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Muacevic A, Adler JR, Gokden N, Menon LP. Incidental, Solitary, and Unilateral Adrenal Metastasis as the Initial Manifestation of Lung Adenocarcinoma. Cureus 2022; 14:e32628. [PMID: 36660511 PMCID: PMC9845493 DOI: 10.7759/cureus.32628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
An adrenal incidentaloma is an adrenal mass ≥ 1 cm in size discovered on imaging performed for indications other than suspected adrenal disease. It has variable etiologies, which can be benign or malignant, including primary or metastatic disease. We present a rare case of metastatic lung adenocarcinoma with isolated unilateral adrenal metastases, presenting as an adrenal incidentaloma in an asymptomatic patient with no known history of malignancy. A 76-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD) and heavy tobacco use was admitted for the evaluation and treatment of pneumonia. He was found to have an incidental 4.6 cm unilateral adrenal mass on his CT chest. He underwent a workup for the mass, including further imaging studies that were indeterminate and a hormonal workup that concluded that the mass was nonfunctional. Due to the patient's comorbidities, it was determined that he was not a surgical candidate. A multidisciplinary team recommended a biopsy, which revealed metastatic lung adenocarcinoma. The primary lung cancer was located using positron emission tomography with 2-deoxy-2-(fluorine-18) fluoro-D-glucose combined with computed tomography (F-FDG-PET/CT). The patient was evaluated by an oncology service and started on chemotherapy. In this case report, we discuss the approach for evaluating adrenal incidentalomas as well as the role the biopsy has in this process based on a literature review. In addition, we draw a comparison between our case and similar cases in the literature while highlighting the differences that make this case unique.
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Kusunoki M, Nakayama T, Nishie A, Yamashita Y, Kikuchi K, Eto M, Oda Y, Ishigami K. A deep learning-based approach for the diagnosis of adrenal adenoma: a new trial using CT. Br J Radiol 2022; 95:20211066. [PMID: 35522787 PMCID: PMC10996310 DOI: 10.1259/bjr.20211066] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 04/03/2022] [Accepted: 04/20/2022] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To develop and validate deep convolutional neural network (DCNN) models for the diagnosis of adrenal adenoma (AA) using CT. METHODS This retrospective study enrolled 112 patients who underwent abdominal CT (non-contrast, early, and delayed phases) with 107 adrenal lesions (83 AAs and 24 non-AAs) confirmed pathologically and with 8 lesions confirmed by follow-up as metastatic carcinomas. Three patients had adrenal lesions on both sides. We constructed six DCNN models from six types of input images for comparison: non-contrast images only (Model A), delayed phase images only (Model B), three phasic images merged into a 3-channel (Model C), relative washout rate (RWR) image maps only (Model D), non-contrast and RWR maps merged into a 2-channel (Model E), and delayed phase and RWR maps merged into a 2-channel (Model F). These input images were prepared manually with cropping and registration of CT images. Each DCNN model with six convolutional layers was trained with data augmentation and hyperparameter tuning. The optimal threshold values for binary classification were determined from the receiver-operating characteristic curve analyses. We adopted the nested cross-validation method, in which the outer fivefold cross-validation was used to assess the diagnostic performance of the models and the inner fivefold cross-validation was used to tune hyperparameters of the models. RESULTS The areas under the curve with 95% confidence intervals of Models A-F were 0.94 [0.90, 0.98], 0.80 [0.69, 0.89], 0.97 [0.94, 1.00], 0.92 [0.85, 0.97], 0.99 [0.97, 1.00] and 0.94 [0.86, 0.99], respectively. Model E showed high area under the curve greater than 0.95. CONCLUSION DCNN models may be a useful tool for the diagnosis of AA using CT. ADVANCES IN KNOWLEDGE The current study demonstrates a deep learning-based approach could differentiate adrenal adenoma from non-adenoma using multiphasic CT.
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Affiliation(s)
- Masaoki Kusunoki
- Department of Clinical Radiology, Kyushu
University, Fukuoka,
Japan
| | - Tomohiro Nakayama
- Department of Radiology, Saiseikai Fukuoka General
Hospital, Fukuoka,
Japan
| | - Akihiro Nishie
- Department of Clinical Radiology, Kyushu
University, Fukuoka,
Japan
| | - Yasuo Yamashita
- Department of Clinical Radiology, Kyushu
University, Fukuoka,
Japan
- Department of Medical Technology, Kyushu
University, Fukuoka,
Japan
| | - Kazufumi Kikuchi
- Department of Clinical Radiology, Kyushu
University, Fukuoka,
Japan
| | - Masatoshi Eto
- Department of Urology, Kyushu University,
Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Kyushu
University, Fukuoka,
Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Kyushu
University, Fukuoka,
Japan
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Stanzione A, Verde F, Galatola R, Romeo V, Liuzzi R, Mainenti PP, Aprea G, Klain M, Guadagno E, Del Basso De Caro M, Maurea S. Qualitative Heterogeneous Signal Drop on Chemical Shift (CS) MR Imaging: Correlative Quantitative Analysis between CS Signal Intensity Index and Contrast Washout Parameters Using T1-Weighted Sequences. Tomography 2021; 7:961-971. [PMID: 34941651 PMCID: PMC8709007 DOI: 10.3390/tomography7040079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022] Open
Abstract
The aim of this study was to calculate MRI quantitative parameters extracted from chemical-shift (CS) and dynamic contrast-enhanced (DCE) T1-weighted (T1-WS) images of adrenal lesions (AL) with qualitative heterogeneous signal drop on CS T1-WS and compare them to those of AL with homogeneous or no signal drop on CS T1-WS. On 3 T MRI, 65 patients with a total of 72 AL were studied. CS images were qualitatively assessed for grouping AL as showing homogeneous (Group 1, n = 19), heterogeneous (Group 2, n = 23), and no (Group 3, n = 30) signal drop. Histopathology or follow-up data served as reference standard to classify AL. ROIs were drawn both on CS and DCE images to obtain adrenal CS signal intensity index (ASII), absolute (AWO), and relative washout (RWO) values. Quantitative parameters (QP) were compared with ANOVA analysis and post hoc Dunn’s test. The performance of QP to classify AL was assessed with receiver operating characteristic analysis. CS ASII values were significantly different among the three groups (p < 0.001) with median values of 71%, 53%, and 3%, respectively. AWO/RWO values were similar in Groups 1 (adenomas) and 2 (benign AL) but significantly (p < 0.001) lower in Group 3 (20 benign AL and 10 malignant AL). With cut-offs, respectively, of 60% (Group 1 vs. 2), 20% (Group 2 vs. 3), and 37% (Group 1 vs. 3), CS ASII showed areas under the curve of 0.85, 0.96, and 0.93 for the classification of AL, overall higher than AWO/RWO. In conclusion, AL with qualitative heterogeneous signal drop at CS represent benign AL with QP by DCE sequence similar to those of AL with homogeneous signal drop at CS, but different to those of AL with no signal drop at CS; ASII seems to be the only quantitative parameter able to differentiate AL among the three different groups.
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Affiliation(s)
- Arnaldo Stanzione
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Francesco Verde
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Roberta Galatola
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
- Correspondence: ; Tel.: +39-0817463560; Fax: +39-0815457081
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Raffaele Liuzzi
- Institute of Biostructures and Bioimaging, The National Research Council (CNR), 80131 Naples, Italy; (R.L.); (P.P.M.)
| | - Pier Paolo Mainenti
- Institute of Biostructures and Bioimaging, The National Research Council (CNR), 80131 Naples, Italy; (R.L.); (P.P.M.)
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Michele Klain
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (A.S.); (F.V.); (V.R.); (M.K.); (E.G.); (M.D.B.D.C.); (S.M.)
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Schloetelburg W, Ebert I, Petritsch B, Weng AM, Dischinger U, Kircher S, Buck AK, Bley TA, Deutschbein T, Fassnacht M. Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant adrenal masses. Eur J Endocrinol 2021; 186:183-193. [PMID: 34813495 PMCID: PMC8679842 DOI: 10.1530/eje-21-0650] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/23/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Reliable results of wash-out CT in the diagnostic workup of adrenal incidentalomas are scarce. Thus, we evaluated the diagnostic accuracy of delayed wash-out CT and determined thresholds to accurately differentiate adrenal masses. DESIGN Retrospective, single-center cohort study including 216 patients with 252 adrenal lesions who underwent delayed wash-out CT. Definitive diagnoses based on histopathology (n = 92) or comprehensive follow-up. METHODS Size, average attenuation values of the adrenal lesions in all CT scan phases, and absolute and relative percentage wash-out (APW/RPW) were determined by an expert radiologist blinded for clinical data. Adrenal lesions with unenhanced attenuation values >10 Hounsfield units (HU) built a subgroup (n = 142). Diagnostic accuracy was calculated. RESULTS The study group consisted of 171 adenomas, 32 other benign tumors, 11 pheochromocytomas, 9 adrenocortical carcinomas, and 29 other malignant tumors. All (potentially) malignant and 46% of benign lesions showed unenhanced attenuation values >10 HU. In this most relevant subgroup, the established thresholds of 60% for APW and 40% for RPW misclassified 35.9 and 35.2% of the masses, respectively. When we applied optimized cutoffs (APW >83%; RPW >58%) and excluded pheochromocytomas, we missed only one malignant tumor by APW and none by RPW. However, only 11 and 15% of the benign tumors were correctly identified. CONCLUSIONS Wash-out CT with the established thresholds for APW and RPW is insufficient to reliably diagnose adrenal masses. Using the proposed cutoff of 58% for RPW, malignant tumors will be correctly identified, but the added value is limited, namely 15% of patients with benign tumors can be prevented from additional imaging or even unnecessary surgery.
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Affiliation(s)
- Wiebke Schloetelburg
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Nuclear Medicine, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ines Ebert
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Bernhard Petritsch
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andreas Max Weng
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefan Kircher
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Andreas Konrad Buck
- Department of Nuclear Medicine, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Correspondence should be addressed to M Fassnacht;
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Nawar MMA, Hanna SAAZ, El-Sawy SS, Shokralla SY. Adrenal incidentalomas: imaging challenges—role of MDCT scan versus MRI in evaluating adrenal incidentalomas. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00437-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The term adrenal incidentaloma (AI), by definition, is an adrenal mass that is unexpectedly detected through an imaging procedure performed for reasons unrelated to adrenal dysfunction or suspected dysfunction. Despite their frequent appearance, the challenge remains in recognizing and treating the small percentage of AI that poses a significant risk, either because of their hormonal activity or because of their malignant histology. The aim of this study is to study the role of MRI, specifically chemical shift imaging (CSI), against various MDCT scans (non-enhanced, enhanced, and delayed) in the characterization of incidentally discovered adrenal masses to offer a way for the patients to avoid unnecessary time and money-wasting imaging modalities used to reach a diagnosis of their incidentally discovered adrenal lesions. We examined a total number of 20 patients with total of 22 adrenal lesions. The mean age was 51.1 ± 15.27.
Results
In our study, we found that among CT parameters, APW and RPW showed the highest sensitivity and specificity for detection of lipid-rich adenomas. CSI has also proven to be the best MR technique. However, there is no statistically significant difference in the diagnostic capability of CSI versus the CT washout technique. Both modalities could be conducted, according to specific patient preferences and/or limitations, with comparable highly accurate outcomes.
Conclusion
This study demonstrates that a similar diagnostic outcome is obtained from contrast-enhanced CT (CECT) and MRI with CSI of adrenal lesions.
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Garay-Lechuga D, Pérez-Soto RH, Hernández-Acevedo JD, Butrón-Hernández D, Sierra-Salazar M, Pantoja-Millán JP, Herrera MF, Velázquez-Fernández D. Computed tomography (CT) scan identified necrosis, but is it a reliable single parameter for discerning between malignant and benign adrenocortical tumors? Surgery 2021; 171:104-110. [PMID: 34183180 DOI: 10.1016/j.surg.2021.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/20/2021] [Accepted: 04/05/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare malignant tumor with a poor prognosis. Discernment of adrenocortical carcinoma in an adrenal mass through imaging studies is paramount for early surgical treatment. Recently, necrosis has been proposed as a single morphological parameter for adrenocortical carcinoma diagnosis. The aim of this study was to analyze the measures of diagnostic efficiency of necrosis and the different computed tomography-scan features related to adrenocortical carcinoma diagnosis. METHODS We conducted a case-control study of patients surgically treated for an adrenal mass with histopathological report consistent with adrenocortical carcinoma (cases) and adrenocortical adenoma (control patients) between 1987 and 2019. Radiological features on computed tomography scan were collected. Bivariate and multivariate statistical analyses were performed for the different imaging features. The measures of diagnostic efficiency for each feature were calculated. Concordance analysis between image-detected and histopathological-identified necrosis was performed. RESULTS Eighteen adrenocortical carcinoma and 41 adrenocortical adenomas were included. Differences between adrenocortical carcinoma and adrenocortical adenoma were found regarding heterogeneity (odds ratio 4.53, 95% confidence interval 2.3-8.9; P < .0001), tumor size ≥4 cm (odds ratio 3.5, 95% confidence interval 2.05-6.14; P < .0001), and attenuation index ≥10 Hounsfield units (odds ratio 1.9, 95% confidence interval 1.3-2.6; P = .001). Necrosis was the most important imaging feature significantly associated with adrenocortical carcinoma (odds ratio 35, 95% confidence interval 5.1-241.6; P < .0001), present in all adrenocortical carcinoma cases. After measures of diagnostic efficiency calculation, necrosis had the highest diagnostic accuracy (98%). Cohen's kappa for concordance between image-detected and histopathological-identified necrosis was 90.4% (P < .0001). CONCLUSION Computed tomography scan-detected necrosis is a reliable radiological feature to discern adrenocortical carcinoma from adrenocortical adenomas.
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Affiliation(s)
- Daniel Garay-Lechuga
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico.
| | - Rafael Humberto Pérez-Soto
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico. https://twitter.com/@rafaperezdr
| | - Juan David Hernández-Acevedo
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico. https://twitter.com/@reconditojp
| | - David Butrón-Hernández
- Department of Radiology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Mauricio Sierra-Salazar
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico. https://twitter.com/@DrMSierra
| | - Juan Pablo Pantoja-Millán
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Miguel F Herrera
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - David Velázquez-Fernández
- Endocrine and Advanced Laparoscopic Surgery Service, Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Dietrich CF, Correas JM, Dong Y, Nolsoe C, Westerway SC, Jenssen C. WFUMB position paper on the management incidental findings: adrenal incidentaloma. Ultrasonography 2020; 39:11-21. [PMID: 31786909 PMCID: PMC6920619 DOI: 10.14366/usg.19029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/26/2022] Open
Abstract
Focal lesions of the adrenal glands are incidentally detected in approximately 5% of cases by modern imaging techniques. Fewer than 5% of these adrenal incidentalomas are malignant and approximately 10% have endocrine activity. Reliable differentiation of malignant versus benign and hormonally active versus nonfunctional adrenal incidentalomas significantly influences therapeutic management and the outcome of affected individuals. Therefore, each adrenal incidentaloma should undergo a standardized diagnostic work-up to exclude malignancy and endocrine activity. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on the management of adrenal incidentaloma and describes efficient management strategies with particular reference to the role of ultrasound techniques.
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Affiliation(s)
- Christoph F. Dietrich
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
- Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Germany
| | - Jean Michel Correas
- Service de Radiologie Adultes, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Yi Dong
- Medical Department, Caritas-Krankenhaus, Bad Mergentheim, Germany
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Christian Nolsoe
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital, Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen and Brandenburg Institute for Clinical Ultrasound, Neuruppin, Germany
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9
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Coppola M, Romeo V, Verde F, Raia G, Mainolfi CG, Aprea G, Guadagno E, Cavaliere C, Baldi D, Soricelli A, Mainenti PP, Maurea S. Integrated imaging of adrenal oncocytoma: a case of diagnostic challenge. Quant Imaging Med Surg 2019; 9:1896-1901. [PMID: 31867239 DOI: 10.21037/qims.2019.06.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Milena Coppola
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Francesco Verde
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Giorgio Raia
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Ciro Gabriele Mainolfi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Giovanni Aprea
- Department of General and Mini-invasive Surgery, University of Naples "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | | | | | | | - Pier Paolo Mainenti
- Institute of Biostructures and Bioimaging of the National Research Council (CNR), Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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10
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Buitenwerf E, Berends AMA, van Asselt ADI, Korteweg T, Greuter MJW, Veeger NJM, Links TP, Dullaart RPF, Kerstens MN. Diagnostic Accuracy of Computed Tomography to Exclude Pheochromocytoma: A Systematic Review, Meta-analysis, and Cost Analysis. Mayo Clin Proc 2019; 94:2040-2052. [PMID: 31515105 DOI: 10.1016/j.mayocp.2019.03.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the diagnostic accuracy of unenhanced computed tomography (CT) attenuation values to exclude a pheochromocytoma in the diagnostic work-up of patients with an adrenal incidentaloma and to model the associated difference in diagnostic costs. METHODS The MEDLINE and Embase databases were searched from indexing to September 27, 2018, and studies reporting the proportion of pheochromocytomas on either side of the 10-Hounsfield unit (HU) threshold on unenhanced CT were included. The pooled proportion of pheochromocytomas with an attenuation value greater than 10 HU was determined, as were the modeled financial costs of the current and alternative diagnostic approaches. RESULTS Of 2957 studies identified, 31 were included (N=1167 pheochromocytomas). Overall risk of bias was low. Heterogeneity was not observed between studies (Q=11.5, P=.99, I2=0%). The pooled proportion of patients with attenuation values greater than 10 HU was 0.990 (95% CI, 0.984-0.995). The modeled financial costs using the new diagnostic approach were €55 (∼$63) lower per patient. CONCLUSION Pheochromocytomas can be reliably ruled out in the case of an adrenal lesion with an unenhanced CT attenuation value of 10 HU or less. Therefore, determination of metanephrine levels can be restricted to adrenal tumors with an unenhanced CT attenuation value greater than 10 HU. Implementing this novel diagnostic strategy is cost-saving.
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Affiliation(s)
- Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Annika M A Berends
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Antoinette D I van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tijmen Korteweg
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel J W Greuter
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nic J M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
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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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The role of dynamic post-contrast T1-w MRI sequence to characterize lipid-rich and lipid-poor adrenal adenomas in comparison to non-adenoma lesions: preliminary results. Abdom Radiol (NY) 2018; 43:2119-2129. [PMID: 29214448 DOI: 10.1007/s00261-017-1429-4] [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: 01/06/2023]
Abstract
PURPOSE The purpose of the article is to compare the features of wash-out (WO) parameters between lipid-rich and lipid-poor adrenal adenomas as well as with a group of non-adenoma adrenal lesions. METHODS 46 patients (36 F and 10 M, median age 58 years) with unilateral adrenal lesions (35 adenomas, 7 pheochromocytomas, 1 carcinoma, and 3 metastases) were prospectively evaluated; adrenal lesions were divided into adenomas (Group 1) and non-adenomas (Group 2). MR imaging was performed with a 3-Tesla scanner using pre- and post-contrast dedicated sequences. On the basis of the evaluation of qualitative chemical-shift (CS) signal intensity (SI) loss, adrenal adenomas were, respectively, divided in Group 1A (n = 25) as lipid-rich and Group 1B (n = 10) as lipid-poor; non-adenoma adrenal lesions were grouped in Group 2 (n = 11). The following parameters were evaluated: size (mm), CS SI index (%), early (5 min), and delayed (10 min) Relative (R) and Absolute (A) WO values (%). RESULTS The comparison of AWO and RWO showed significant (p ≤ 0.05) differences between Group 1A and Groups 1B and 2, both using 5- and 10-min images for calculation; conversely, no differences in these dynamic parameters were found between Group 1B and 2; AWO and RWO values were significantly lower in adrenal lesions of Groups 1B and 2 compared to Group 1A, both using 5- and 10-min images for calculation. CONCLUSIONS The quantitative evaluation of WO parameters could not be used to characterize lipid-poor adrenal adenomas for which alternative imaging modalities are required.
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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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Characterization of adrenal lesions using MDCT wash-out parameters: diagnostic accuracy of several combinations of intermediate and delayed phases. Radiol Med 2018; 123:833-840. [PMID: 29923085 DOI: 10.1007/s11547-018-0911-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of wash-out parameters calculated using multiple intermediate and delayed phases. MATERIALS AND METHODS This prospective study had institutional review board approval and informed consent was obtained from all patients. Between January 2012 and October 2016, 108 consecutive oncologic patients (59 males, 49 females, mean age 52.6 years; 129 diagnosed lesions) underwent multiphasic CT protocol including unenhanced (UE), arterial (AE), portal (PE), 5-min (DE-5) and the 15-min (DE-15) delayed phases of adrenal glands. All images were randomly reviewed in consensus by two radiologists experienced in abdominal CT, unaware of clinical or pathologic data. Location, size and density were recorded. Absolute wash-out, percentage wash-out (PWO) and percentage enhancement wash-out ratio were calculated. The thresholds yielding the best accuracy in differentiating adenomas from nonadenomas were retrospectively determined on the basis of ROC curves. The corresponding diagnostic accuracy values were calculated. Paired sample t test was used to assess differences among imaging parameters within subgroups. Student t test was applied to compare lesions between independent subgroups. p values ≤ 0.05 were considered significant. RESULTS The final diagnosis included 82 adenomas (62 lipid-rich and 20 lipid-poor) and 47 nonadenomas (42 metastases, 3 pheochromocytomas, 2 carcinomas). All the 62 lipid-rich adenomas were correctly diagnosed as benign lesions on the basis of their UE attenuation < 10 HU. The PEAK attenuation was achieved during AE phase for 51/129 lesions (39.5%) and at the time of PE phase in 78/129 lesions (60.5%). The best overall accuracy in diagnosing adenomas (97.6%; 126/129 lesions correctly diagnosed) was obtained using 40% threshold for calculating PWO from PEAK to DE-15 scan. CONCLUSIONS If only an intermediate phase is available, the 15-min delayed scan should be acquired to avoid any drop in diagnostic accuracy. The availability of two intermediate phase may be used to easy CT schedule by obviating the need to acquire a longer delayed phase.
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Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, Tabarin A, Terzolo M, Tsagarakis S, Dekkers OM. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175:G1-G34. [PMID: 27390021 DOI: 10.1530/eje-16-0467] [Citation(s) in RCA: 936] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022]
Abstract
: 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.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Wiebke Arlt
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA
| | - Henning Dralle
- Department of GeneralVisceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - John Newell-Price
- Department of Oncology and MetabolismMedical School, University of Sheffield, Sheffield, UK Endocrine UnitRoyal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anju Sahdev
- Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK
| | - Antoine Tabarin
- Department of Endocrinology and INSERM U862University and CHU of Bordeaux, Pessac, France
| | - Massimo Terzolo
- Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Stylianos Tsagarakis
- Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal MedicineLeiden University Medical Centre, Leiden, The Netherlands Department of Clinical EpidemiologyAarhus University, Aarhus, Denmark
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Dinnes J, Bancos I, Ferrante di Ruffano L, Chortis V, Davenport C, Bayliss S, Sahdev A, Guest P, Fassnacht M, Deeks JJ, Arlt W. MANAGEMENT OF ENDOCRINE DISEASE: Imaging for the diagnosis of malignancy in incidentally discovered adrenal masses: a systematic review and meta-analysis. Eur J Endocrinol 2016; 175:R51-64. [PMID: 27257145 PMCID: PMC5065077 DOI: 10.1530/eje-16-0461] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 05/29/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Adrenal masses are incidentally discovered in 5% of CT scans. In 2013/2014, 81 million CT examinations were undertaken in the USA and 5 million in the UK. However, uncertainty remains around the optimal imaging approach for diagnosing malignancy. We aimed to review the evidence on the accuracy of imaging tests for differentiating malignant from benign adrenal masses. DESIGN A systematic review and meta-analysis was conducted. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL Register of Controlled Trials, Science Citation Index, Conference Proceedings Citation Index, and ZETOC (January 1990 to August 2015). We included studies evaluating the accuracy of CT, MRI, or (18)F-fluoro-deoxyglucose (FDG)-PET compared with an adequate histological or imaging-based follow-up reference standard. RESULTS We identified 37 studies suitable for inclusion, after screening 5469 references and 525 full-text articles. Studies evaluated the accuracy of CT (n=16), MRI (n=15), and FDG-PET (n=9) and were generally small and at high or unclear risk of bias. Only 19 studies were eligible for meta-analysis. Limited data suggest that CT density >10HU has high sensitivity for detection of adrenal malignancy in participants with no prior indication for adrenal imaging, that is, masses with ≤10HU are unlikely to be malignant. All other estimates of test performance are based on too small numbers. CONCLUSIONS Despite their widespread use in routine assessment, there is insufficient evidence for the diagnostic value of individual imaging tests in distinguishing benign from malignant adrenal masses. Future research is urgently needed and should include prospective test validation studies for imaging and novel diagnostic approaches alongside detailed health economics analysis.
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Affiliation(s)
| | - Irina Bancos
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Vasileios Chortis
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK
| | | | | | - Anju Sahdev
- Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK
| | - Peter Guest
- Department of RadiologyQueen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Fassnacht
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | | | - Wiebke Arlt
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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