1
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Reimondo G, Solitro F, Puglisi S, Balbi M, Tiranti GM, Perini AME, Cultrera A, Brero D, Botto C, Perotti P, Caramello V, Boccuzzi A, Pia A, Veltri A, Terzolo M. Serendipitous Adrenal Hyperplasia in Patients Admitted to the Emergency Department for Suspected SARS-CoV-2 Infection is Linked to Increased Mortality. Arch Med Res 2024; 55:103010. [PMID: 38805767 DOI: 10.1016/j.arcmed.2024.103010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Few data are available on adrenal morphology in patients with acute diseases, although it is known that endogenous glucocorticoids are essential for survival under stress conditions and that an adequate response is driven by activation of the hypothalamic-pituitary-adrenal (HPA) axis. AIMS The aim of this study was to assess adrenal morphology in patients with acute disease compared with patients with non-acute disease. METHODS This cross-sectional study included: 402 patients admitted to the emergency department (ED) for suspected SARS-CoV-2 infection (March-May, 2020) [main cohort]; 200 patients admitted to the ED for acute conditions (December 2018-February 2019) [control group A]; 200 outpatients who underwent radiological evaluation of non-acute conditions (January-February 2019) [control group B]. Chest and/or abdominal CT scans were reviewed to identify adrenal nodules or hyperplasia. RESULTS In the main cohort, altered adrenal morphology was found in 24.9% of the patients (15.4% adrenal hyperplasia; 9.5% adrenal nodules). The frequency of adrenal hyperplasia was higher both in the main cohort (15.4%) and control group A (15.5%) compared to control group B (8.5%; p = 0.02 and p = 0.03, respectively). In the main cohort, 14.9% patients died within 30 d. According to a multivariate analysis, adrenal hyperplasia was an independent risk factor for mortality (p = 0.04), as were older age (p <0.001) and active cancer (p = 0.01). CONCLUSIONS The notable frequency of adrenal hyperplasia in patients with acute diseases suggests an exaggerated activation of the HPA axis due to stressful conditions. The increased risk of short-term mortality found in patients with adrenal hyperplasia suggests that it may be a possible hallmark of worse prognosis.
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Affiliation(s)
- Giuseppe Reimondo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Federica Solitro
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Soraya Puglisi
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
| | - Maurizio Balbi
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Giorgio Maria Tiranti
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Anna Maria Elena Perini
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Alessandra Cultrera
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Dalila Brero
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Cristina Botto
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Paola Perotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | | | - Adriana Boccuzzi
- Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Anna Pia
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Andrea Veltri
- Radiology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
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2
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Nicola R. Will histogram analysis replace mean attenuation threshold in the diagnosis of adrenal lesions? Radiol Bras 2023; 56:V. [PMID: 37168040 PMCID: PMC10165969 DOI: 10.1590/0100-3984.2023.56.2e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Affiliation(s)
- Refky Nicola
- Associate Professor of Radiology, Division of Abdominal Radiology, SUNY Upstate Medical University, Syracuse, NY, USA.
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3
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Teixeira AP, Haddad Jr. W, Barreto LO, Secaf A, Mermejo LM, Lucchesi FR, Tucci Jr. S, Elias Junior J, Molina CAF, Muglia VF. Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement. Radiol Bras 2023; 56:59-66. [PMID: 37168042 PMCID: PMC10165976 DOI: 10.1590/0100-3984.2022.0067] [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] [Received: 07/03/2022] [Accepted: 09/12/2022] [Indexed: 05/13/2023] Open
Abstract
Objective To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.
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Affiliation(s)
- Ana P. Teixeira
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - William Haddad Jr.
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Luan Oliveira Barreto
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Livia M. Mermejo
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Silvio Tucci Jr.
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Jorge Elias Junior
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Carlos A. F. Molina
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Valdair F. Muglia
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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4
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Mody RN, Remer EM, Nikolaidis P, Khatri G, Dogra VS, Ganeshan D, Gore JL, Gupta RT, Heilbrun ME, Lyshchik A, Mayo-Smith WW, Purysko AS, Savage SJ, Smith AD, Wang ZJ, Wolfman DJ, Wong-You-Cheong JJ, Yoo DC, Lockhart ME. ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update. J Am Coll Radiol 2021; 18:S251-S267. [PMID: 34794587 DOI: 10.1016/j.jacr.2021.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 11/24/2022]
Abstract
The appropriate evaluation of adrenal masses is strongly dependent on the clinical circumstances in which it is discovered. Adrenal incidentalomas are masses that are discovered on imaging studies that have been obtained for purposes other than adrenal disease. Although the vast majority of adrenal incidentalomas are benign, further radiological and biochemical evaluation of these lesions is important to arrive at a specific diagnosis. Patients with a history of malignancy or symptoms of excess hormone require different imaging evaluations than patients with incidentalomas. This document reviews imaging approaches to adrenal masses and the various modalities utilized in evaluation of adrenal lesions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Rekha N Mody
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio.
| | - Erick M Remer
- Cleveland Clinic, Cleveland, Ohio; Chair, Gaps And Harmonization Committee, ACR Appropriateness Criteria; Portfolio Director, Society of Abdominal Radiology; Chair, Section Urinary Imaging, Scientific Program Committee, American Roentgen Ray Society
| | - Paul Nikolaidis
- Panel Chair, Northwestern University, Chicago, Illinois; Vice-Chair, Operations - Diagnostic Imaging, Northwestern University
| | - Gaurav Khatri
- Panel Vice-Chair, UT Southwestern Medical Center, Dallas, Texas
| | - Vikram S Dogra
- University of Rochester Medical Center, Rochester, New York; and Chair, Penile Performance Consensus Statement
| | | | - John L Gore
- University of Washington, Seattle, Washington; American Urological Association
| | - Rajan T Gupta
- Duke University Medical Center, Durham, North Carolina; and Chair, ACR Meetings Sub-committee, Commission on Publications and Lifelong Learning
| | - Marta E Heilbrun
- Vice-Chair for Quality, Emory Radiology Department, Emory University School of Medicine, Atlanta, Georgia; and RSNA Structured Reporting Subcommittee Chair
| | - Andrej Lyshchik
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Board Member, ICUS
| | | | | | - Stephen J Savage
- Medical University of South Carolina, Charleston, South Carolina; American Urological Association
| | - Andrew D Smith
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Zhen J Wang
- University of California San Francisco School of Medicine, San Francisco, California
| | - Darcy J Wolfman
- Clinical Director, Ultrasound Hopkins NCR; and Committee Chair, ACR US Accreditation Johns Hopkins University School of Medicine, Washington, District of Columbia
| | - Jade J Wong-You-Cheong
- University of Maryland School of Medicine, Baltimore, Maryland; and Vice-Chair Quality and Safety, Diagnostic Radiology, University of Maryland Medical Center
| | - Don C Yoo
- Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mark E Lockhart
- Speciatly Chair, University of Alabama at Birmingham, Birmingham, Alabama; Chair, Radiology Departmental Appointments, Promotions, and Tenure Committee, and Departmental Chief, Genitourinary Imaging, University of Alabama at Birmingham, Birmingham, Alabama; Chair, ACR Appropriateness Committee; Chair, Society of Radiologists in Ultrasound, Annual Meeting Program Committee; and Chair, Research Committee of AIUM Future Fund
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5
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Wang K, Tang G, Peng Y, Li C, Fu W, Li R, Guan J. Adrenal pheochromocytoma: is it all or the tip of the iceberg? Jpn J Radiol 2021; 40:120-134. [PMID: 34546504 DOI: 10.1007/s11604-021-01199-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022]
Abstract
Adrenal pheochromocytoma is not always a simple retroperitoneal tumor but may be part of a more complicated condition. It often has a spectrum of complex and variable imaging features, may present as a collision tumor and composite tumor, and is associated with a variety of clinical syndromes. A comprehensive understanding of the clinical, pathological, and variable imaging manifestations of pheochromocytoma can help radiologists make an accurate diagnosis. This article reviews various special imaging features of pheochromocytoma and pheochromocytoma-related diseases.
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Affiliation(s)
- Ke Wang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Guanglei Tang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yang Peng
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Chang Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Wenhao Fu
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Ruixi Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jian Guan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No. 58 Zhongshanerlu Road, Guangzhou, 510080, Guangdong, People's Republic of China.
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Nagayama Y, Inoue T, Oda S, Tanoue S, Nakaura T, Morinaga J, Ikeda O, Hirai T. Unenhanced Dual-Layer Spectral-Detector CT for Characterizing Indeterminate Adrenal Lesions. Radiology 2021; 301:369-378. [PMID: 34427466 DOI: 10.1148/radiol.2021202435] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Unenhanced dual-layer spectral-detector CT may facilitate adrenal lesion characterization; however, no studies have evaluated its incremental diagnostic yield for indeterminate lesions (unenhanced attenuation >10 HU) in comparison to that with conventional unenhanced CT. Purpose To determine whether spectral attenuation analysis improves characterization of lipid-poor adrenal adenomas from nonadenomas compared to that with mean attenuation and histogram analysis of conventional CT images. Materials and Methods This retrospective study included patients with indeterminate adrenal lesions who underwent unenhanced dual-layer spectral-detector CT between March 2018 and June 2020. Mean attenuation on conventional 120-kVp images (HUconv), histogram-based percentage negative pixels (proportion of all pixels <0 HU) on conventional 120-kVp images, and mean attenuation on virtual monoenergetic images (VMIs) at 40-140 keV were measured for each lesion. The attenuation difference between virtual monoenergetic 140- and 40-keV images (ΔHU; ie, Hounsfield unit at 140 keV - Hounsfield unit at 40 keV) and ΔHU indexed with HUconv (ΔHU index; ie, ΔHU/HUconv × 100) were calculated. Conventional and virtual monoenergetic imaging parameters were compared between lipid-poor adenomas and nonadenomas by using the Mann-Whitney U test. Receiver operating characteristic analysis was performed to determine the sensitivity for attaining at least 95% specificity in characterizing adenomas from nonadenomas; sensitivity was compared by using the McNemar test. Results A total of 232 patients (mean age ± standard deviation, 67 years ± 11; 145 men) with 129 lipid-poor adenomas and 103 nonadenomas were evaluated. HUconv and mean attenuation on VMIs at 40-140 keV were lower and the percentage negative pixels, ΔHU, and ΔHU index higher in lipid-poor adenomas than in nonadenomas (P < .001 for all). Attenuation differences between adenomas and nonadenomas on VMIs were maximal at 40 keV (23 HU at 40 keV vs 5 HU at 140 keV). The highest sensitivities for differentiating adenomas and nonadenomas were achieved for virtual monoenergetic ΔHU index (77% [99 of 129 adenomas]), attenuation on 40-keV images (71% [91 of 129 adenomas]), and ΔHU (67% [87 of 129 adenomas]) compared to HUconv (35% [45 of 129 adenomas]) and percentage negative pixels (30% [39 of 129 adenomas]) (P < .001 for all; specificity, 95% [98 of 103 nonadenomas]). Conclusion Spectral attenuation analysis enabled differentiation of lipid-poor adenomas from nonadenomas with higher sensitivity than mean attenuation or histogram analysis of conventional CT images. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Yasunori Nagayama
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Taihei Inoue
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Seitaro Oda
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Shota Tanoue
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Takeshi Nakaura
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Jun Morinaga
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Osamu Ikeda
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
| | - Toshinori Hirai
- From the Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556, Japan (Y.N., T.I., S.O., S.T., T.N., O.I., T.H.); and Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan (J.M.)
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Abstract
Incidentally detected adrenal nodules are common, and prevalence increases with patient age. Although most are benign, it is important for the radiologist to be able to accurately determine which nodules require further testing and which are safely left alone. The American College of Radiology incidental adrenal White Paper provides a structured algorithm based on expert consensus for management of incidental adrenal nodules. If further diagnostic testing is indicated, adrenal computed tomography is the most appropriate test in patients for nodules less than 4 cm. In addition to imaging, biochemical testing and endocrinology referral is warranted to exclude a functioning mass.
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Affiliation(s)
- Daniel I Glazer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Michael T Corwin
- Department of Radiology, University of California, Davis, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
| | - William W Mayo-Smith
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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8
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Szász P, Kučera P, Čtvrtlík F, Langová K, Hartmann I, Tüdös Z. Diagnostic Value of Unenhanced CT Attenuation and CT Histogram Analysis in Differential Diagnosis of Adrenal Tumors. MEDICINA-LITHUANIA 2020; 56:medicina56110597. [PMID: 33182333 PMCID: PMC7695290 DOI: 10.3390/medicina56110597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 01/13/2023]
Abstract
Background and Objectives: Our aim was to verify the optimal cut-off value for unenhanced CT attenuation and the percentage of negative voxels in the volume CT histogram analysis of adrenal masses. Materials and Methods: We retrospectively analyzed the CT data of patients who underwent an adrenalectomy in the period 2002-2019. In total, 413 adrenalectomies were performed. Out of these, 233 histologically verified masses (123 adenomas, 58 pheochromocytomas, 18 carcinomas, and 34 metastases) fulfilled the inclusion criteria and were selected for analysis. The mean unenhanced attenuation in Hounsfield units (HU) and the percentage of voxels with attenuation less than 0 HU (negative voxels) were measured in each mass. Results: The mean unenhanced attenuation with a cut-off value of 10 HU reached a sensitivity of 59.4% and a specificity of 99.1% for benign adenomas. The mean unenhanced attenuation with a cut-off value of 15 HU reached a sensitivity of 69.1% and a specificity of 98.2%. For the histogram analysis, a cut-off value of 10% of negative pixels reached a sensitivity of 82.9% and a specificity of 98.2%, whereas a cut-off value of 5% of negative pixels reached a sensitivity of 87.8% and a specificity of 75.5%. The percentage of negative voxels reached a slightly better area under the curve (0.919) than unenhanced attenuation (0.908). Conclusion: Mean unenhanced attenuation with a cut-off value of 10 HU represents a simple tool, and the most specific one, to distinguish adrenal adenomas from non-adenomas. CT histogram analysis with cut-off values of 10% of negative voxels improves sensitivity without any loss of specificity.
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Affiliation(s)
- Paulína Szász
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic; (P.S.); (P.K.); (F.Č.)
| | - Petr Kučera
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic; (P.S.); (P.K.); (F.Č.)
| | - Filip Čtvrtlík
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic; (P.S.); (P.K.); (F.Č.)
| | - Kateřina Langová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University, 775 15 Olomouc, Czech Republic;
| | - Igor Hartmann
- Department of Urology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic;
| | - Zbyněk Tüdös
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic; (P.S.); (P.K.); (F.Č.)
- Correspondence: ; Tel.: +420-588-445-995
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9
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Glazer DI, Mayo-Smith WW. Letter to the editor response. Abdom Radiol (NY) 2020; 45:2939. [PMID: 32700211 DOI: 10.1007/s00261-020-02666-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Daniel I Glazer
- Division of Abdominal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - William W Mayo-Smith
- Division of Abdominal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA, 02120, USA
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10
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Tüdös Z, Čtvrtlík F. Possible impact of CT histogram analysis in incidentally discovered adrenal masses. Abdom Radiol (NY) 2020; 45:2937-2938. [PMID: 32451677 DOI: 10.1007/s00261-020-02596-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Zbyněk Tüdös
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, I. P. Pavlova 6, 77900, Olomouc, Czech Republic.
| | - Filip Čtvrtlík
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, I. P. Pavlova 6, 77900, Olomouc, Czech Republic
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11
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Comparison of Histogram-Based Gaussian Analysis With and Without Noise Correction for the Characterization of Indeterminate Adrenal Nodules. AJR Am J Roentgenol 2020; 215:896-902. [PMID: 32809863 DOI: 10.2214/ajr.19.22531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study is to determine whether gaussian-based histogram analysis without and with noise correction can characterize indeterminate adrenal nodules (those with attenuation greater than 10 HU on unenhanced CT) as lipid-poor adenomas. MATERIALS AND METHODS. This retrospective study evaluated adrenal nodules larger than 1 cm on unenhanced CT using gaussian analysis without and with noise correction on intralesional ROIs. Two independent readers who were blinded to the final diagnoses evaluated the nodules. The final diagnosis for each nodule was determined on the basis of pathologic findings or accepted imaging criteria. Interreader agreement was assessed using the intraclass correlation coefficient. Algorithm performance was summarized using sensitivity, specificity, and the AUC. RESULTS. Ninety-four adrenal nodules in 85 patients were analyzed; 36 of these were metastases (34 of which were pathologically confirmed), and 58 were presumed adenomas. Interreader agreement was excellent for nodule size, mean attenuation, SD of attenuation, and the gaussian index. Noise-corrected gaussian analysis had significantly higher specificity (81.9% vs 55.6%; p < 0.001) and lower sensitivity (36.2% vs 56.9%; p < 0.001) for identifying adenomas than did the uncorrected gaussian analysis. The AUC of corrected gaussian analysis was 0.72, which is significantly greater than that of uncorrected gaussian analysis (0.51; p ≤ 0.001) and similar to that of mean attenuation (0.77). CONCLUSION. Noise correction is necessary when using a gaussian analysis characterization of indeterminate adrenal nodules on modern unenhanced CT examinations. This method may be able to discriminate between adenomas and nonadenomas.
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Influence of slice thickness on result of CT histogram analysis in indeterminate adrenal masses. Abdom Radiol (NY) 2019; 44:1461-1469. [PMID: 30460531 DOI: 10.1007/s00261-018-1835-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE The aim was to determine the optimal slice thickness of CT images and the optimal threshold of negative voxels for CT histogram analysis to distinguish adrenal adenomas from non-adenomas with a mean attenuation more than 10 Hounsfield units (HU). METHODS Volume CT histogram analysis of 83 lipid-poor adenomas and 80 non-adenomas was performed retrospectively. The volume of interest was extracted from each adrenal lesion, and the mean attenuation, standard deviation (SD), and percentage of voxels with a negative CT value were recorded using reconstructions with different slice thicknesses (5 mm, 2.5 mm, 1.25 mm). The percentage of negative voxels was correlated with SD as a measure of image noise and with the reference splenic tissue values. The sensitivity, specificity, and positive predictive value (PPV) for the identification of adenomas were calculated using reconstructions with different slice thicknesses and three different thresholds of negative voxels (1%, 5%, 10%). RESULTS The percentage of negative voxels increased with a thinner slice thickness and correlated with increasing CT image noise in adenomas, non-adenomas, and spleen. Using a threshold of 10% negative voxels and a slice thickness of 5 mm, we reached a sensitivity of 53.0%, specificity of 98.8% and the highest PPV, and thus we propose this combination for clinical use. Other combinations achieved a clearly lower specificity and PPV as a result of the increasing noise in CT images. CONCLUSION The CT slice thickness significantly affects the result and diagnostic value of histogram analysis. Thin CT slice reconstructions are inappropriate for histogram analysis.
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Clark TJ, Hsu LD, Hippe D, Cowan S, Carnell J, Wang CL. Evaluation of diagnostic accuracy: multidetector CT image noise correction improves specificity of a Gaussian model-based algorithm used for characterization of incidental adrenal nodules. Abdom Radiol (NY) 2019; 44:1033-1043. [PMID: 30600378 DOI: 10.1007/s00261-018-1871-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate whether the histogram analysis method of characterizing adrenal nodules as adenomas is affected by increased noise with modern CT technique, and if an extension that allows for noise correction will improve diagnostic performance. MATERIALS AND METHODS This is a HIPAA-compliant, IRB-approved retrospective study performed on 58 total patients. The first group of 29 patients had 33 adrenal lesions that were pathology-proven non-adenomas. The second group had 29 patients with 33 pathology-proven or presumed adenomas based on established imaging criteria. The nodules were evaluated using the histogram method, mean attenuation method, and a Gaussian model-based algorithm without (uncorrected Gaussian algorithm) and with correction (corrected Gaussian algorithm) for image noise. Sensitivity, specificity, and accuracy for identifying adenoma were derived. RESULTS There were no significant differences in identifying adenoma from non-adenoma when using the histogram analysis method and the uncorrected Gaussian algorithm, both of which had low specificities of 42.4% and 47.0%, respectively (p = 0.30). Adding noise correction to the Gaussian algorithm resulted in a statistically significant increase in specificity relative to the histogram method (86.4% vs. 42.4%, p < 0.001). The corrected Gaussian algorithm improved sensitivity compared to the mean attenuation method (71.2% vs. 54.5%, p < 0.001), but had lower specificity (86.4% vs. 100%, p < 0.001), and similar overall accuracy (78.8% vs. 77.3%, p = 0.74). CONCLUSION With modern low-dose CT technique, the specificity scores of the histogram method for discrimination of adrenal adenomas and non-adenomas are lower than with previous higher dose scans. The specificity and accuracy of a histogram-equivalent method can be increased mathematically through image noise correction, and the corrected Gaussian algorithm has improved sensitivity to the mean attenuation with similar accuracy albeit with lower specificity. Although this suggests limited utility for histogram analysis in adrenal nodule characterization, our study demonstrates the potential mathematical application for other noise-dependent CT characterization methods.
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Affiliation(s)
- Toshimasa J Clark
- Abdominal Imaging Division, Department of Radiology, University of Colorado Denver, Anschutz Medical Campus, 12401 E 17th Ave, Mail Stop L954, Aurora, CO, 80045, USA.
| | - Larson D Hsu
- Department of Radiology, Roswell Park Cancer Institute, Body Imaging Section Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - Daniel Hippe
- Body Imaging Section, Department of Radiology, University of Washington, Box 358081, 825 Eastlake Ave E, G2-600, Seattle, WA, 98109, USA
| | - Sophie Cowan
- Body Imaging Section, Department of Radiology, University of Washington, Box 358081, 825 Eastlake Ave E, G2-600, Seattle, WA, 98109, USA
| | - Jonathan Carnell
- Body Imaging Section, Department of Radiology, University of Washington, Box 358081, 825 Eastlake Ave E, G2-600, Seattle, WA, 98109, USA
| | - Carolyn L Wang
- Body Imaging Section, Department of Radiology, University of Washington, Box 358081, 825 Eastlake Ave E, G2-600, Seattle, WA, 98109, USA
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Can Texture Analysis Be Used to Distinguish Benign From Malignant Adrenal Nodules on Unenhanced CT, Contrast-Enhanced CT, or In-Phase and Opposed-Phase MRI? AJR Am J Roentgenol 2019; 212:554-561. [PMID: 30620676 DOI: 10.2214/ajr.18.20097] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this study is to determine whether second-order texture analysis can be used to distinguish lipid-poor adenomas from malignant adrenal nodules on unenhanced CT, contrast-enhanced CT (CECT), and chemical-shift MRI. MATERIALS AND METHODS In this retrospective study, 23 adrenal nodules (15 lipid-poor adenomas and eight adrenal malignancies) in 20 patients (nine female patients and 11 male patients; mean age, 59 years [range, 15-80 years]) were assessed. All patients underwent unenhanced CT, CECT, and chemical-shift MRI. Twenty-one second-order texture features from the gray-level cooccurrence matrix and gray-level run-length matrix were calculated in 3D. The mean values for 21 texture features and four imaging features (lesion size, unenhanced CT attenuation, CECT attenuation, and signal intensity index) were compared using a t test. The diagnostic performance of texture analysis versus imaging features was also compared using AUC values. Multivariate logistic regression models to predict malignancy were constructed for texture analysis and imaging features. RESULTS Lesion size, unenhanced CT attenuation, and the signal intensity index showed significant differences between benign and malignant adrenal nodules. No significant difference was seen for CECT attenuation. Eighteen of 21 CECT texture features and nine of 21 unenhanced CT texture features revealed significant differences between benign and malignant adrenal nodules. CECT texture features (mean AUC value, 0.80) performed better than CECT attenuation (mean AUC value, 0.60). Multivariate logistic regression models showed that CECT texture features, chemical-shift MRI texture features, and imaging features were predictive of malignancy. CONCLUSION Texture analysis has a potential role in distinguishing benign from malignant adrenal nodules on CECT and may decrease the need for additional imaging studies in the workup of incidentally discovered adrenal nodules.
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Histogram Analysis of Adrenal Lesions With a Single Measurement for 10th Percentile: Feasibility and Incremental Value for Diagnosing Adenomas. AJR Am J Roentgenol 2018; 211:1227-1233. [DOI: 10.2214/ajr.17.19159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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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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Čtvrtlík F, Koranda P, Schovánek J, Škarda J, Hartmann I, Tüdös Z. Current diagnostic imaging of pheochromocytomas and implications for therapeutic strategy. Exp Ther Med 2018; 15:3151-3160. [PMID: 29545830 PMCID: PMC5840941 DOI: 10.3892/etm.2018.5871] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/03/2018] [Indexed: 12/13/2022] Open
Abstract
The topic of pheochromocytomas is becoming increasingly popular as a result of major advances in different medical fields, including laboratory diagnosis, genetics, therapy, and particularly in novel advances in imaging techniques. The present review article discusses current clinical, biochemical, genetic and histopathological aspects of the diagnosis of pheochromocytomas and planning of pre-surgical preparation and subsequent surgical treatment options. The main part of the paper is focused on the role of morphological imaging methods (primarily computed tomography and magnetic resonance imaging) and functional imaging (scintigraphy and positron emission tomography) in the diagnosis and staging of pheochromocytomas.
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Affiliation(s)
- Filip Čtvrtlík
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
| | - Pavel Koranda
- Department of Nuclear Medicine, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
| | - Jan Schovánek
- Department of Internal Medicine III-Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
| | - Jozef Škarda
- Department of Clinical and Molecular Pathology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
| | - Igor Hartmann
- Department of Urology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
| | - Zbyněk Tüdös
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry, Palacky University, 779 00 Olomouc, Czech Republic
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Differentiation of Malignant and Benign Adrenal Lesions With Delayed CT: Multivariate Analysis and Predictive Models. AJR Am J Roentgenol 2018; 210:W156-W163. [PMID: 29412015 DOI: 10.2214/ajr.17.18428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study is to identify imaging and patient parameters that affect the diagnostic performance of delayed contrast-enhanced CT for distinguishing malignant from benign adrenal lesions larger than 1 cm in adult patients and to derive predictive models. MATERIALS AND METHODS This retrospective study assessed 97 pathologically proven adrenal lesions that had undergone unenhanced, portal venous, and 15-minute delayed CT. Quantitatively, single-parameter evaluations of lesion attenuation (in Hounsfield units) and absolute percentage enhancement washout (APEW) and relative percentage enhancement washout (RPEW) were performed. In addition, descriptive CT features (lesion size, margin definition, heterogeneity vs homogeneity, fat, and calcification) and patients' demographic characteristics and medical history of malignancy were evaluated for association with lesion status using multiple logistic regression with stepwise model selection. Areas under the ROC curve (Az) were determined for univariate and multivariate analyses. Leave-one-lesion-out cross-validation was applied to ascertain the predictive performance of single-parameter and multivariate evaluations. RESULTS The Az values for unenhanced attenuation, portal venous attenuation, delayed attenuation, APEW, and RPEW were 0.835, 0.534, 0.847, 0.792, and 0.871, respectively. Multivariate analyses revealed that portal venous attenuation, delayed attenuation, and APEW were significant features, with an Az of 0.923 when combined. The addition of the descriptive CT features increased the Az to 0.938; patient age and a history of malignancy were additional significant factors, increasing the Az to 0.956 and 0.972, respectively. The combined predictive classifier yielded 89% accuracy under cross-validation, compared with the best commonly applied single-parameter evaluation (77% for RPEW < 40%). CONCLUSION Multivariate imaging evaluation applied to delayed contrast-enhanced CT alone, with or without patient characteristics, improves diagnostic performance for characterizing adrenal lesions beyond those of single-parameter evaluations. Predictive formulas assessing the probabilities of lesion benignity or malignancy are provided.
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Romeo V, Maurea S, Cuocolo R, Petretta M, Mainenti PP, Verde F, Coppola M, Dell'Aversana S, Brunetti A. Characterization of Adrenal Lesions on Unenhanced MRI Using Texture Analysis: A Machine-Learning Approach. J Magn Reson Imaging 2018; 48:198-204. [DOI: 10.1002/jmri.25954] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/30/2017] [Indexed: 12/16/2022] Open
Affiliation(s)
- Valeria Romeo
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Renato Cuocolo
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Mario Petretta
- Department of Translational Medical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Pier Paolo Mainenti
- Institute of Biostructures and Bioimaging of the National Research Council (CNR); Naples Italy
| | - Francesco Verde
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Milena Coppola
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Serena Dell'Aversana
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences; University of Naples “Federico II,”; Naples Italy
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Melo-Leite AFD, Elias PCL, Teixeira SR, Tucci S, Barros GE, Antonini SR, Muglia VF, Elias J. Adrenocortical neoplasms in adulthood and childhood: distinct presentation. Review of the clinical, pathological and imaging characteristics. J Pediatr Endocrinol Metab 2017; 30:253-276. [PMID: 28170340 DOI: 10.1515/jpem-2016-0080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 10/05/2016] [Indexed: 12/21/2022]
Abstract
Adrenocortical tumors (ACT) in adulthood and childhood vary in clinical, histopathological, molecular, prognostic, and imaging aspects. ACT are relatively common in adults, as adenomas are often found incidentally on imaging. ACT are rare in children, though they have a significantly higher prevalence in the south and southeast regions of Brazil. In clinical manifestation, adults with ACT present more frequently with glucocorticoid overproduction (Cushing syndrome), mineralocorticoid syndromes (Conn syndrome), or the excess of androgens in women. Subclinical tumors are frequently diagnosed late, associated with compression symptoms of abdominal mass. In children, the usual presentation is the virilizing syndrome or virilizing association and hypercortisolism. Histopathological grading and ACT classification in malignant and benign lesions are different for adults and children. In adults, the described criteria are the Hough, Weiss, modified Weiss, and Van Slooten. These scores are not valid for children; there are other criteria, such as proposed by Wieneke and colleagues. In molecular terms, there is also a difference related to genetic alterations found in these two populations. This review discusses the imaging findings of ACT, aiming to characterize the present differences between ACT found in adults and children. We listed several differences between magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography-computed (PET-CT) and also performed a literature review, which focuses on studied age groups of published articles in the last 10 years regarding cortical neoplasm and imaging techniques. Published studies on ACT imaging in children are rare. It is important to stress that the majority of publications related to the differentiation of malignant and benign tumors are based almost exclusively on studies in adults. A minority of articles, however, studied adults and children together, which may not be appropriate.
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Abstract
OBJECTIVE The objective of this article is to review the current role of CT and MRI for the characterization of adrenal nodules. CONCLUSION Unenhanced CT and chemical-shift MRI have high specificity for lipid-rich adenomas. Dual-energy CT provides comparable to slightly lower sensitivity for the diagnosis of lipid-rich adenomas but may improve characterization of lipid-poor adenomas. Nonadenomas containing intracellular lipid pose an imaging challenge; however, nonadenomas that contain lipid may be potentially diagnosed using other imaging features. Multiphase adrenal washout CT can be used to differentiate lipid-poor adenomas from metastases but is limited for the diagnosis of hypervascular malignancies and pheochromocytoma.
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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: 910] [Impact Index Per Article: 113.8] [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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Priola AM, Priola SM. Is Computed Tomography Really Reliable in Differentiation of Thymomas According to the Masaoka-Koga Staging System? Ann Thorac Surg 2016; 101:2022. [DOI: 10.1016/j.athoracsur.2015.10.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 10/10/2015] [Accepted: 10/16/2015] [Indexed: 11/27/2022]
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Zhu M, Qu J, Han Z. Evaluate the efficacy of minimum attenuation value in differentiation of adrenal adenomas from nonadenomas on unenhanced CT. Clin Imaging 2016; 40:86-9. [DOI: 10.1016/j.clinimag.2015.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/05/2015] [Accepted: 09/04/2015] [Indexed: 11/26/2022]
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Petersenn S, Richter PA, Broemel T, Ritter CO, Deutschbein T, Beil FU, Allolio B, Fassnacht M. Computed tomography criteria for discrimination of adrenal adenomas and adrenocortical carcinomas: analysis of the German ACC registry. Eur J Endocrinol 2015; 172:415-22. [PMID: 25599706 DOI: 10.1530/eje-14-0916] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Thresholds of 2-20 hounsfield units (HU) in unenhanced computed tomography (CT) are suggested to discriminate benign adrenal tumors (BATs) from malignant adrenal tumors. However, these studies included only low numbers of adrenocortical carcinomas (ACCs). This study defines a HU threshold by inclusion of a large cohort of ACCs. DESIGN Retrospective, blinded, comparative analysis of CT scans from 51 patients with ACCs (30 females, median age 49 years) and 25 patients with BATs (12 females, median age 64 years) diagnosed during the period of 2005-2010 was performed. METHODS Tumor density was evaluated in unenhanced CT by two blinded investigators. RESULTS Median tumor size was 9 cm (range 2.0-20) for ACCs vs 4 cm (2.0-7.5) for BATs (P<0.0001). In ACCs, the median unenhanced HU value was 34 (range 14-74) in comparison with 5 (-13 to 40) in BATs (P<0.0001). ROC analysis revealed a HU of 21 as threshold with the best diagnostic accuracy (sensitivity 96%, specificity 80%, and AUC 0.89). However, two ACCs that were 5 and 6 cm in size would have been missed. Setting the threshold to 13.9 allowed for 100% sensitivity, but a lower specificity of 68%. CONCLUSIONS This first large study on ACCs confirmed that the vast majority of ACCs have unenhanced HU >21. However, to avoid misdiagnosing an ACC as benign, a threshold of 13 should be used.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Paul-Ajoy Richter
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Thomas Broemel
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Christian O Ritter
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Frank-Ulrich Beil
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Bruno Allolio
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany ENDOC Center for Endocrine TumorsAltonaer Street 59, 20357 Hamburg, GermanyDepartment of Internal MedicineUniversity of Hamburg, Hamburg, GermanyPraenobis HamburgHamburg, GermanyDepartment of RadiologyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University HospitalComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
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Histogram analysis for characterization of indeterminate adrenal nodules on noncontrast CT. ACTA ACUST UNITED AC 2014; 40:1666-74. [DOI: 10.1007/s00261-014-0307-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Low yield of chemical shift MRI for characterization of adrenal lesions with high attenuation density on unenhanced CT. ACTA ACUST UNITED AC 2014; 40:318-26. [DOI: 10.1007/s00261-014-0208-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
PURPOSE OF REVIEW Adrenal incidentalomas are common in this era of ubiquitous imaging. There is a lack of consensus on the mode and extent of evaluation, and follow-up of adrenal incidentalomas. RECENT FINDINGS There is increasing evidence of morbidity associated with subclinical hormone excess from functioning adrenal masses. Improved radiological techniques and interpretation have helped identify lipid-rich adenomas more accurately and tailor the evaluation of adrenal incidentalomas. SUMMARY A practical outline in the investigation and follow-up of adrenal incidentalomas incorporating the recent evidence is presented.
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Affiliation(s)
- Subramanian Kannan
- Endocrinology Diabetes and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
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Goenka AH, Shah SN, Remer EM, Berber E. Adrenal imaging: a primer for oncosurgeons. J Surg Oncol 2012; 106:543-8. [PMID: 22886706 DOI: 10.1002/jso.23235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 07/10/2012] [Indexed: 12/21/2022]
Abstract
Differentiation of an incidental adrenal lesion into benign and malignant etiologies is an endeavor with significant and obvious clinical benefit. Advances in imaging now enable this differentiation in high proportion of patients in a non-invasive manner. The ACR guidelines elaborated in this review seek to promote clinically meaningful, evidence-based approach to an IAL. Knowledge of the potential as well the limitations of individual modalities is essential so as to streamline investigations in a cost-effective manner.
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Affiliation(s)
- Ajit H Goenka
- Section of Abdominal Imaging, Cleveland Clinic, Imaging Institute, Cleveland, Ohio 44195, USA
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32
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Radiologie der Nebennieren. Radiologe 2012; 52:463-74. [DOI: 10.1007/s00117-012-2322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McDermott S, O'Connor OJ, Cronin CG, Blake MA. Radiological evaluation of adrenal incidentalomas: current methods and future prospects. Best Pract Res Clin Endocrinol Metab 2012; 26:21-33. [PMID: 22305450 DOI: 10.1016/j.beem.2011.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Incidental adrenal lesions are very common. Computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) all have a role to play in characterizing adrenal lesions. The purpose of this review is to discuss the rationale behind both established and emerging imaging techniques. We also discuss how to follow up incidentally found lesions.
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Affiliation(s)
- S McDermott
- Department of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA 02114, USA.
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34
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Sancho JJ, Triponez F, Montet X, Sitges-Serra A. Surgical management of adrenal metastases. Langenbecks Arch Surg 2011; 397:179-94. [DOI: 10.1007/s00423-011-0889-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/30/2011] [Indexed: 10/14/2022]
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Abstract
OBJECTIVE Adrenal nodules are frequently encountered on current high-resolution imaging, and accurate characterization of such lesions is critical for appropriate patient care. Our article highlights how imaging techniques such as CT densitometry, CT washout characteristics, chemical shift MRI, PET, and PET/CT help characterize most adrenal lesions. We focus on these techniques as well as specifically, because of space constraints, the varied imaging appearances of adrenocortical carcinoma, pheochromocytoma, and lymphoma on these techniques. CONCLUSION The imaging characterization of adrenal lesions has continued to advance over the past decade as new technologies have evolved. CT, MRI, PET, and PET/CT are now established clinical techniques capable of differentiating benign from malignant adrenal lesions.
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Abstract
With the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are being detected more often. The important clinical question is whether these lesions are benign adenomas or malignant primary or secondary masses. Benign adrenal masses such as lipid-rich adenomas, myelolipomas, adrenal cysts and adrenal haemorrhage have pathognomonic cross-sectional imaging appearances. However, there remains a significant overlap between imaging features of some lipid-poor adenomas and malignant lesions. The nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography (CT) and magnetic resonance imaging (MRI) alone. Positron emission tomography (PET) is also increasingly used in clinical practice in characterizing incidentally detected lesions. We review the performance of the established and new techniques in CT, MRI and PET that can be used to distinguish benign adenomas and malignant lesions of the adrenal gland.
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Affiliation(s)
- Anju Sahdev
- Department of Radiology, St Bartholomew's Hospital, Dominion House, 59 Bartholomew's Close, London, EC1A 7ED, UK.
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Halefoglu AM, Bas N, Yasar A, Basak M. Differentiation of adrenal adenomas from nonadenomas using CT histogram analysis method: A prospective study. Eur J Radiol 2010; 73:643-51. [DOI: 10.1016/j.ejrad.2008.12.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Revised: 10/31/2008] [Accepted: 12/11/2008] [Indexed: 10/21/2022]
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Johnson PT, Horton KM, Fishman EK. Adrenal imaging with multidetector CT: evidence-based protocol optimization and interpretative practice. Radiographics 2009; 29:1319-31. [PMID: 19755598 DOI: 10.1148/rg.295095026] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Computed tomography (CT) is an integral tool in the assessment of adrenal masses. Dedicated adrenal CT is performed for a range of indications, including hormonal abnormalities suggestive of a functional adrenal mass and adrenal cancer staging. It is important to have an understanding of the published data that guide protocol design and image interpretation. Whether an adrenal mass is identified serendipitously or is being imaged for further characterization, there are several CT findings that contribute to the diagnosis, such as lesion size, precontrast attenuation, level of enhancement at 60 seconds and on delayed images, percentage washout on delayed images, histogram analysis, and extent (involvement of the inferior vena cava and bilaterality). In the past decade, a body of pertinent literature has evolved, addressing each of these measures individually.
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Affiliation(s)
- Pamela T Johnson
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N Caroline St, Baltimore, MD 21287, USA.
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Boland GWL, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 2008; 249:756-75. [PMID: 19011181 DOI: 10.1148/radiol.2493070976] [Citation(s) in RCA: 230] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Incidental adrenal lesions are commonly detected at computed tomography, and lesion characterization is critical, particularly in the oncologic patient. Imaging tests have been developed that can accurately differentiate these lesions by using a variety of principles and techniques, and each is discussed in turn. An imaging algorithm is provided to guide radiologists toward the appropriate test to make the correct diagnosis.
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Affiliation(s)
- Giles W L Boland
- Department of Radiology, Massachusetts General Hospital, White Building 270C, 55 Fruit St, Boston, MA 02114, USA.
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Lipid-poor adenomas on unenhanced CT: does histogram analysis increase sensitivity compared with a mean attenuation threshold? AJR Am J Roentgenol 2008; 191:234-8. [PMID: 18562751 DOI: 10.2214/ajr.07.3150] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of our study was to evaluate the efficacy of CT histogram analysis for further characterization of lipid-poor adenomas on unenhanced CT. MATERIALS AND METHODS One hundred thirty-two adrenal nodules were identified in 104 patients with lung cancer who underwent PET/CT. Sixty-five nodules were classified as lipid-rich adenomas if they had an unenhanced CT attenuation of less than or equal to 10 H. Thirty-one masses were classified as lipid-poor adenomas if they had an unenhanced CT attenuation greater than 10 H and stability for more than 1 year. Thirty-six masses were classified as lung cancer metastases if they showed rapid growth in 1 year (n = 27) or were biopsy-proven (n = 9). Histogram analysis was performed for all lesions to provide the mean attenuation value and percentage of negative pixels. RESULTS All lipid-rich adenomas had more than 10% negative pixels; 51.6% of lipid-poor adenomas had more than 10% negative pixels and would have been classified as indeterminate nodules on the basis of mean attenuation alone. None of the metastases had more than 10% negative pixels. Using an unenhanced CT mean attenuation threshold of less than 10 H yielded a sensitivity of 68% and specificity of 100% for the diagnosis of an adenoma. Using an unenhanced CT threshold of more than 10% negative pixels yielded a sensitivity of 84% and specificity of 100% for the diagnosis of an adenoma. CONCLUSION CT histogram analysis is superior to mean CT attenuation analysis for the evaluation of adrenal nodules and may help decrease referrals for additional imaging or biopsy.
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Catalano OA, Samir AE, Sahani DV, Hahn PF. Pixel Distribution Analysis: Can It be Used to Distinguish Clear Cell Carcinomas from Angiomyolipomas with Minimal Fat? Radiology 2008; 247:738-46. [DOI: 10.1148/radiol.2473070785] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sectional anatomy of the adrenal gland in the coronal plane. Surg Radiol Anat 2008; 30:271-80. [PMID: 18246295 DOI: 10.1007/s00276-008-0308-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 01/17/2008] [Indexed: 10/22/2022]
Abstract
To provide practical anatomic data for the imaging diagnosis and surgical treatment of adrenal disease, we investigated the anatomy of the adrenal gland and its relationships to regional structures using 31 sets of serial coronal sections of upper abdomen of Chinese adult cadavers and correlated coronal magnetic resonance (MR) images of ten upper abdomens of adult healthy volunteers and coronal reconstructed multislice spiral computed tomography (MSCT) images of five patients without lesions in the adrenal gland. The adrenal glands were visualized mainly on the successive coronal sections between 18 mm anterior to the posterior margin of inferior vena cava and 24 mm posterior to the posterior margin of inferior vena cava. In general, the left adrenal gland was visualized two sections earlier than the right adrenal gland. On the plane through the anterior parts of bilateral renal hili (A18), the appearance rate of bilateral adrenal glands was 100%, and the maximal measurements of bilateral adrenal glands were visualized. The length, width, thickness of right adrenal body, thickness of medial limb and lateral limb were, respectively, 34.02 +/- 2.12 mm, 10.91 +/- 0.89 mm, 5.82 +/- 0.26 mm, 2.78 +/- 0.08 mm, 2.62 +/- 0.06 mm, whereas the measurements of left adrenal gland were 28.31 +/- 2.46 mm, 18.40 +/- 1.06 mm, 6.84 +/- 0.24 mm, 3.02 +/- 0.08 mm, 2.86 +/- 0.07 mm, respectively. The coronal plane has superior advantage in showing the bilateral adrenal glands. The shapes of adrenal glands are various, whereas the range of adrenal thickness is quite narrow. The thickness of adrenal medial and lateral limbs, especially the thickness of lateral limb are useful for the diagnosis of the bilateral adrenocortical disease.
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Blake MA, Holalkere NS, Boland GW. Imaging Techniques for Adrenal Lesion Characterization. Radiol Clin North Am 2008; 46:65-78, vi. [DOI: 10.1016/j.rcl.2008.01.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
With the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are frequently detected. The commonest clinical question is whether these are benign adenomas or malignant primary or secondary masses. The nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography (CT) and magnetic resonance imaging (MRI) as benign adrenal masses such as myelolipomas, lipid-rich adenomas, adrenal cysts and adrenal haemorrhage which have pathognomonic imaging findings. However, there remains a significant overlap between the imaging features of some lipid-poor adenomas and malignant lesions. We review the recent advances in CT, MRI and positron emission tomography (PET) which can be used to distinguish between benign adenomas and malignant lesions of the adrenal gland.
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Affiliation(s)
- A Sahdev
- Department of Radiology, St Bartholomew's Hospital, Dominion House, 59 Bartholomew's Close, London, EC1A 7ED, UK.
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Jhaveri KS, Lad SV, Haider MA. Computed tomographic histogram analysis in the diagnosis of lipid-poor adenomas: comparison to adrenal washout computed tomography. J Comput Assist Tomogr 2007; 31:513-8. [PMID: 17882024 DOI: 10.1097/01.rct.0000250105.93423.a2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the ability of computed tomographic histogram analysis to diagnose lipid poor adenoma in comparison with adrenal washout computed tomography (CT). MATERIALS AND METHODS Adrenal CT washout examinations performed during a period from January 2000 to July 2005 were reviewed. Computed tomographic histogram analysis was performed on the unenhanced component of the study, and sensitivity was assessed at thresholds of more than 5% and 10% negative pixels. Liver and spleen were used to represent the control/nonadenoma group. Computed tomographic noise was measured recording standard deviation (SD) of mean CT attenuation in adrenal, liver, and spleen. RESULTS Twenty-four lipid-poor adenomas included exhibited more than 60% absolute enhancement washout (range, 60%-79%, mean, 69%) and remained stable for a period greater than 6 months. At threshold of more than 5% or 10% negative pixels CT histogram analysis yielded sensitivities of 91.6% and 70.8%, respectively, with 100% specificity. The mean SDs of adrenal, liver, and spleen were 18.2, 16.4 and 15, respectively. These differences in the mean SD were much smaller compared with the differences in the percentage of negative pixels in adrenal, liver, and spleen of 12.75%, 0.75%, and 0.25%, respectively. CONCLUSIONS Computed tomographic histogram analysis has good potential in the diagnosis of lipid-poor adenoma and can reduce the need to perform adrenal washout CT.
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Affiliation(s)
- Kartik S Jhaveri
- Department of Medical Imaging, University Health Network and Mount Sinai Hospital, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9.
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