living Kidney Donors With Adrenal Incidentalomas: Are They Appropriate Donors?

OBJECTIVE

To determine the incidence of adrenal incidentalomas (AIs) in a single-center series of living renal donors, to describe an evaluation algorithm for AIs in this patient population, and to compare the complication rates of hand-assisted laparoscopic donor nephrectomy (HALDN) with those of combined HALDN and adrenalectomy.

METHODS

We performed a single-center, retrospective study of consecutive living kidney donors who underwent laparoscopic nephrectomy for transplantation, with or without simultaneous ipsilateral adrenalectomy, between January 2008 and September 2014.

RESULTS

During the study period, AIs were detected in 18 of 1033 potential living renal donors who underwent computerized tomographic angiography. Application of additional donor selection criteria and of an adrenal mass assessment algorithm resulted in 849 HALDN, of which 13 were combined with simultaneous adrenalectomy. The hospital length of stay (2.4 vs 2.6 days), perioperative (0.025 vs 0.077), early (0.073 vs 0.077), and late (0.014 vs 0.077) postoperative complication rates, and conversion to open donor nephrectomy (0.008 vs 0.00) were not significantly different. Mean operative time was significantly longer in the adrenalectomy group. None of the adrenal masses were malignant.

CONCLUSION

Here, we presented our algorithm to manage the living kidney donors with AIs. Although donor population with AIs was relatively small in number, simultaneous adrenalectomy and ipsilateral nephrectomy seemed to be technically safe and conferred no identifiable increased risk of malignancy for the kidney transplant donor, when the incidentaloma is nonfunctional and less than or equal to 4 cm as assessed by preoperative imaging.

Do additional imaging studies change operative management in patients undergoing adrenalectomy?

BACKGROUND

The purpose of this study is to determine the incidence of a secondary imaging modality (SIM) in the workup of adrenal masses and the usefulness of this additional imaging in changing surgical management.

METHODS

A retrospective analysis of our adrenalectomy database was performed on adult patients who underwent ≥1 imaging study before surgery. A multivariate logistic regression model was then constructed to identify patient factors that predisposed SIM.

RESULTS

From February 2001 to August 2014, 264 cases met inclusion criteria, of which 98 (37%) were identified to have SIM. Patients with cancer (P = .001), incidentaloma (P = .002), and pheochromocytoma (P < .0001) were more likely to undergo additional imaging. MRI was the most commonly obtained SIM. In addition, 90 of the 98 cases (92%) met indications for adrenalectomy with primary imaging study and biochemical screening alone. Of the remaining 8 cases, in only 4 instances (4%) did SIM modify surgical decision making.

CONCLUSION

The high incidence of unnecessary additional imaging performed in patients undergoing adrenalectomy is counterproductive to efforts toward cost-conscious, high-quality health care. Patients with adrenal tumors would benefit from early surgical referral to allow the surgeon to help guide clinical decision making and to avoid the use of excessive imaging.

Adrenal Mass in Patients who Underwent Abdominal Computed Tomography Examination

BACKGROUND

Adrenal masses are usually discovered incidentally (IAM) during abdominal computed tomography (CT).

AIMS

We aimed to describe the prevalence, management, and outcome of incidentally discovered adrenal mass on radiological investigation.

MATERIALS AND METHODS

A retrospective analysis was conducted to look for IAM identified by abdominal CT performed for other reasons between 2004 and 2008 and were followed for 4 years. IAM patients with known malignancy or clinically evident adrenal disease or overt disease originally missed due to insufficient clinical examination were excluded.

RESULTS

A total of 13,115 patients underwent abdominal CT, of which 136 were identified with adrenal mass (69 males and 67 females). Overall, 84 patients had benign IAM and six had primary adrenal carcinoma (all had tumor size ≥4 cm and five were males). Hormonal evaluation was performed in 80 cases, which revealed hypersecretion in 10 cases (six had Conn's syndrome and four had pheochromocytoma). Males had higher frequency of right-sided IAMs; whereas, left-sided IAM swere more common among females (P = 0.02). Seven patients underwent surgery and all were males (one Conn's syndrome, one pheochromocytoma, three primary adrenal adenocarcinoma, one benign nonfunctional adenoma, and one metastatic tumor). Only one patient died due to brain metastasis.

CONCLUSION

The overall prevalence of adrenal incidentaloma is 1% in Qatar. Unfortunately, hormonal evaluation, surgical referral, and follow-up are not appropriate in this study. Moreover, screening of IAM warrants more attention to rule out malignancy. This work could be of value as a local auditing for the current management.

Bilateral Adrenal Incidentalomas: A Rare Presentation of Lung Cancer

Adrenal incidentalomas are found incidentally during a radiologic examination performed for indications other than an adrenal disease, and 15% of them are bilateral adrenal masses. This study describes a 51-year-old male smoker patient admitted with diabetes mellitus. An abdominal ultrasonography performed due to his anemia revealed bilateral adrenal masses. His chest X-ray showed abnormal 10 cm opacity at the right upper lung, and brain, thorax, and abdomen CT scans showed multiple lesions compatible with lung cancer metastases. The pathological examination of the transthoracic lung biopsy specimen was consistent with lung adenocarcinoma. Findings in this patient indicate that, in middle aged patients with bilateral adrenal mass and a history or finding of any malignancy, the first diagnosis which should be considered is adrenal metastasis, and confirming the diagnosis by adrenal biopsy may be useless. Furthermore, screening all smoking patients by chest X-ray or thoracic CT for lung cancer may not be accepted as a routine procedure, but in smokers admitted to a hospital due to signs and symptoms attributed to a pulmonary disease, at least a chest X-ray should be requested.

Metabolic and anatomic characteristics of benign and malignant adrenal masses on positron emission tomography/computed tomography: a review of literature

PET/CT with (18)F-fluorodeoxyglucose (FDG) or using different radiocompounds has proven accuracy for detection of adrenal metastases in patients undergoing cancer staging. It can assist the diagnostic work-up in oncology patients by identifying distant metastases to the adrenal(s) and defining oligometastatic disease that may benefit from targeted intervention. In patients with incidentally discovered adrenal nodules, so-called adrenal "incidentaloma" FDG PET/CT is emerging as a useful test to distinguish benign from malignant etiology. Current published evidence suggests a role for FDG PET/CT in assessing the malignant potential of an adrenal lesion that has been 'indeterminately' categorized with unenhanced CT, adrenal protocol contrast-enhanced CT, or chemical-shift MRI. FDG PET/CT could be used to stratify patients with higher risk of malignancy for surgical intervention, while recommending surveillance for adrenal masses with low malignant potential. There are caveats for interpretation of the metabolic activity of an adrenal nodule on PET/CT that may lead to false-positive and false-negative interpretation. Adrenal lesions represent a wide spectrum of etiologies, and the typical appearances on PET/CT are still being described, therefore our goal was to summarize the current diagnostic strategies for evaluation of adrenal lesions and present metabolic and anatomic appearances of common and uncommon adrenal lesions. In spite of the emerging role of PET/CT to differentiate benign from malignant adrenal mass, especially in difficult cases, it should be emphasized that PET/CT is not needed for most patients and that many diagnostic problems can be resolved by CT and/or MR imaging.

Surgical treatment of potentially primary malignant adrenal tumors: an unresolved issue

Although the great majority of incidentalomas are adrenocortical adenomas, a number of them, depending on the size and radiological characteristics of the lesions, will turn out to be carcinomas. These tumors may present as suspicious on initial evaluation and potentially malignant or malignant on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the extensive experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update the existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors.The interpretation of radiologic characteristics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack sufficient accuracy to exclude primary malignancy in tumors from 4 cm to 10 cm in size. An initial laparoscopic approach can be used in this group of patients, but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors >10 cm of malignant potential should be treated by the open approach from the start. Solitary adrenal metastasis from another primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer should be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.

Transcutaneous biopsy of adrenocortical carcinoma is rarely helpful in diagnosis, potentially harmful, but does not affect patient outcome

CONTEXT

Adrenocortical carcinoma (ACC) is a rare malignancy with high recurrence and mortality rates. The utility, sensitivity, and effect on patient outcome of transcutaneous adrenal biopsy (TAB) for single, large, adrenal masses are unclear.

OBJECTIVE

This study evaluated the utility, diagnostic sensitivity, and effect on patient outcome of TAB in patients with ACC.

DESIGN AND SETTING

We conducted a retrospective review of the electronic medical records of all ACC patients who were evaluated at the University of Michigan Health System from 1991 to 2011. We evaluated the sensitivity of TAB for tumors with the final pathological diagnosis of ACC. We compared the characteristics and survival of patients with stage I-III disease who underwent TAB with those who did not undergo TAB.

RESULTS

A total of 75 ACC patients with TAB were identified. Complications occurred in at least 11% of patients and were mainly associated with bleeding. The maximum sensitivity of the procedure in diagnosing ACC was 70%. For stage I-III patients, baseline characteristics, stage at diagnosis, and adjuvant treatment with mitotane or radiation were not significantly different between the TAB (n=36) and the non-TAB (n=254) groups. There was no significant difference in recurrence-free (P=0.7) or overall survival (P=0.7) between patients who underwent TAB and those who did not.

CONCLUSIONS

TAB of single, large, adrenal masses is usually unnecessary, exposes patients to risk, but does not affect recurrence-free or overall survival.

Giant adrenal myelolipoma: when trauma and oncology collide

Three patients presented some decades after severe traumatic injury with atypical bowel symptoms which were caused by a giant myelolipoma of the adrenal gland. The aetiology of this rare, benign and generally asymptomatic tumour is virtually unknown at present and several hypotheses have been devised. This report describes a possible association between high-energy trauma and the development of giant myelolipomas, further contributing to the hypothesis that severe systemic stress could be an aetiological factor in the development of an adrenal myelolipoma.

Surgical management of adrenal metastases

In the presence of a history of cancer, adrenal masses are commonly, but not exclusively, metastases. Depending upon the status of the patient's ongoing cancer therapy, overall tumor burden, and performance score, adrenalectomy is a viable treatment option. Herein we review the prevalence, diagnostic evaluation, and selection for surgical treatment of adrenal metastases. Additional attention is paid to recent data supporting the safety and oncologic efficacy of laparoscopic adrenalectomy.

A rare adrenal incidentaloma: adrenal schwannoma

Adrenal schwannoma is an extremely uncommon cause of incidentaloma. It originates from neural sheath Schwann cells of the adrenal gland. We report the case of a left adrenal schwannoma incidentally discovered in a 32-year-old woman during examination of bloated feeling and stomach ache. The patient was incidentally found to have a left adrenal mass of 9 cm on abdominal ultrasonography. Computed tomography (CT) of the abdomen and [¹⁸F] fluorodeoxyglucose positron emission tomography (PET) were also performed. Metabolic evaluation was unremarkable. Due to the large size of the tumor, left adrenalectomy was performed. The postoperative course was uneventful. Histological examination established the diagnosis of schwannoma. This diagnosis was supported by immunohistochemistry of S-100 and vimentin positivity. In conclusion, adrenal schwannoma is an extremely rare entity and can grow considerably in size. The present case report emphasizes that clinicians should be aware of the possibility of retroperitoneal schwannoma. Total excision of benign schwannoma is associated with a favorable outcome. To our knowledge, there are case reports of schwannoma with CT and magnetic resonance imaging findings in the literature, although this is the first schwannoma case with PET-CT imaging.

Laparoscopic adrenalectomy for cancer

Laparoscopic procedures are preferred by surgeons and patients alike because of decreased pain, reduced perioperative morbidity, and an earlier return to self-reliance. During the last decade, laparoscopic adrenalectomy has become the technique most commonly used for the removal of benign adrenal tumors. The indications for laparoscopy in malignant adrenal tumors remains controversial, because oncologic resections have not been reproducible compared with open techniques.

Current status and controversies in adrenal incidentalomas

Adrenal incidentalomas (AI) are serendipitously discovered lesions during abdominal imaging studies that need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Because imaging modalities can reliably identify lesions that carry a high risk of malignancy, we focus on the identification of hypersecretory lesions and those with subclinical activity, particularly Cushing syndrome. Because diverse diagnostic tests and cut-offs are employed, the prevalence of hypersecretory AI varies widely, and there is controversy regarding their long-term sequelae. In this article we provide information regarding current radiological means to define the nature of AI, and the most appropriate biochemical tests for delineating hypersecretory states. We also discuss the duration and intensity of AI follow-up as well as the identification of AI that require specific therapeutic intervention.

Fine-needle aspiration cytology of adrenal masses: a re-assessment with histological confirmation

BACKGROUND

Fine-needle aspiration (FNA) of adrenal masses is a method currently indicated in lesions suspected of being extra-adrenal in origin; even though its diagnostic reliability has already been determined in many studies, few have used histological examination obtained after adrenalectomy for diagnostic confirmation.

AIM

To analyze the diagnostic performance of adrenal FNA in subjects with an available histological confirmation.

SUBJECTS AND METHODS

Fifty subjects (26 benign adrenal lesions, 9 primary malignant lesions, and 15 metastatic lesions) who had undergone ultrasound (US)-guided adrenal FNA and then adrenalectomy were re-analyzed retrospectively.

RESULTS

FNA guaranteed a sensitivity of 85.7% and a specificity of 100% in all subjects; after having divided the subjects into oncologic and non-oncologic groups, the sensitivity of the test in oncologic patients (100%) increased significantly compared to non-oncologic (57.1%) with no difference in specificity (100% in both groups). Considering also non-diagnostic samples in our analysis (no.=11; 22% of all samples studied), FNA correctly diagnosed malignancy only in 75% of the cases and benignancy only in 66.6%; however, even after including non-diagnostic samples, the percentage of correct malignancy diagnosis remained significantly higher in oncologic (93.3%) than in non-oncologic patients (44.4%) without significant statistical difference between the 2 groups regarding the percentage of correct benignancy diagnosis (respectively 100% and 63.6%).

CONCLUSIONS

Our study, based on histological confirmation, underlines the low discriminant value of US-guided adrenal FNA, though the method may have value in oncologic patients.

Evaluation and management of adrenal incidentaloma

Adrenal incidentaloma is the most common adrenal neoplasm encountered in clinical practice. The timely, accurate, and cost-effective evaluation and management of adrenal lesions found incidentally can be challenging for clinicians. Evaluation begins with biochemical screening and additional imaging. Management strategies vary by patient factors and tumor characteristics. Adrenalectomy is indicated for lesions that are hormonally active, larger than 4-5 cm, symptom-related, and have an imaging appearance that is atypical of a benign lesion.

CT-guided adrenal biopsy: comparison of ipsilateral decubitus versus prone patient positioning for biopsy approach

OBJECTIVES

To compare ipsilateral decubitus and prone patient positioning for performing computed tomography guided adrenal biopsy using the requirements for out-of-plane approach (OOP) and the needle insertion time (NIT) as a surrogate for procedure complexity.

METHODS

The study included 106 adrenal biopsies performed in 104 patients with lesions measuring ≤ 4 cm that were divided into two groups: Ipsilateral decubitus (Group I) and prone (Group II) positions. The frequency of use of an OOP biopsy path and the NIT were recorded as well as diagnostic yield, adverse events and transgression of organs to approach the target lesion.

RESULTS

Groups I and II comprised 54 and 50 patients, respectively. The use of the OOP approach was significantly less frequent (P < 0.01) in Group I (n = 4) compared to Group II (n = 38). NIT was statistically shorter (P < 0.01) in Group I (9 min and 43 s) compared to Group II (19 min and 7 s). There were fewer organs traversed in Group I versus Group II. Diagnostic yield and post-biopsy complications were equal in both groups.

CONCLUSION

Ipsilateral adrenal biopsy approach is a less complex, equally reliable and safe compared to the prone approach based on the less frequent use of the OOP approach and the shorter NIT.

KEY POINTS

• Ipsilateral adrenal biopsy decubitus positioning provides a direct, non-transpulmonary path for sampling • Ipsilateral decubitus positioning reduces the need for potentially dangerous out-of-plane approaches (OOP) • Ipsilateral decubitus and prone positioning are equally reliable and safe techniques.