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Oloukoi C, Dohan A, Gaillard M, Hoeffel C, Groussin-Rouiller L, Bertherat J, Jouinot A, Assié G, Fuks D, Sibony M, Soyer P, Jannot AS, Barat M. Differentiation between adrenocortical carcinoma and lipid-poor adrenal adenoma using a multiparametric MRI-based diagnostic algorithm. Diagn Interv Imaging 2024:S2211-5684(24)00081-0. [PMID: 38575426 DOI: 10.1016/j.diii.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the capabilities of multiparametric magnetic resonance imaging (MRI) in differentiating between lipid-poor adrenal adenoma (LPAA) and adrenocortical carcinoma (ACC). MATERIALS AND METHODS Patients of two centers who underwent surgical resection of LPAA or ACC after multiparametric MRI were retrospectively included. A training cohort was used to build a diagnostic algorithm obtained through recursive partitioning based on multiparametric MRI variables, including apparent diffusion coefficient and chemical shift signal ratio (i.e., tumor signal intensity index). The diagnostic performances of the multiparametric MRI-based algorithm were evaluated using a validation cohort, alone first and then in association with adrenal tumor size using a cut-off of 4 cm. Performances of the diagnostic algorithm for the diagnosis of ACC vs. LPAA were calculated using pathology as the reference standard. RESULTS Fifty-four patients (27 with LPAA and 27 with ACC; 37 women; mean age, 48.5 ± 13.3 [standard deviation (SD)] years) were used as the training cohort and 61 patients (24 with LPAA and 37 with ACC; 47 women; mean age, 49 ± 11.7 [SD] years) were used as the validation cohort. In the validation cohort, the diagnostic algorithm yielded best accuracy for the diagnosis of ACC vs. LPAA (75%; 46/61; 95% CI: 55-88) when used without lesion size. Best sensitivity was obtained with the association of the diagnostic algorithm with tumor size (96%; 23/24; 95% CI: 80-99). Best specificity was obtained with the diagnostic algorithm used alone (76%; 28/37; 95% CI: 60-87). CONCLUSION A multiparametric MRI-based diagnostic algorithm that includes apparent diffusion coefficient and tumor signal intensity index helps discriminate between ACC and LPAA with high degrees of specificity and accuracy. The association of the multiparametric MRI-based diagnostic algorithm with adrenal lesion size helps maximize the sensitivity of multiparametric MRI for the diagnosis of ACC.
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Affiliation(s)
- Carmelia Oloukoi
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Anthony Dohan
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France
| | - Martin Gaillard
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Pancreatic and Endocrine Surgery, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Christine Hoeffel
- Department of Radiology, Hôpital Robert Debré, CRESTIC, URCA, 51000 Reims, France
| | - Lionel Groussin-Rouiller
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Jérome Bertherat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Anne Jouinot
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Guillaume Assié
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France; Department of Endocrinology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - David Fuks
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Pancreatic and Endocrine Surgery, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Mathilde Sibony
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Pathology, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Philippe Soyer
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Anne-Sophie Jannot
- AP-HP.Centre- Université Paris Cité, Hôpital Européen Georges Pompidou, Medical Informatics, Biostatistics and Public Health Department, 75015, Paris, France; INSERM, UMR_S1138, Cordeliers Research Center, Université Paris Cité, 75006 Paris, France
| | - Maxime Barat
- Department of Radiology, Hôpital Cochin, AP-HP, 75014 Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Génomique et Signalisation des Tumeurs Endocrines, Institut Cochin, INSERM U 1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France.
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Sahdev A. Imaging incidental adrenal lesions. Br J Radiol 2023; 96:20220281. [PMID: 35543634 PMCID: PMC9975514 DOI: 10.1259/bjr.20220281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 01/27/2023] Open
Abstract
Incidental adrenal masses are among the most common incidental lesions detected on cross-sectional imaging. The majority are benign lesions, adenomas and myelolipomas being the most common. Simple cross-sectional imaging techniques using CT and MRI permit the characterization of over 80%, thereby requiring no further imaging. The remaining lesions are considered indeterminate. These lesions consist of benign and malignant lesions sharing imaging features. Further imaging and management of these indeterminate lesions should be guided by close collaboration between different specialists in an MDT setting. Advanced imaging options include dedicated adrenal scintigraphy, positron emission tomography CT, biopsy and surveillance. Biochemical and hormonal evaluation is also important to identify hyperfunctioning adrenal lesions. This review focuses on imaging features of benign and malignant adrenal masses used for characterization and suggests an imaging pathway for indeterminate adrenal masses.
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Pancreatic Mass Characterization Using IVIM-DKI MRI and Machine Learning-Based Multi-Parametric Texture Analysis. Bioengineering (Basel) 2023; 10:bioengineering10010083. [PMID: 36671655 PMCID: PMC9854749 DOI: 10.3390/bioengineering10010083] [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: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Non-invasive characterization of pancreatic masses aids in the management of pancreatic lesions. Intravoxel incoherent motion-diffusion kurtosis imaging (IVIM-DKI) and machine learning-based texture analysis was used to differentiate pancreatic masses such as pancreatic ductal adenocarcinoma (PDAC), pancreatic neuroendocrine tumor (pNET), solid pseudopapillary epithelial neoplasm (SPEN), and mass-forming chronic pancreatitis (MFCP). A total of forty-eight biopsy-proven patients with pancreatic masses were recruited and classified into pNET (n = 13), MFCP (n = 6), SPEN (n = 4), and PDAC (n = 25) groups. All patients were scanned for IVIM-DKI sequences acquired with 14 b-values (0 to 2500 s/mm2) on a 1.5T MRI. An IVIM-DKI model with a 3D total variation (TV) penalty function was implemented to estimate the precise IVIM-DKI parametric maps. Texture analysis (TA) of the apparent diffusion coefficient (ADC) and IVIM-DKI parametric map was performed and reduced using the chi-square test. These features were fed to an artificial neural network (ANN) for characterization of pancreatic mass subtypes and validated by 5-fold cross-validation. Receiver operator characteristics (ROC) analyses were used to compute the area under curve (AUC). Perfusion fraction (f) was significantly higher (p < 0.05) in pNET than PDAC. The f showed better diagnostic performance for PDAC vs. MFCP with AUC:0.77. Both pseudo-diffusion coefficient (D*) and f for PDAC vs. pNET showed an AUC of 0.73. ADC and diffusion coefficient (D) showed good diagnostic performance for pNET vs. MFCP with AUC: 0.79 and 0.76, respectively. In the TA of PDAC vs. non-PDAC, f and combined IVIM-DKI parameters showed high accuracy ≥ 84.3% and AUC ≥ 0.84. Mean f and combined IVIM-DKI parameters estimated that the IVIM-DKI model with TV texture features has the potential to be helpful in characterizing pancreatic masses.
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Cao L, Xu W. Radiomics approach based on biphasic CT images well differentiate "early stage" of adrenal metastases from lipid-poor adenomas: A STARD compliant article. Medicine (Baltimore) 2022; 101:e30856. [PMID: 36197274 PMCID: PMC9509040 DOI: 10.1097/md.0000000000030856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study was to develop an optimal radiomics model based on abdominal contrast-enhanced computed tomography (CECT) for pre-operative differentiation of "early stage" adrenal metastases from lipid-poor adenomas (LPAs). This retrospective study included 188 patients who underwent abdominal CECT (training cohort: LPAs, 68; metastases, 64; validation cohort: LPAs, 29; metastases, 27). Abdominal CECT included plain, arterial, portal, and venous imaging. Clinical and CECT radiological features were assessed and significant features were selected. Radiomic features of the adrenal lesions were extracted from four-phase CECT images. Significant radiomics features were selected using the least absolute shrinkage and selection operator (LASSO) and multivariable logistic regression. The clinical-radiological, unenhanced radiomics, arterial radiomics, portal radiomics, venous radiomics, combined radiomics, and clinical-radiological-radiomics models were established using a support vector machine (SVM). The DeLong test was used to compare the areas under the receiver operating characteristic curves (AUCs) of all models. The AUCs of the unenhanced (0.913), arterial (0.845), portal (0.803), and venous (0.905) radiomics models were all higher than those of the clinical-radiological model (0.788) in the testing dataset. The AUC of the combined radiomics model (incorporating plain and venous radiomics features) was further improved to 0.953, which was significantly higher than portal radiomics model (P = .033) and clinical-radiological model (P = .009), with the highest accuracy (89.13%) and a relatively stable sensitivity (91.67%) and specificity (86.36%). As the optimal model, the combined radiomics model based on biphasic CT images is effective enough to differentiate "early stage" adrenal metastases from LPAs by reducing the radiation dose.
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Affiliation(s)
- Lixiu Cao
- Department of Molecular Imaging and Nuclear Medicine, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for China, Tianjin, China
- Department of ECT, Tangshan People’s Hospital, Tangshan, China
| | - Wengui Xu
- Department of Molecular Imaging and Nuclear Medicine, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for China, Tianjin, China
- *Correspondence: Wengui Xu, Department of Molecular Imaging and Nuclear Medicine, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for China, No. 1 Huanhu West Road, Hexi District, Tianjin 300060, China (e-mail: )
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Barat M, Cottereau AS, Gaujoux S, Tenenbaum F, Sibony M, Bertherat J, Libé R, Gaillard M, Jouinot A, Assié G, Hoeffel C, Soyer P, Dohan A. Adrenal Mass Characterization in the Era of Quantitative Imaging: State of the Art. Cancers (Basel) 2022; 14:cancers14030569. [PMID: 35158836 PMCID: PMC8833697 DOI: 10.3390/cancers14030569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 12/30/2022] Open
Abstract
Simple Summary Non-invasive characterization of adrenal lesions requires a rigorous approach. Although CT is the cornerstone of adrenal lesion characterization, a multimodality multiparametric imaging approach helps improve confidence in adrenal lesion characterization. Abstract Detection and characterization of adrenal lesions have evolved during the past two decades. Although the role of imaging in adrenal lesions associated with hormonal secretion is usually straightforward, characterization of non-functioning adrenal lesions may be challenging to confidently identify those that need to be resected. Although many adrenal lesions can be readily diagnosed when they display typical imaging features, the diagnosis may be challenging for atypical lesions. Computed tomography (CT) remains the cornerstone of adrenal imaging, but other morphological or functional modalities can be used in combination to reach a diagnosis and avoid useless biopsy or surgery. Early- and delayed-phase contrast-enhanced CT images are essential for diagnosing lipid-poor adenoma. Ongoing studies are evaluating the capabilities of dual-energy CT to provide valid virtual non-contrast attenuation and iodine density measurements from contrast-enhanced examinations. Adrenal lesions with attenuation values between 10 and 30 Hounsfield units (HU) on unenhanced CT can be characterized by MRI when iodinated contrast material injection cannot be performed. 18F-FDG PET/CT helps differentiate between atypical benign and malignant adrenal lesions, with the adrenal-to-liver maximum standardized uptake value ratio being the most discriminative variable. Recent studies evaluating the capabilities of radiomics and artificial intelligence have shown encouraging results.
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Affiliation(s)
- Maxime Barat
- Department of Radiology, Cochin Teaching Hospital, AP-HP, Université de Paris, 75014 Paris, France; (M.B.); (P.S.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
| | - Anne-Ségolène Cottereau
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Nuclear Medicine, Cochin Hospital, AP-HP, 75014 Paris, France;
| | - Sébastien Gaujoux
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Pancreatic and Endocrine Surgery, Pitié-Salpetrière Hospital, AP-HP, 75013 Paris, France
| | - Florence Tenenbaum
- Department of Nuclear Medicine, Cochin Hospital, AP-HP, 75014 Paris, France;
| | - Mathilde Sibony
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Pathology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Rossella Libé
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Martin Gaillard
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Anne Jouinot
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Guillaume Assié
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | | | - Philippe Soyer
- Department of Radiology, Cochin Teaching Hospital, AP-HP, Université de Paris, 75014 Paris, France; (M.B.); (P.S.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
| | - Anthony Dohan
- Department of Radiology, Cochin Teaching Hospital, AP-HP, Université de Paris, 75014 Paris, France; (M.B.); (P.S.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (A.-S.C.); (S.G.); (M.S.); (J.B.); (R.L.); (M.G.); (A.J.); (G.A.)
- Correspondence:
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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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Özcan HN, Tan AA, Ardıçlı B, Oguz B, Ekinci S, Kutluk T, Haliloglu M. Imaging findings of primary adrenal tumors in pediatric patients. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:811-815. [PMID: 34792039 DOI: 10.5152/dir.2021.20701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Apart from neuroblastomas, adrenal tumors are rarely seen in children. The most common adrenal tumors are adrenocortical carcinoma and pheochromocytoma. Adrenocortical carcinoma is usually a large heterogeneous, well-marginated mass with solid/cystic areas and calcifications, with poor prognosis. Most of the pheochromocytomas are benign tumors and usually show intense contrast enhancement, the pattern of which may be diffuse, mottled, or peripheral on computed tomography and magnetic resonance imaging. The purpose of this article is to evaluate primary nonneurogenic adrenal tumors.
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Affiliation(s)
- H Nursun Özcan
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aziz Anıl Tan
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Burak Ardıçlı
- Department of Pediatric Surgery, Hacettepe University School of Medicine Ankara, Turkey
| | - Berna Oguz
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Saniye Ekinci
- Department of Pediatric Surgery, Hacettepe University School of Medicine Ankara, Turkey
| | - Tezer Kutluk
- Division of Pediatric Oncology, Department of Pediatrics, Hacettepe University School of Medicine Ankara, Turkey
| | - Mithat Haliloglu
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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Tu W, Gerson R, Abreu-Gomez J, Udare A, Mcphedran R, Schieda N. Comparison of MRI features in lipid-rich and lipid-poor adrenal adenomas using subjective and quantitative analysis. Abdom Radiol (NY) 2021; 46:4864-4872. [PMID: 34120206 DOI: 10.1007/s00261-021-03161-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare MR-imaging features in benign lipid-rich and lipid-poor adrenal adenomas. MATERIALS AND METHODS With institutional review board approval, we compared 23 consecutive lipid-poor adenomas (chemical shift [CS] signal intensity [SI] index < 16.5%) imaged with MRI to 29 consecutive lipid-rich adenomas (CS-SI index ≥ 16.5%) imaged during the same time period. A blinded radiologist measured T2-weighted (T2W) SI ratio (adrenal adenoma/psoas muscle), dynamic enhancement wash-in (WI) and wash-out (WO) indices, and T2W texture features. Two blinded Radiologists (R1/R2) assessed T2W-SI (relative to renal cortex) and T2W heterogeneity (using 5-Point Likert scales). Comparisons were performed between groups using independent t tests and Chi-square with Holm-Bonferroni correction. RESULTS There was no difference in age or gender between groups (p = 0.594, 0.051 respectively). Subjectively, all lipid-rich and lipid-poor adenomas were rated hypointense or isointense compared to renal cortex and T2W-SI did not differ between groups (p = 0.129, 0.124 for R1, R2). Agreement was substantial (Kappa = 0.67). There was no difference in T2W SI ratio (1.8 ± 0.9 [0.5-4.3] lipid rich versus 2.2 ± 1.0 [0.6-4.3] lipid poor, p = 0.139). Enhancement WI and WO did not differ comparing lipid-rich and lipid-poor adenomas (p = 0.759, 0.422 respectively). There was no difference comparing lipid-rich and lipid-poor adenomas T2W heterogeneity judged subjectively (p = 0.695, 0.139 for R1, R2; Kappa = 0.19) or by texture analysis (entropy, kurtosis, skewness; p = 0.134-0.191) with all adenomas except for one rated as mostly or completely homogeneous. CONCLUSIONS There is no difference in T2W signal intensity, enhancement pattern or T2W heterogeneity judged subjectively or by quantitative texture analysis comparing lipid-poor and lipid-rich adrenal adenomas.
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Affiliation(s)
- Wendy Tu
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Rosalind Gerson
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jorge Abreu-Gomez
- Joint Department of Medical Imaging, The University Health Network, Toronto, ON, Canada
| | - Amar Udare
- Juravinski Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Rachel Mcphedran
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Nicola Schieda
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
- C1 Radiology, The Ottawa Hospital, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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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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Korb TA, Chernina VY, Blokhin IA, Aleshina OO, Vorontsov AV, Morozov SP, Gombolevskiy VA. [Adrenal imaging: anatomy and pathology (literature review)]. ACTA ACUST UNITED AC 2021; 67:26-36. [PMID: 34297499 DOI: 10.14341/probl12752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/04/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022]
Abstract
This literature review focuses on the normal adrenal gland anatomy and typical imaging features necessary to evaluate benign and malignant lesions. In particular, adenoma, pheochromocytoma, metastases and adrenocortical carcinoma were discussed as some of the most common lesions. For this purpose, a review of relevant local and international literature sources up to January 2021 was conducted.In many cases, adrenal incidentalomas have distinctive features allowing characterization using noninvasive methods. It is possible to suspect a malignant nature and promptly refer the patient for the necessary invasive examinations in some cases. -Computed tomography, especially with intravenous contrast enhancement, is the primary imaging modality because it enables differential diagnosis. Magnetic resonance tomography remains a sensitive method in lesion detection and follow-up but is not very specific for determining the malignant potential. Positron emission computed tomography also remains an additional method and is used mainly for differential diagnosis of malignant tumors, detecting metastases and recurrences after surgical treatment. Ultrasound has a limited role but is nevertheless of great importance in the pediatric population, especially newborns. Promising techniques such as radiomics and dual-energy CT can expand imaging capabilities and improve diagnostic accuracy.Because adrenal lesions are often incidentally detected by imaging performed for other reasons, it is vital to interpret such findings correctly. This review should give the reader a broad overview of how different imaging modalities can evaluate adrenal pathology and guide radiologists and clinicians.
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Affiliation(s)
- T A Korb
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
| | - V Yu Chernina
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
| | - I A Blokhin
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
| | - O O Aleshina
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
| | | | - S P Morozov
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
| | - V A Gombolevskiy
- Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies of the Moscow Health Care Department
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Handcrafted MRI radiomics and machine learning: Classification of indeterminate solid adrenal lesions. Magn Reson Imaging 2021; 79:52-58. [PMID: 33727148 DOI: 10.1016/j.mri.2021.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/16/2020] [Accepted: 03/11/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE To assess a radiomic machine learning (ML) model in classifying solid adrenal lesions (ALs) without fat signal drop on chemical shift (CS) as benign or malignant. METHOD 55 indeterminate ALs (21 lipid poor adenomas, 15 benign pheocromocytomas, 1 oncocytoma, 12 metastases, 6 primary tumors) showing no fat signal drop on CS were retrospectively included. Manual 3D segmentation on T2-weighted and CS images was performed for subsequent radiomic feature extraction. After feature stability testing and an 80-20% train-test split, the train set was balanced via oversampling. Following a multi-step feature selection, an Extra Trees model was tuned with 5-fold stratified cross-validation in the train set and then tested on the hold-out test set. RESULTS A total of 3396 features were extracted from each AL, of which 133 resulted unstable while none had low variance (< 0.01). Highly correlated (r > 0.8) features were also excluded, leaving 440 parameters. Among these, Support Vector Machine 5-fold stratified cross-validated recursive feature elimination selected a subset of 6 features. ML obtained a cross-validation accuracy of 0.94 on the train and 0.91 on the test sets. Precision, recall and F1 score were respectively 0.92, 0.91 and 0.91. CONCLUSIONS Our MRI handcrafted radiomics and ML pipeline proved useful to characterize benign and malignant solid indeterminate adrenal lesions.
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Padilla RM, Way AR, Soule E, Gopireddy D, Lall C. Diffusion Weighted Imaging in Unilateral Adrenal Infarction: A Case of Colicky Right Upper Quadrant Pain in a Pregnant Female. Cureus 2021; 13:e13289. [PMID: 33728222 PMCID: PMC7949625 DOI: 10.7759/cureus.13289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/08/2022] Open
Abstract
Diffusion weighted imaging (DWI) is a magnetic resonance imaging (MRI) non-contrast sequence that can indicate tissue ischemia or infarction. Adrenal infarct may present similarly to biliary or gallbladder pathologies, and the differential diagnosis during emergency work-up can be narrowed utilizing DWI sequences. In this paper, we describe the usefulness of DWI for urgent diagnosis in a case of non-hemorrhagic adrenal infarct of a pregnant female presenting with right upper quadrant pain. Although uncommon, adrenal infarct may occur in patients with hypercoagulability and localizing pain that is unexplained by other imaging modalities. We outline the imaging features of DWI in evaluating adrenal infarct as a safe and time effective application for patients with contraindications to imaging with ionizing radiation.
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Affiliation(s)
- Rebekah M Padilla
- Diagnostic Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Ashley R Way
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Erik Soule
- Interventional Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Dheeraj Gopireddy
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Chandana Lall
- Abdominal Imaging, University of Florida College of Medicine, Jacksonville, USA
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13
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Tu W, Abreu-Gomez J, Udare A, Alrashed A, Schieda N. Utility of T2-weighted MRI to Differentiate Adrenal Metastases from Lipid-Poor Adrenal Adenomas. Radiol Imaging Cancer 2020; 2:e200011. [PMID: 33778748 DOI: 10.1148/rycan.2020200011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022]
Abstract
Purpose To evaluate T2-weighted MRI features to differentiate adrenal metastases from lipid-poor adenomas. Materials and Methods With institutional review board approval, this study retrospectively compared 40 consecutive patients (mean age, 66 years ± 10 [standard deviation]) with metastases to 23 patients (mean age, 60 years ± 15) with lipid-poor adenomas at 1.5- and 3-T MRI between June 2016 and March 2019. A blinded radiologist measured T2-weighted signal intensity (SI) ratio (SInodule/SIpsoas muscle), T2-weighted histogram features, and chemical shift SI index. Two blinded radiologists (radiologist 1 and radiologist 2) assessed T2-weighted SI and T2-weighted heterogeneity using five-point Likert scales. Results Subjectively, T2-weighted SI (P < .001 for radiologist 1 and radiologist 2) and T2-weighted heterogeneity (P < .001, for radiologist 1 and radiologist 2) were higher in metastases compared with adenomas when assessed by both radiologists. Agreement between the radiologists was substantial for T2-weighted SI (Cohen κ = 0.67) and T2-weighted heterogeneity (κ = 0.62). Metastases had higher T2-weighted SI ratio than adenomas (3.6 ± 1.7 [95% confidence interval {CI}: 0.2, 8.2] vs 2.2 ± 1.0 [95% CI: 0.6, 4.3], P < .001) and higher T2-weighted entropy (6.6 ± 0.6 [95% CI: 4.9, 7.5] vs 5.0 ± 0.8 [95% CI: 3.5, 6.6], P < .001). At multivariate analysis, T2-weighted entropy was the best differentiating feature (P < .001). Chemical shift SI index did not differ between metastases and adenomas (P = .748). Area under the receiver operating characteristic curve (AUC) for T2-weighted SI ratio and T2-weighted entropy were 0.76 (95% CI: 0.64, 0.88) and 0.94 (95% CI: 0.88, 0.99). The logistic regression model combining T2-weighted SI ratio with T2-weighted entropy yielded AUC of 0.95 (95% CI: 0.91, 0.99) and did not differ compared with T2-weighted entropy alone (P = .268). There was no difference in logistic regression model accuracy comparing the data by either field strength, 1.5- or 3-T MRI (P > .05). Conclusion Logistic regression models combining T2-weighted SI and T2-weighted heterogeneity can differentiate metastases from lipid-poor adenomas. Validation of these preliminary results is required.Keywords: Adrenal, MR-Imaging, UrinarySupplemental material is available for this article.© RSNA, 2020.
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Affiliation(s)
- Wendy Tu
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, 1053 Carling Ave, C1 Radiology, Ottawa, ON, Canada K1Y 4E9 (W.T., J.A.G., A.U., N.S.); and Department of Radiology and Medical Imaging, King Saud University Medical City, King Khalid University Hospital, Riyadh, Saudi Arabia (A.A.)
| | - Jorge Abreu-Gomez
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, 1053 Carling Ave, C1 Radiology, Ottawa, ON, Canada K1Y 4E9 (W.T., J.A.G., A.U., N.S.); and Department of Radiology and Medical Imaging, King Saud University Medical City, King Khalid University Hospital, Riyadh, Saudi Arabia (A.A.)
| | - Amar Udare
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, 1053 Carling Ave, C1 Radiology, Ottawa, ON, Canada K1Y 4E9 (W.T., J.A.G., A.U., N.S.); and Department of Radiology and Medical Imaging, King Saud University Medical City, King Khalid University Hospital, Riyadh, Saudi Arabia (A.A.)
| | - Abdulmohsen Alrashed
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, 1053 Carling Ave, C1 Radiology, Ottawa, ON, Canada K1Y 4E9 (W.T., J.A.G., A.U., N.S.); and Department of Radiology and Medical Imaging, King Saud University Medical City, King Khalid University Hospital, Riyadh, Saudi Arabia (A.A.)
| | - Nicola Schieda
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, 1053 Carling Ave, C1 Radiology, Ottawa, ON, Canada K1Y 4E9 (W.T., J.A.G., A.U., N.S.); and Department of Radiology and Medical Imaging, King Saud University Medical City, King Khalid University Hospital, Riyadh, Saudi Arabia (A.A.)
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Diffusion-Weighted Imaging in Oncology: An Update. Cancers (Basel) 2020; 12:cancers12061493. [PMID: 32521645 PMCID: PMC7352852 DOI: 10.3390/cancers12061493] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023] Open
Abstract
To date, diffusion weighted imaging (DWI) is included in routine magnetic resonance imaging (MRI) protocols for several cancers. The real additive role of DWI lies in the "functional" information obtained by probing the free diffusivity of water molecules into intra and inter-cellular spaces that in tumors mainly depend on cellularity. Although DWI has not gained much space in some oncologic scenarios, this non-invasive tool is routinely used in clinical practice and still remains a hot research topic: it has been tested in almost all cancers to differentiate malignant from benign lesions, to distinguish different malignant histotypes or tumor grades, to predict and/or assess treatment responses, and to identify residual or recurrent tumors in follow-up examinations. In this review, we provide an up-to-date overview on the application of DWI in oncology.
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Gadelkareem RA, Moeen AM, Khalil M, Reda A, Farouk M, Abdelkawi IF, Makboul R, Mohammed N, Hameed DA. Experience of a Tertiary-Level Urology Center in Clinical Urological Events of Rare and Very Rare Incidence. V. Urological Tumors: 1. Adrenal Myelolipoma. Curr Urol 2020; 14:85-91. [PMID: 32774233 PMCID: PMC7390982 DOI: 10.1159/000499254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To present our center's experience in the management of adrenal myelolipoma in the context of shifting from the open to the laparoscopic adrenalectomy approach. MATERIALS AND METHODS A retrospective search of our center's records was done for reported cases of adrenal myelolipoma during the period July 2001-June 2016. All the cases with histopathologically-documented adrenal myelolipoma diagnosis were included. Relevant demographic and clinical variables were studied with a comparison between the open and laparoscopic approaches. RESULTS Of more than 82,000 urological surgeries, 238 adrenalectomies were done with only 22 cases of myelolipoma that had a mean age and body mass index of 52.4 ± 10.3 years and 30.23 kg/m2, respectively. The main clinical presentation was accidental discovery. The largest dimension of tumors varied from 6 to 16 cm. Computed tomography described a characteristic picture of hypodense heterogeneous adrenal tumors in all cases, while magnetic resonance imaging was indicated for malignancy suspicion in only 5 cases. Adrenal tumor markers were normal in all cases. Open and transperitoneal laparoscopic adrenalectomies were used in 14 and 8 cases, respectively. The latter approach was insignificantly advantageous in the need for blood transfusion, postoperative pain degree, need for analgesia, and hospital stay duration (p = 0.22). Histo-pathological examination revealed benign adipose tissue and myeloid cells and confirmed the diagnosis of adrenal myelolipoma in all cases. CONCLUSIONS Adrenal myelolipoma is a rare non-functioning benign tumor. Laparoscopic excision seems to be a promising alternative approach to the traditional open adrenalectomy, even in the context of large tumors and obesity.
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Affiliation(s)
- Rabea A. Gadelkareem
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
- *Rabea Ahmed Gadelkareem, Elgamaa Street, Faculty of Medicine, Assiut University, EG-71515 Assiut (Egypt), E-Mail
| | - Ahmed M. Moeen
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
| | - Mahmoud Khalil
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
| | - Ahmed Reda
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
| | - Mahmoud Farouk
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
| | | | - Rania Makboul
- Department of Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Nasreldin Mohammed
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
- Department of Urology, Martin-Luther University, Halle, Germany
| | - Dia A. Hameed
- Assiut Urology and Nephrology Hospital, Faculty of Medicine
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Albano D, Agnello F, Midiri F, Pecoraro G, Bruno A, Alongi P, Toia P, Di Buono G, Agrusa A, Sconfienza LM, Pardo S, La Grutta L, Midiri M, Galia M. Imaging features of adrenal masses. Insights Imaging 2019; 10:1. [PMID: 30684056 PMCID: PMC6349247 DOI: 10.1186/s13244-019-0688-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/03/2019] [Indexed: 12/14/2022] Open
Abstract
The widespread use of imaging examinations has increased the detection of incidental adrenal lesions, which are mostly benign and non-functioning adenomas. The differentiation of a benign from a malignant adrenal mass can be crucial especially in oncology patients since it would greatly affect treatment and prognosis. In this setting, imaging plays a key role in the detection and characterization of adrenal lesions, with several imaging tools which can be employed by radiologists. A thorough knowledge of the imaging features of adrenal masses is essential to better characterize these lesions, avoiding a misinterpretation of imaging findings, which frequently overlap between benign and malignant conditions, thus helping clinicians and surgeons in the management of patients. The purpose of this paper is to provide an overview of the main imaging features of adrenal masses and tumor-like conditions recalling the strengths and weaknesses of imaging modalities commonly used in adrenal imaging.
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Affiliation(s)
- Domenico Albano
- Unità di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.
| | - Francesco Agnello
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Federico Midiri
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Giusy Pecoraro
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Alberto Bruno
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Pierpaolo Alongi
- Department of Radiological Sciences, Nuclear Medicine Service, Fondazione Istituto G. Giglio, Contrada Pietrapollastra-Pisciotto, 90015, Cefalu, Italy
| | - Patrizia Toia
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Giuseppe Di Buono
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Antonino Agrusa
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Luca Maria Sconfienza
- Unità di Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Salvatore Pardo
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Ludovico La Grutta
- Department PROMISE, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Massimo Midiri
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Massimo Galia
- Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli studi di Palermo, Via del Vespro 127, 90127, Palermo, Italy
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Abstract
Various pathologies can affect the adrenal gland. Noninvasive cross-sectional imaging is used for evaluating adrenal masses. Accurate diagnosis of adrenal lesions is critical, especially in cancer patients; the presence of adrenal metastasis changes prognosis and treatment. Characterization of adrenal lesions predominantly relies on morphologic and physiologic features to enable correct diagnosis and management. Key diagnostic features to differentiate benign and malignant adrenal lesions include presence/absence of intracytoplasmic lipid, fat cells, hemorrhage, calcification, or necrosis and locoregional and distant disease; enhancement pattern and washout values; and lesion size and stability. This article reviews a spectrum of adrenal pathologies.
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Affiliation(s)
- Khaled M Elsayes
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA.
| | - Sally Emad-Eldin
- Department of Diagnostic and Intervention Radiology, Cairo University, Kasr Al-Ainy Street, Cairo 11652, Egypt
| | - Ajaykumar C Morani
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA
| | - Corey T Jensen
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA
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18
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Diffusion-weighted imaging in hemorrhagic abdominal and pelvic lesions: restricted diffusion can mimic malignancy. Abdom Radiol (NY) 2018; 43:1772-1784. [PMID: 29110051 DOI: 10.1007/s00261-017-1366-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diffusion-weighted imaging (DWI) is an increasingly utilized sequence in the assessment of abdominal and pelvic lesions. Benign lesions containing hemorrhagic products, with conglomerates of tightly packed blood cells or fibers, can have restricted water diffusion on DWI and apparent diffusion coefficient maps. Such lesions can have restricted diffusion erroneously attributed to malignancy. This review illustrates benign hemorrhagic lesions displaying restricted diffusion, with histopathologic correlation in relevant cases.
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20
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Comparison of Absolute Apparent Diffusion Coefficient (ADC) Values in ADC Maps Generated Across Different Postprocessing Software: Reproducibility in Endometrial Carcinoma. AJR Am J Roentgenol 2017; 209:1312-1320. [PMID: 28952809 DOI: 10.2214/ajr.17.18002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Apparent diffusion coefficient (ADC) maps are usually generated by builtin software provided by the MRI scanner vendors; however, various open-source postprocessing software packages are available for image manipulation and parametric map generation. The purpose of this study is to establish the reproducibility of absolute ADC values obtained using different postprocessing software programs. MATERIALS AND METHODS DW images with three b values were obtained with a 1.5-T MRI scanner, and the trace images were obtained. ADC maps were automatically generated by the in-line software provided by the vendor during image generation and were also separately generated on postprocessing software. These ADC maps were compared on the basis of ROIs using paired t test, Bland-Altman plot, mountain plot, and Passing-Bablok regression plot. RESULTS There was a statistically significant difference in the mean ADC values obtained from the different postprocessing software programs when the same baseline trace DW images were used for the ADC map generation. CONCLUSION For using ADC values as a quantitative cutoff for histologic characterization of tissues, standardization of the postprocessing algorithm is essential across processing software packages, especially in view of the implementation of vendor-neutral archiving.
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Farrugia FA, Martikos G, Surgeon C, Tzanetis P, Misiakos E, Zavras N, Charalampopoulos A. Radiology of the adrenal incidentalomas. Review of the literature. Endocr Regul 2017; 51:35-51. [PMID: 28222025 DOI: 10.1515/enr-2017-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The term "adrenal incidentaloma" is a radiological term. Adrenal incidentalomas are adrenal tumors discovered in an imaging study that has been obtained for indications exclusive to adrenal conditions (Udelsman 2001; Linos 2003; Bulow et al. 2006; Anagnostis et al. 2009). This definition excludes patients undergoing imaging testing as part of staging and work-up for cancer (Grumbach et al. 2003; Anagnostis et al. 2009). Papierska et al. (2013) have added the prerequisite that the size of a tumor must be "greater than 1cm in diameter", in order to be called incidentaloma. Although in the most cases these masses are non-hypersecreting and benign, they still represent an important clinical concern because of the risk of malignancy or hormone hyperfunction (Barzon et al. 2003). Th e adrenal tumors belong to the commonest incidental findings having been discovered (Kanagarajah et al. 2012).
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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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Lanzman RS, Wittsack HJ. Diffusion tensor imaging in abdominal organs. NMR IN BIOMEDICINE 2017; 30:e3434. [PMID: 26556181 DOI: 10.1002/nbm.3434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/18/2015] [Accepted: 09/20/2015] [Indexed: 06/05/2023]
Abstract
Initially, diffusion tensor imaging (DTI) was mainly applied in studies of the human brain to analyse white matter tracts. As DTI is outstanding for the analysis of tissue´s microstructure, the interest in DTI for the assessment of abdominal tissues has increased continuously in recent years. Tissue characteristics of abdominal organs differ substantially from those of the human brain. Further peculiarities such as respiratory motion and heterogenic tissue composition lead to difficult conditions that have to be overcome in DTI measurements. Thus MR measurement parameters have to be adapted for DTI in abdominal organs. This review article provides information on the technical background of DTI with a focus on abdominal imaging, as well as an overview of clinical studies and application of DTI in different abdominal regions. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rotem Shlomo Lanzman
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University of Dusseldorf, Dusseldorf, Germany
| | - Hans-Jörg Wittsack
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University of Dusseldorf, Dusseldorf, Germany
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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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Teixeira SR, Elias PCL, Leite AFDM, de Oliveira TMG, Muglia VF, Elias Junior J. Apparent diffusion coefficient of normal adrenal glands. Radiol Bras 2017; 49:363-368. [PMID: 28057963 PMCID: PMC5210033 DOI: 10.1590/0100-3984.2015.0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objective To assess the feasibility and reliability of apparent diffusion coefficient
(ADC) measurements of normal adrenal glands. Materials and methods This was a retrospective study involving 32 healthy subjects, divided into
two groups: prepubertal (PreP, n = 12), aged from 2 months
to 12.5 years (4 males; 8 females); and postpubertal (PostP,
n = 20), aged from 11.9 to 61 years (5 males; 15
females). Diffusion-weighted magnetic resonance imaging (DW-MRI) sequences
were acquired at a 1.5 T scanner using b values of 0, 20,
500, and 1000 s/mm2. Two radiologists evaluated the images. ADC
values were measured pixel-by-pixel on DW-MRI scans, and automatic
co-registration with the ADC map was obtained. Results Mean ADC values for the right adrenal glands were 1.44 ×
10-3 mm2/s for the PreP group and 1.23 ×
10-3 mm2/s for the PostP group, whereas they were
1.58 × 10-3 mm2/s and 1.32 ×
10-3 mm2/s, respectively, for the left glands. ADC
values were higher in the PreP group than in the PostP group
(p < 0.05). Agreement between readers was almost
perfect (intraclass correlation coefficient, 0.84-0.94; p
< 0.05). Conclusion Our results demonstrate the feasibility and reliability of performing DW-MRI
measurements of normal adrenal glands. They could also support the
feasibility of ADC measurements of small structures.
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Affiliation(s)
- Sara Reis Teixeira
- MD, PhD, Attending Physician at the Centro de Ciências das Imagens e Física Médica (CCIFM), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Paula Condé Lamparelli Elias
- MD, PhD, Endocrinology Division of the Department of Internal Medicine, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Andrea Farias de Melo Leite
- MD, PhD, Attending Physician at the Instituto de Medicina Integral Professor Fernando Figueira de Pernambuco (IMIP), Recife, PE, Brazil
| | - Tatiane Mendes Gonçalves de Oliveira
- MD, PhD, Attending Physician at the Centro de Ciências das Imagens e Física Médica (CCIFM), Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Valdair Francisco Muglia
- MD, PhD, Associate Professor in the Radiology Division of the Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Jorge Elias Junior
- MD, PhD, Associate Professor in the Radiology Division of the Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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Abstract
Various pathologies can affect the adrenal gland. Noninvasive cross-sectional imaging is used for evaluating adrenal masses. Accurate diagnosis of adrenal lesions is critical, especially in cancer patients; the presence of adrenal metastasis changes prognosis and treatment. Characterization of adrenal lesions predominantly relies on morphologic and physiologic features to enable correct diagnosis and management. Key diagnostic features to differentiate benign and malignant adrenal lesions include presence/absence of intracytoplasmic lipid, fat cells, hemorrhage, calcification, or necrosis and locoregional and distant disease; enhancement pattern and washout values; and lesion size and stability. This article reviews a spectrum of adrenal pathologies.
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Affiliation(s)
- Khaled M Elsayes
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA.
| | - Sally Emad-Eldin
- Department of Diagnostic and Intervention Radiology, Cairo University, Kasr Al-Ainy Street, Cairo 11652, Egypt
| | - Ajaykumar C Morani
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA
| | - Corey T Jensen
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street Unit 1473, Houston, TX 77030, USA
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Lim G, Horowitz JM, Berggruen S, Ernst LM, Linn RL, Hewlett B, Kim J, Chalifoux LA, McCarthy RJ. Correlation of probability scores of placenta accreta on magnetic resonance imaging with hemorrhagic morbidity. J Clin Anesth 2016; 34:261-9. [DOI: 10.1016/j.jclinane.2016.04.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 03/28/2016] [Accepted: 04/24/2016] [Indexed: 11/25/2022]
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Bougias H, Ghiatas A, Priovolos D, Veliou K, Christou A. Whole-lesion apparent diffusion coefficient (ADC) metrics as a marker of breast tumour characterization-comparison between ADC value and ADC entropy. Br J Radiol 2016; 89:20160304. [PMID: 27718592 DOI: 10.1259/bjr.20160304] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To prospectively assess the role of whole-lesion apparent diffusion coefficient (ADC) metrics in the characterization of breast tumours by comparing ADC value with ADC entropy. METHODS 49 patients with 53 breast lesions underwent phased-array breast coil 1.5-T MRI. Two radiologists experienced in breast MRI, blinded to the final diagnosis, reviewed the ADC maps and placed a volume of interest on all slices including each lesion on the ADC map to obtain whole-lesion mean ADC value and ADC entropy. The mean ADC value and ADC entropy in benign and malignant lesions were compared by the Mann-Whitney U-test. Receiver-operating characteristic analysis was performed to assess the sensitivity and specificity of the two variables in the characterization of the breast lesions. RESULTS The benign (n = 19) and malignant lesions (n = 34) had mean diameters of 20.8 mm (10.1-31.5 mm) and 26.4 mm (10.5-42.3 mm), respectively. The mean ADC value of the malignant lesions was significantly lower than that of the benign ones (0.87 × 10-3 vs 1.49 × 10-3 mm2 s-1; p < 0.0001). Malignant ADC entropy was higher than benign entropy, without reaching levels of statistical significance (5.4 vs 5.0; p = 0.064). At a mean ADC cut-off value of 1.16 × 10-3 mm2 s-1, the sensitivity and specificity for diagnosing malignancy became optimal (97.1% and 93.7, respectively) with an area under the curve (AUC) of 0.975. With regard to ADC entropy, the sensitivity and specificity at a cut-off of 5.18 were 67.6 and 68.7%, respectively, with an AUC of 0.664. CONCLUSION Whole-lesion mean ADC could be a helpful index in the characterization of suspicious breast lesions, with higher sensitivity and specificity than ADC entropy. Advances in knowledge: Two separate parameters of the whole-lesion histogram were compared for their diagnostic accuracy in characterizing breast lesions. Mean ADC was found to be able to characterize breast lesions, whereas entropy proved to be unable to differentiate benign from malignant breast lesions. It is, however, likely that entropy may distinguish these two groups if a larger cohort were used, or the fact that this may be influenced by the molecular subtypes of breast cancers included.
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Affiliation(s)
- Haralambos Bougias
- 1 Department of Medical Imaging University Hospital of loannina, loannina, Greece
| | - Abraham Ghiatas
- 2 Department of Medical Imaging IASO Maternity Hospital, Athens, Greece
| | | | - Konstantia Veliou
- 3 Department of Medical Imaging Chatzikosta General Hospital of loannina, loannina, Greece
| | - Alexandra Christou
- 4 Department of Medical Imaging, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
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Assessment of Early Treatment Response With DWI After CT-Guided Radiofrequency Ablation of Functioning Adrenal Adenomas. AJR Am J Roentgenol 2016; 207:804-810. [DOI: 10.2214/ajr.16.16207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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30
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Umanodan T, Fukukura Y, Kumagae Y, Shindo T, Nakajo M, Takumi K, Nakajo M, Hakamada H, Umanodan A, Yoshiura T. ADC histogram analysis for adrenal tumor histogram analysis of apparent diffusion coefficient in differentiating adrenal adenoma from pheochromocytoma. J Magn Reson Imaging 2016; 45:1195-1203. [PMID: 27571307 DOI: 10.1002/jmri.25452] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/16/2016] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To determine the diagnostic performance of apparent diffusion coefficient (ADC) histogram analysis in diffusion-weighted (DW) magnetic resonance imaging (MRI) for differentiating adrenal adenoma from pheochromocytoma. MATERIALS AND METHODS We retrospectively evaluated 52 adrenal tumors (39 adenomas and 13 pheochromocytomas) in 47 patients (21 men, 26 women; mean age, 59.3 years; range, 16-86 years) who underwent DW 3.0T MRI. Histogram parameters of ADC (b-values of 0 and 200 [ADC200 ], 0 and 400 [ADC400 ], and 0 and 800 s/mm2 [ADC800 ])-mean, variance, coefficient of variation (CV), kurtosis, skewness, and entropy-were compared between adrenal adenomas and pheochromocytomas, using the Mann-Whitney U-test. Receiver operating characteristic (ROC) curves for the histogram parameters were generated to differentiate adrenal adenomas from pheochromocytomas. Sensitivity and specificity were calculated by using a threshold criterion that would maximize the average of sensitivity and specificity. RESULTS Variance and CV of ADC800 were significantly higher in pheochromocytomas than in adrenal adenomas (P < 0.001 and P = 0.001, respectively). With all b-value combinations, the entropy of ADC was significantly higher in pheochromocytomas than in adrenal adenomas (all P ≤ 0.001), and showed the highest area under the ROC curve among the ADC histogram parameters for diagnosing adrenal adenomas (ADC200 , 0.82; ADC400 , 0.87; and ADC800 , 0.92), with sensitivity of 84.6% and specificity of 84.6% (cutoff, ≤2.82) with ADC200 ; sensitivity of 89.7% and specificity of 84.6% (cutoff, ≤2.77) with ADC400 ; and sensitivity of 94.9% and specificity of 92.3% (cutoff, ≤2.67) with ADC800 . CONCLUSION ADC histogram analysis of DW MRI can help differentiate adrenal adenoma from pheochromocytoma. LEVEL OF EVIDENCE 3 J. Magn. Reson. Imaging 2017;45:1195-1203.
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Affiliation(s)
- Tomokazu Umanodan
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Yoshihiko Fukukura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Yuichi Kumagae
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Toshikazu Shindo
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Masatoyo Nakajo
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Koji Takumi
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Masanori Nakajo
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Hiroto Hakamada
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Aya Umanodan
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
| | - Takashi Yoshiura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima City, Japan
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31
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El-Kalioubie M, Emad-Eldin S, Abdelaziz O. Diffusion-weighted MRI in adrenal lesions: A warranted adjunct? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Park JJ, Park BK, Kim CK. Adrenal imaging for adenoma characterization: imaging features, diagnostic accuracies and differential diagnoses. Br J Radiol 2016; 89:20151018. [PMID: 26867466 DOI: 10.1259/bjr.20151018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adrenocortical adenoma is the most common adrenal tumour. This lesion is frequently encountered on cross-sectional imaging that has been performed for unrelated reasons. Adrenal adenoma manifests various imaging features on CT, MRI and positron emission tomography/CT. The learning objectives of this review are to describe the imaging findings of adrenocortical adenoma, to compare the sensitivities of different imaging modalities for adenoma characterization and to introduce differential diagnoses.
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Affiliation(s)
- Jung Jae Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chan Kyo Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Adam SZ, Nikolaidis P, Horowitz JM, Gabriel H, Hammond NA, Patel T, Yaghmai V, Miller FH. Chemical Shift MR Imaging of the Adrenal Gland: Principles, Pitfalls, and Applications. Radiographics 2016; 36:414-32. [DOI: 10.1148/rg.2016150139] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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34
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McDermott S, McCarthy CJ, Blake MA. Images of pheochromocytoma in adrenal glands. Gland Surg 2015; 4:350-8. [PMID: 26310999 DOI: 10.3978/j.issn.2227-684x.2014.11.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 11/27/2014] [Indexed: 12/12/2022]
Abstract
Pheochromocytomas are relatively rare tumors of the adrenal medulla. A wide spectrum of imaging findings has been described. The aim of this article is to describe the multimodality imaging features of pheochromocytomas including diagnostic pearls that can help differentiate them from other adrenal lesions and pitfalls to avoid.
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Affiliation(s)
- Shaunagh McDermott
- Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Colin J McCarthy
- Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Blake
- Division of Abdominal Imaging, Massachusetts General Hospital, Boston, MA, USA
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35
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Abstract
CLINICAL/METHODICAL ISSUE Adrenal masses are very common and are usually detected incidentally. Less frequently, imaging is performed for the localization of the underlying lesion in the case of endocrine disease. The differentiation between adenomas and non-adenomas is fundamental. METHODICAL INNOVATIONS Adenomas show a low density on unenhanced computed tomography (CT) and a rapid washout of contrast agents. In magnetic resonance imaging (MRI) adenomas are characterized by a low signal in opposed phase imaging as compared to in phase imaging. PERFORMANCE According to the literature a density of less than 10 HU in an adrenal mass has a specificity of 98% and a sensitivity of 71% for the presence of an adenoma and MRI is slightly more sensitive. Some adrenal lesions, e.g. cysts or myelolipomas can be diagnosed with high accuracy due to pathognomonic findings. ACHIEVEMENTS In the majority of cases the synopsis of imaging along with clinical and laboratory findings is necessary for a reliable diagnosis. PRACTICAL RECOMMENDATIONS For the evaluation of an adrenal mass the CT examination should begin with an unenhanced scan, if necessary followed by a washout examination. In the case of MRI in phase and opposed phase imaging are essential components of the examination.
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Affiliation(s)
- C Degenhart
- Institut für klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Innenstadt, Nussbaumstr. 20, 80336, München, Deutschland,
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Launay N, Silvera S, Tenenbaum F, Groussin L, Tissier F, Audureau E, Vignaux O, Dousset B, Bertagna X, Legmann P. Value of 18-F-FDG PET/CT and CT in the Diagnosis of Indeterminate Adrenal Masses. Int J Endocrinol 2015; 2015:213875. [PMID: 25722719 PMCID: PMC4333271 DOI: 10.1155/2015/213875] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/01/2015] [Accepted: 01/07/2015] [Indexed: 12/26/2022] Open
Abstract
The purpose of this paper was to study the value of 18-FDG PET/CT and reassess the value of CT for the characterization of indeterminate adrenal masses. 66 patients with 67 indeterminate adrenal masses were included in our study. CT/MRI images and 18F-FDG PET/CT data were evaluated blindly for tumor morphology, enhancement features, apparent diffusion coefficient values, maximum standardized uptake values, and adrenal-to-liver maxSUV ratio. The study population comprised pathologically confirmed 16 adenomas, 19 metastases, and 32 adrenocortical carcinomas. Macroscopic fat was observed in 62.5% of the atypical adenomas at CT but not in malignant masses. On 18F-FDG PET/CT, SUVmax and adrenal-to-liver maxSUV ratio were significantly lower in adenomas than in malignant tumors. An SUVmax value of less than 3.7 or an adrenal-to-liver maxSUV ratio of less than 1.29 is highly predictive of benignity.
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Affiliation(s)
- Nathalie Launay
- Department of Radiology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- *Nathalie Launay:
| | - Stéphane Silvera
- Department of Radiology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Florence Tenenbaum
- Department of Nuclear Medicine, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Lionel Groussin
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- Department of Endocrinology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Frédérique Tissier
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- Department of Anatomopathology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Etienne Audureau
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- Department of Epidemiology and Biostatistics, Hôtel Dieu University Hospital, 1 Parvis Notre Dame-place Jean Paul II, 75004 Paris, France
| | - Olivier Vignaux
- Department of Radiology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
| | - Bertrand Dousset
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- Department of Digestive and Endocrine Surgery, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Xavier Bertagna
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
- Department of Endocrinology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
| | - Paul Legmann
- Department of Radiology, Cochin University Hospital, 27 rue du Faubourg St. Jacques, 75014 Paris, France
- Sorbonne Paris Cité, Université Paris Descartes, 12 rue de l'École de Medicine, 75006 Paris, France
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Diagnostic performances of FDG-PET/CT and diffusion-weighted imaging indices for differentiating benign pheochromocytoma from other benign adrenal tumors. ACTA ACUST UNITED AC 2014; 40:1655-65. [DOI: 10.1007/s00261-014-0291-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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38
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Emad-Eldin S, El-Kalioubie M. Diagnostic value of combined versus individual MRI parameters in distinguishing adenomatous from non-adenomatous adrenal lesions in cancer patients. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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39
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Abstract
In this article, functional magnetic resonance (MR) imaging techniques in the abdomen are discussed. Diffusion-weighted imaging (DWI) increases the confidence in detecting and characterizing focal hepatic lesions. The potential uses of DWI in kidneys, adrenal glands, bowel, and pancreas are outlined. Studies have shown potential use of quantitative dynamic contrast-enhanced MR imaging parameters, such as K(trans), in predicting outcomes in cancer therapy. MR elastography is considered to be a useful tool in staging liver fibrosis. A major issue with all functional MR imaging techniques is the lack of standardization of the protocol.
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Affiliation(s)
- Kumar Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, 550 N University Blvd, UH 0279, Indianapolis, IN 46202, USA.
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40
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Hida T, Nishie A, Asayama Y, Ishigami K, Ushijima Y, Takayama Y, Fujita N, Shimamoto D, Yokomizo A, Tatsugami K, Inokuchi J, Kubo Y, Honda H. Apparent diffusion coefficient characteristics of various adrenal tumors. Magn Reson Med Sci 2014; 13:183-9. [PMID: 24990461 DOI: 10.2463/mrms.2013-0113] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Using pathologically proven tumors and 3 methods of apparent diffusion coefficient (ADC) measurement, we examined the potential of diffusion-weighted imaging (DWI) to differentiate adrenal tumors. METHODS We evaluated adrenal tumors of 52 patients who underwent magnetic resonance (MR) examination including DWI and adrenal resection or biopsy between July 2006 and August 2011. Tumors included 25 cortical adenomas, 14 pheochromocytomas, 6 adrenal metastases, and seven others. We defined the tumor's "solid" region as an enhancing area on contrast-enhanced MR or computed tomography (CT) and measured the ADC of the tumor's "entire" and "solid" regions within a region of interest (ROI) placed on an ADC map ("entire" and "solid" ADCs). We obtained a "minimum" ADC by placing an ROI in an area showing the lowest ADC within the "solid" region. We also calculated the ratio of "non-solid" area to "entire" tumor and compared the average "entire," "solid," and "minimum" ADCs and the ratio of "non-solid" area to "entire" tumor between benign and malignant groups. RESULTS The average "entire" ADC was significantly higher for the benign (1.35 ± 0.38 × 10(-3) mm2/s) than malignant group (1.01 ± 0.17 × 10(-3) mm2/s), and the average "solid" and "minimum" ADC and the ratio of "non-solid" area to "entire" tumor did not differ significantly between the benign and malignant groups. CONCLUSION The higher "entire" ADC value of the benign group, which might be obtained incidentally, can be considered dependent on the condition of necrosis, hemorrhage, and degeneration. ADC measurement of a tumor's "solid" region was not useful for differentiating pathologically proven adrenal tumors.
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Affiliation(s)
- Tomoyuki Hida
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University
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Added value of diffusion-weighted acquisitions in MRI of the abdomen and pelvis. AJR Am J Roentgenol 2014; 202:995-1006. [PMID: 24758652 DOI: 10.2214/ajr.12.9563] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review abdominopelvic applications of diffusion-weighted imaging (DWI), discuss advantages and limitations of DWI, and illustrate these with examples. CONCLUSION High-quality abdominopelvic DWI can be performed routinely on current MRI systems and may offer added value in image interpretation. Particularly in unenhanced MRI examinations, DWI may provide an alternative source of image contrast and improved conspicuity to identify and potentially characterize pathology. DWI is a powerful technique that warrants implementation in routine abdominal and pelvic imaging protocols.
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42
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Ciçekçi M, Onur MR, Aydin AM, Gül Y, Ozkan Y, Akpolat N, Kocakoç E. The role of apparent diffusion coefficient values in differentiation between adrenal masses. Clin Imaging 2014; 38:148-53. [DOI: 10.1016/j.clinimag.2013.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/08/2013] [Accepted: 11/08/2013] [Indexed: 12/25/2022]
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43
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Korivi BR, Elsayes KM. Cross-sectional imaging work-up of adrenal masses. World J Radiol 2013; 5:88-97. [PMID: 23671745 PMCID: PMC3650209 DOI: 10.4329/wjr.v5.i3.88] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 08/12/2012] [Accepted: 01/31/2013] [Indexed: 02/06/2023] Open
Abstract
Advances in medical imaging with current cross-section modalities enable non-invasive characterization of adrenal lesions. Computed tomography (CT) provides characterization with its non-contrast and wash-out features. Magnetic resonance imaging (MRI) is helpful in further characterization using chemical shift imaging (CSI) and MR spectroscopy. For differentiating between benign and malignant masses, positron emission tomography (PET) imaging is useful with its qualitative analysis, as well as its ability to detect the presence of extra-adrenal metastases in cancer patients. The work-up for an indeterminate adrenal mass includes evaluation with a non-contrast CT. If a lesion is less than 10 Hounsfield Units on a non-contrast CT, it is a benign lipid-rich adenoma and no further work-up is required. For the indeterminate adrenal masses, a lipid-poor adenoma can be differentiated from a metastasis utilizing CT wash-out features. Also, MRI is beneficial with CSI and MR spectroscopy. If a mass remains indeterminate, PET imaging may be of use, in which benign lesions demonstrate low or no fluorodeoxyglucose activity. In the few cases in which adrenal lesions remain indeterminate, surgical sampling such as percutaneous biopsy can be performed.
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Morani AC, Elsayes KM, Liu PS, Weadock WJ, Szklaruk J, Dillman JR, Khan A, Chenevert TL, Hussain HK. Abdominal applications of diffusion-weighted magnetic resonance imaging: Where do we stand. World J Radiol 2013; 5:68-80. [PMID: 23671743 PMCID: PMC3650207 DOI: 10.4329/wjr.v5.i3.68] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 10/21/2012] [Accepted: 01/31/2013] [Indexed: 02/06/2023] Open
Abstract
Diffusion-weighted imaging (DWI) is one of the magnetic resonance imaging (MRI) sequences providing qualitative as well as quantitative information at a cellular level. It has been widely used for various applications in the central nervous system. Over the past decade, various extracranial applications of DWI have been increasingly explored, as it may detect changes even before signal alterations or morphological abnormalities become apparent on other pulse sequences. Initial results from abdominal MRI applications are promising, particularly in oncological settings and for the detection of abscesses. The purpose of this article is to describe the clinically relevant basic concepts of DWI, techniques to perform abdominal DWI, its analysis and applications in abdominal visceral MR imaging, in addition to a brief overview of whole body DWI MRI.
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Song J, Zhang C, Liu Q, Yu T, Jiang X, Xia Q, Zhang Y, Sequeiros RB. Utility of chemical shift and diffusion-weighted imaging in characterization of hyperattenuating adrenal lesions at 3.0T. Eur J Radiol 2012; 81:2137-43. [DOI: 10.1016/j.ejrad.2011.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 09/19/2011] [Accepted: 09/20/2011] [Indexed: 12/27/2022]
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Siegelman ES. Adrenal MRI: Techniques and clinical applications. J Magn Reson Imaging 2012; 36:272-85. [DOI: 10.1002/jmri.23601] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Vermoolen MA, Kwee TC, Nievelstein RAJ. Apparent diffusion coefficient measurements in the differentiation between benign and malignant lesions: a systematic review. Insights Imaging 2012; 3:395-409. [PMID: 22695951 PMCID: PMC3481080 DOI: 10.1007/s13244-012-0175-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 03/16/2012] [Accepted: 04/13/2012] [Indexed: 12/11/2022] Open
Abstract
Objectives To systematically review the value of apparent diffusion coefficient (ADC) measurement in the differentiation between benign and malignant lesions. Methods A systematic search of the Medline/Pubmed and Embase databases revealed 109 relevant studies. Quality of these articles was assessed using the Quality Assessment of the Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) criteria. Reported ADC values of benign and malignant lesions were compared per organ. Results The mean quality score of the reviewed articles was 50%. Comparison of ADC values showed marked variation among studies and between benign and malignant lesions in various organs. In several organs, such as breast, liver, and uterus, ADC values discriminated well between benign and malignant lesions. In other organs, such as the salivary glands, thyroid, and pancreas, ADCs were not significantly different between benign and malignant lesions. Conclusion The potential utility of ADC measurement for the characterisation of tumours differs per organ. Future well-designed studies are required before ADC measurements can be recommended for the differentiation of benign and malignant lesions. These future studies should use standardised acquisition protocols and provide complete reporting of study methods, to facilitate comparison of results and clinical implementation of ADC measurement for tumour characterisation. Electronic supplementary material The online version of this article (doi:10.1007/s13244-012-0175-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M A Vermoolen
- Department of Radiology, University Medical Center, Heidelberglaan 100 HP. E.01.132, PO Box 85500, 3508 GA, Utrecht, The Netherlands,
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Taffel M, Haji-Momenian S, Nikolaidis P, Miller FH. Adrenal imaging: a comprehensive review. Radiol Clin North Am 2012; 50:219-43, v. [PMID: 22498440 DOI: 10.1016/j.rcl.2012.02.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The discovery of an incidental adrenal mass (adrenal incidentaloma) continues to rise with the increasing use of cross-sectional imaging. Although most adrenal lesions are benign and asymptomatic, radiologists should guide evaluation of these lesions, whether benign or malignant. This article reviews the various imaging techniques used to evaluate adrenal masses and their relative strengths and weaknesses. It focuses on the most prevalent adrenal pathologies and their typical imaging characteristics, and concludes with a brief discussion of developing techniques, including diffusion-weighted imaging and dual-energy CT.
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Affiliation(s)
- Myles Taffel
- Department of Radiology, George Washington University Medical Center, Washington, DC, USA.
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Bittner JG, Brunt LM. Evaluation and management of adrenal incidentaloma. J Surg Oncol 2012; 106:557-64. [PMID: 22623268 DOI: 10.1002/jso.23161] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/29/2012] [Indexed: 12/14/2022]
Abstract
Adrenal incidentaloma is the most common adrenal neoplasm encountered in clinical practice. The timely, accurate, and cost-effective evaluation and management of adrenal lesions found incidentally can be challenging for clinicians. Evaluation begins with biochemical screening and additional imaging. Management strategies vary by patient factors and tumor characteristics. Adrenalectomy is indicated for lesions that are hormonally active, larger than 4-5 cm, symptom-related, and have an imaging appearance that is atypical of a benign lesion.
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Affiliation(s)
- James G Bittner
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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