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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. Journal of Endocrinological Investigation. 29(4):298-302, 2006 Apr.J Endocrinol Invest. 29(4):298-302, 2006 Apr. Review/Other-Dx 520 subjects (382 males and 138 females To perform a prospective evaluation of the prevalence of adrenal incidentalomas among subjects undergoing computerized tomography (CT) scan of the chest in a screening program of lung cancer (Tic TAC study) in Piedmont, a region of Northwestern Italy Twenty-three patients with adrenal masses were identified: 21 adrenal adenomas, 1 myelolipoma, and 1 metastasis of lung cancer. Therefore, the overall prevalence of adrenal lesions was 4.4%, and that of benign adrenal masses was 4.2%. This prevalence is higher than those found in previous CT scan series reported in the literature, probably because of the use of high-resolution CT scanning technology. Another factor that influenced our results is that subject age is skewed towards the decades characterized by a greater occurrence of adrenal masses. 4
2. Singh PK, Buch HN. Adrenal incidentaloma: evaluation and management. [Review] [117 refs]. Journal of Clinical Pathology. 61(11):1168-73, 2008 Nov.J Clin Pathol. 61(11):1168-73, 2008 Nov. Review/Other-Dx N/A To provide an overview of the epidemiological and clinical aspects of this condition, and to offer a practical approach towards its assessmentand management. No results stated in abstract. 4
3. Terzolo M, Stigliano A, Chiodini I, et al. AME position statement on adrenal incidentaloma. [Review]. EUR. J. ENDOCRINOL.. 164(6):851-70, 2011 Jun. Review/Other-Dx N/A To assess currently available evidence on adrenal incidentaloma and provide recommendations for clinical practice. Unenhanced computed tomography (CT) is recommended as the initial test with the use of an attenuation value of =10 Hounsfield units (HU) to differentiate between adenomas and non-adenomas. For tumors with a higher baseline attenuation value, we suggest considering delayed contrast-enhanced CT studies. Positron emission tomography (PET) or PET/CT should be considered when CT is inconclusive, whereas fine needle aspiration biopsy may be used only in selected cases suspicious of metastases (after biochemical exclusion of pheochromocytoma). HORMONAL ASSESSMENT: Pheochromocytoma and excessive overt cortisol should be ruled out in all patients, whereas primary aldosteronism has to be considered in hypertensive and/or hypokalemic patients. The 1 mg overnight dexamethasone suppression test is the test recommended for screening of subclinical Cushing's syndrome (SCS) with a threshold at 138 nmol/l for considering this condition. A value of 50 nmol/l virtually excludes SCS with an area of uncertainty between 50 and 138 nmol/l. 4
4. Gajraj H, Young AE. Adrenal incidentaloma. Br J Surg. 1993; 80(4):422-426 Review/Other-Dx N/A To determine a policy for adrenal incidentaloma in patients without known malignancy. No results stated in abstract. 4
5. Herrera MF, Grant CS, van Heerden JA, Sheedy PF, Ilstrup DM. Incidentally discovered adrenal tumors: an institutional perspective. Surgery. 1991; 110(6):1014-1021. Review/Other-Dx 342 patients To investigate the effect of size of incidental adrenal masses in patients without known malignancy. Studies to evaluate biochemical hyperfunction were performed in 172 patients (50%), 2 of whom were found to have cortisol-producing tumors and 5 pheochromocytomas. Histologic proof of diagnosis was obtained in 55 patients at the time of adrenalectomy. Malignancy was discovered in five patients (four primary and one metastatic), the smallest malignant tumor measuring 5 cm. In the 287 patients without histologic diagnoses, a minimum of 1 year of clinical follow-up was obtained in 251 (88%), including repeat CT scan in 156 (54%). None of these patients had clinical or biochemical adrenal abnormalitie. Authors suggest biochemical screening and surgical excision for all lesions >4 cm. Follow-up CT should be performed at 3 months in lesions <4 cm. 4
6. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR. 2008; 190(5):1163-1168. Review/Other-Dx 973 patients; 1,049 adrenal masses Retrospective study to determine the nature and prevalence of adrenal lesions identified on CT in patients with no known malignancy. 1049 adrenal masses were characterized with the following methods: histopathology (n = 12), imaging characterization (n = 909), imaging follow-up (n = 87), and clinical follow-up (n = 41). There were 788 adenomas constituting 75% of all lesions. There were 68 myelolipomas (6%), 47 hematomas (4%), and 13 cysts (1%). Three pheochromocytomas (0.3%) and one cortisol-producing adenoma (0.1%) were found incidentally. One hundred twenty-eight lesions (12%) were presumed to be benign by imaging or clinical stability. No malignant adrenal masses were found, even among the 14 patients who later developed malignancy elsewhere. 4
7. Bernardino ME, Walther MM, Phillips VM, et al. CT-guided adrenal biopsy: accuracy, safety, and indications. AJR. 1985; 144(1):67-69. Observational-Dx 53 patients; 58 needle biopsies To review the accuracy of CT-guided adrenal biopsy performed in a mixed population. 44 (83%) of 53 had correct tissue diagnosis at initial biopsy. 17% of samples were insufficient for diagnosis. Accurate diagnosis was obtained in 48 (90.6%) when both first and second biopsy attempts were combined. 46% of lesions were malignant. 11.3% had complications, mainly bleeding. Authors conclude that procedure is accurate and safe alternative to surgical biopsy. 4
8. Francis IR, Smid A, Gross MD, Shapiro B, Naylor B, Glazer GM. Adrenal masses in oncologic patients: functional and morphologic evaluation. Radiology. 1988; 166(2):353-356. Observational-Dx 28 patients Prospective study to investigate the role of NP-59 scintigraphy in the evaluation of unilateral adrenal masses detected by CT in the oncologic patient with normal adrenal function. In 14 of the 28 patients, there was increased uptake of the NP-59 on the side of the adrenal mass detected at CT (concordant uptake). Thirteen of the 14 masses with concordant uptake were greater than 2 cm in diameter, and one was 1.5 cm; all were found to be adenomas. In 11 of 28 patients there was decreased uptake on the side of the mass detected at CT (discordant uptake). None of these 11 masses were adenomas; nine were metastases and two were adrenal cysts. Uptake was indeterminate (symmetric) in three patients, two of whom had adrenal adenomas and one an adrenal metastasis; each mass with indeterminate uptake was less than 2 cm in diameter. 3
9. McGahan JP. Adrenal gland: MR imaging. Radiology. 1988; 166(1 Pt 1):284-285. Review/Other-Dx N/A Comment on an article by Chang et al on MRI of the adrenal gland. In this article, Chang et al found that intensity ratios of adrenal masses to liver were not statistically significant in distinguishing benign and malignant adrenal lesions. However, the mass/fat intensity ratio was statistically significant in separating benign and malignant adrenal lesions. In this study, all lesions with a mass/fat intensity ratio >0.8 were malignant and all adrenal masses with a ratio <0.6 were benign (adenomas). 8 of the masses were indeterminate. 4
10. Oliver TW, Jr., Bernardino ME, Miller JI, Mansour K, Greene D, Davis WA. Isolated adrenal masses in nonsmall-cell bronchogenic carcinoma. Radiology. 1984; 153(1):217-218. Review/Other-Dx 330 patients Combined retrospective-prospective study to determine the incidence of benign vs malignant isolated adrenal lesions in patients undergoing CT staging for nonsmall-cell bronchogenic carcinoma. 32 had adrenal masses. 8/32 masses were metastases, 17 were adenomas, and 7 did not undergo biopsy. In patients with nonsmall-cell bronchogenic carcinoma, an isolated adrenal mass is more likely benign than metastatic, and biopsy is advocated prior to withholding potentially curative surgery. CT has become useful in staging of patients with bronchogenic carcinoma. 4
11. Candel AG, Gattuso P, Reyes CV, Prinz RA, Castelli MJ. Fine-needle aspiration biopsy of adrenal masses in patients with extraadrenal malignancy. Surgery. 1993; 114(6):1132-1136; discussion 1136-1137. Review/Other-Dx 36 patients To investigate the effect of size of incidental adrenal masses on fine-needle outcome in patients with known malignancies. Using 3 cm as a dividing value, 87% of masses <3 cm were benign and more than 95% of lesions >3 cm were malignant in patients with known malignancies. Authors conclude that there is a significant correlation between the size of an adrenal nodule and the presence of metastases. 4
12. Mayo-Smith WW, Song JH, Boland GL, et al. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee. J. Am. Coll. Radiol.. 14(8):1038-1044, 2017 Aug. Review/Other-Dx N/A To represent an update to the adrenal component of the Journal of American College of Radiology (JACR) 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. No results stated in abstract. 4
13. Kapoor A, Morris T, Rebello R. Guidelines for the management of the incidentally discovered adrenal mass. Canadian Urological Association Journal. 5(4):241-7, 2011 Aug.Can Urol Assoc J. 5(4):241-7, 2011 Aug. Review/Other-Dx N/A To propose guidelines for the management of adrenal incidentalomas No abstract available. 4
14. Zeiger MA, Thompson GB, Duh QY, et al. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations. Endocr Pract. 2009; 15(5):450-453. Review/Other-Dx N/A American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations. No abstract available. 4
15. Sangwaiya MJ, Boland GW, Cronin CG, Blake MA, Halpern EF, Hahn PF. Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging protocol revisited in a large patient cohort. Radiology. 256(2):504-10, 2010 Aug.Radiology. 256(2):504-10, 2010 Aug. Observational-Dx 314 patients To reassess the accuracy of the 10-minute delayed scan to differentiate both lipid-rich and lipid-poor lesions in a large cohort of patients. There were 323 adrenal lesions (213 left, 110 right) consisting of 307 adenomas and 16 nonadenomas. The sensitivity, specificity, and accuracy for the RPW test at a washout threshold of 50% were 55.7%, 100%, and 57.9%, respectively; at 40% were 76.9%, 93.7%, and 77.7%; and at 35% were 81.4%, 93.7%, and 82.0%. The sensitivity, specificity, and accuracy for the APW test at a 60% threshold were 52.1%, 93.3%, and 54.0%, respectively; at 55% were 62.5%, 93.3%, and 64.0%; and at 50% were 71.3%, 80.0%, and 71.7%. Areas under the ROC curve were 0.85 (95% confi dence interval: 0.75, 0.95) and 0.91 (95% confi dence interval: 0.85, 0.97) for the APW and RPW tests, respectively, to detect adenomatous disease. 3
16. Caoili EM, Korobkin M, Francis IR, et al. Adrenal masses: characterization with combined unenhanced and delayed enhanced CT. Radiology. 2002; 222(3):629-633. Observational-Dx 116 patients; 166 adrenal masses To assess accuracy of dedicated CT adrenal protocol with unenhanced and delayed washout attenuation values. The final diagnosis was adenoma in 127 masses and non-adenoma in 39. Masses measuring more than 10 HU on unenhanced CT scans were confirmed at biopsy (n = 28) or were examined for stability or change in size at follow-up CT performed at a minimum interval of 6 months (n = 33). Thirty-six (92%) of 39 non-adenomas and 124 (98%) of 127 adenomas were correctly characterized. The sensitivity and specificity of this protocol were 98% and 92%, respectively. This protocol correctly characterized 160 (96%) of 166 masses. 3
17. Ream JM, Gaing B, Mussi TC, Rosenkrantz AB. Characterization of adrenal lesions at chemical-shift MRI: a direct intraindividual comparison of in- and opposed-phase imaging at 1.5 T and 3 T. AJR Am J Roentgenol. 204(3):536-41, 2015 Mar. Observational-Dx 36 patients, 37 adrenal lesions To perform an intraindividual comparison between 1.5 T and 3 T chemical-shift MRI in differentiating adrenal adenomas and nonadenomas, including comparison of quantitative thresholds. Accuracy in qualitative adenoma identification (86.5% [32/37] at 1.5 T and 81.1% [30/37] at 3 T for reader 1; 81.1% [30/37] at 1.5 T and 83.8% [31/37] at 3 T for reader 2; both p = 0.180) was equivalent at both field strengths. AUCs were not statistically significantly different between field strengths for quantitative measures: AUCs at 1.5 T versus 3 T were 0.956 versus 0.915 for SI index, 0.963 versus 0.870 for adrenal-to-spleen ratio, 0.935 versus 0.852 for adrenal-to-liver ratio, and 0.948 versus 0.948 for adrenal-to-muscle ratio (all p > 0.11). The optimal threshold for SI index was lower at 3 T (> 7.4%) than at 1.5 T (> 21.6%) but had similar sensitivity (1.5 T, 92.6% [25/27]; 3 T, 88.9% [24/27]) and specificity (1.5 T, 90.0% [9/10]; 3 T, 90.0% [9/10]). 2
18. Rodacki K, Ramalho M, Dale BM, et al. Combined chemical shift imaging with early dynamic serial gadolinium-enhanced MRI in the characterization of adrenal lesions. AJR Am J Roentgenol. 203(1):99-106, 2014 Jul. Observational-Dx 205 patients To retrospectively evaluate early dynamic serial gadolinium-enhanced and chemical-shift imaging (CSI) MRI to distinguish benign from malignant adrenal tumors Most adenomas exhibited either an arterial blush or homogeneous enhancement, whereas most metastases showed early peripheral or heterogeneous enhancement. Visualization of higher enhancement on arterial and venous phases enabled differentiation of adenomas from metastases in most cases. Moderate to high signal intensity drop on CSI was seen in 95.4% of adenomas and 14.8% of metastases. In lesions with this level of signal intensity drop, 87 of 88 lesions with a capillary blush were adenomas. Early dynamic serial imaging alone was a significant (p < 0.0001) indicator of nonadenoma (area under the curve [AUC], 0.912) with optimal sensitivity of 81% and specificity of 93% for differentiating adenomas from nonadenomas. Combined analysis (CSI and early dynamic serial imaging) was also significant (p < 0.0001 and p=0.0014, respectively) for diagnosing nonadenomas (AUC, 0.983) with optimal sensitivity of 94% and specificity of 98%. 3
19. Inan N, Arslan A, Akansel G, Anik Y, Balci NC, Demirci A. Dynamic contrast enhanced MRI in the differential diagnosis of adrenal adenomas and malignant adrenal masses. Eur J Radiol. 65(1):154-62, 2008 Jan. Observational-Dx 64 masses (48 adenomas, 16 malignant tumors) To evaluate the value of dynamic MR imaging in the differential diagnosis of adrenal adenomas and malignant tumors, especially in cases with atypical adenomas. Chemical shift MR imaging was able to differentiate 44 out of 48 adenomas (91.7%) from non-adenomas. The 4 adenomas (8.3%) which could not be differentiated from non-adenomas by this technique did not exhibit signal loss on out-of-phase images. With a cut-off value of 30, SI indices of adenomas had a sensitivity of 93.8%, specificity of 100% and a positive predictive value of 100%. On visual evaluation of dynamic MR imaging, early phase contrast enhancement patterns were homogeneous in 75% and punctate in 20,83% of the adenomas; while patchy in 56.25% and peripheral in 25% of the malignant tumors. On the late phase images 58.33% of the adenomas showed peripheral ring-shaped enhancement and 10.41% showed heterogeneous enhancement. All of the malignant masses showed heterogeneous enhancement. At the 25th second, the SIs and wash-in rates of the adenomas were significantly higher than those of the malignant masses (p=0.010). Time-to-peak enhancement of the malignant masses was significantly longer than that of the adenomas. With a cut-off value of 52.85 s, the time-to-peak enhancement had 87.5% sensitivity and 80% specificity. 3
20. Becker-Weidman D, Kalb B, Mittal PK, et al. Differentiation of lipid-poor adrenal adenomas from non-adenomas with magnetic resonance imaging: Utility of dynamic, contrast enhancement and single-shot T2-weighted sequences. Eur J Radiol. 84(11):2045-51, 2015 Nov. Observational-Dx 46 patients To evaluate the utility of dynamic, contrast-enhanced magnetic resonance imaging (MRI) in combination with single-shot T2-weighted (ssT2) sequences in the differentiation of lipid-poor adrenal adenomas from non-adenomas. Application of our criteria lead to an MRI diagnosis of lipid-poor adrenal adenoma with a sensitivity of 84.2-89.5% (16/19-17/19), specificity of 96.3% (26/27), positive predictive value of 94.1-94.4% (16/17-17/18), negative predictive value of 89.7-92.9% (26/29-26/28), and accuracy of 91.3-93.5% (42/46-43/46). Agreement between the two readers showed substantial ? agreement for the differentiation of adenoma from non-adenoma. 2
21. Metser U, Miller E, Lerman H, Lievshitz G, Avital S, Even-Sapir E. 18F-FDG PET/CT in the evaluation of adrenal masses. J Nucl Med. 2006; 47(1):32-37. Observational-Dx 150 patients; 175 adrenal masses To evaluate the performance of FDG-PET/CT in characterizing adrenal masses in oncology patients. For combined PET/CT data, the sensitivity, specificity, PPV, and NPV were 100%, 98%, 97%, 100%, respectively. When a cutoff SUV of 3.1 was used for this group, FDG-PET/CT correctly classified all lesions. 3
22. Bhat HS, Tiyadath BN. Management of Adrenal Masses. [Review]. Indian j. surg. oncol.. 8(1):67-73, 2017 Mar. Review/Other-Dx N/A To provide a literature review of the diagnostic workup of adrenal masses, including biochemical evaluation and imaging characteristics of the different pathologies No results stated in abstract. 4
23. Chang CA, Pattison DA, Tothill RW, et al. (68)Ga-DOTATATE and (18)F-FDG PET/CT in Paraganglioma and Pheochromocytoma: utility, patterns and heterogeneity. Cancer Imaging. 16(1):22, 2016 Aug 17. Observational-Dx 23 patients To report our experience using both Ga-68 DOTATATE and F-18 FDG PET/CT imaging in patients with PGLs and PCCs. DOTATATE and FDG were positive at most sites of disease (96.2 % vs 91.4 %), although uptake intensity was significantly higher on DOTATATE with a median SUV of 21 compared to 12.5 for FDG (p?<?0.001). SUVmax on F-18 FDG was significantly higher (p?<?0.001) in clinically aggressive cases. I-123/I-124 MIBG detected fewer lesions (30.4 %). 4
24. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental indeterminate adrenal mass on CT (> 10 H) in patients without cancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. AJR Am J Roentgenol. 189(5):1119-23, 2007 Nov. Review/Other-Dx Two hundred ninety patients (196 women, 94 men) with 321 solid adrenal masses, including 31 bilateral lesions To determine the prevalence of malignancy in incidentally discovered indeterminate adrenal lesions on CT in patients with no known cancer and, further,whether imaging evaluation is necessary to establish benignity in these patients. Of the 321 lesions, 318 masses (99.1%) were confirmed to be benign and clinically insignificant. These included three (0.9%) histologically confirmed adenomas, 198 (61.7%) adenomas by imaging characterization, five (1.6%) other benign lesions, 71 (22.1%) masses stable on imaging follow-up, and 41 (12.8%) masses with clinical stability. There were three (0.9%) clinically unsuspected functioning masses: one cortisol-producing adenoma and two pheochromocytomas. There were no metastatic adrenal lesions, even among the 13 patients who subsequently developed malignancy elsewhere. 4
25. Boland GW, Dwamena BA, Jagtiani Sangwaiya M, et al. Characterization of adrenal masses by using FDG PET: a systematic review and meta-analysis of diagnostic test performance. [Review]. Radiology. 259(1):117-26, 2011 Apr. Meta-analysis 21 studies To perform a systematic review and meta-analysis of published data to determine the diagnostic utility of adrenal fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) for distinguishing benign from malignant adrenal disease. A total of 1391 lesions (824 benign, 567 malignant) in 1217 patients from 21 eligible studies were evaluated. Qualitative (visual) analysis of 841 lesions (in 14 reports) and quantitative analyses based on standardized uptake values (SUVs) for 824 lesions (in 13 reports) and standardized uptake ratios (SURs) for 562 lesions (in eight reports) were performed. Resultant data were highly heterogeneous, with a model-based inconsistency index of 88% (95% confidence interval [CI]: 79%, 98%). Mean sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values for differentiating between benign and malignant adrenal disease were 0.97 (95% CI: 0.93, 0.98), 0.91 (95% CI: 0.87, 0.94), 11.1 (95% CI: 7.5, 16.3), 0.04 (95% CI: 0.02, 0.08), and 294 (95% CI: 107, 805), respectively, with no significant differences in accuracy among the visual, SUV, and SUR analyses. Good
26. Kumar R, Xiu Y, Yu JQ, et al. 18F-FDG PET in evaluation of adrenal lesions in patients with lung cancer. J Nucl Med. 2004; 45(12):2058-2062. Observational-Dx 94 patients: 113 adrenal masses; 3 observers Retrospective study to assess the role of FDG-PET in differentiating benign from metastatic adrenal masses detected on CT or MRI scans of patients with lung cancer. The sensitivity, specificity, and accuracy for detecting metastatic disease were 93%, 90%, and 92%, respectively. FDG-PET is an accurate, noninvasive technique for differentiating benign from metastatic adrenal lesions detected on CT or MRI in patients with lung cancer. It can be falsely negative in necrotic and hemorrhagic metastases and in small lesions (<11 mm in this series). 3
27. Angeli A, Osella G, Ali A, Terzolo M. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Horm Res. 1997; 47(4-6):279-283. Review/Other-Dx 887 patients To perform a multicentric retrospective analysis of adrenal masses incidentally discovered (adrenal incidentalomas). Majority of patients were in the 5th and 6th decade and females were predominantly affected. The frequency of adrenocortical cancer was 12% among operated patients (316 cases). The tumor diameter was highly correlated with the risk of malignancy, as well as the CT characteristics such as density, shape and margins. The frequency of pheochromocytoma was 10% among operated patients. The occurrence of incidentally discovered adrenocortical carcinomas and pheochromocytomas is not rare. Evaluation of the mass size and CT characteristics are simple and effective methods to differentiate malignant lesions. Biochemical screening for pheochromocytoma is mandatory before surgery. 4
28. Mantero F, Arnaldi G. Management approaches to adrenal incidentalomas. A view from Ancona, Italy. [Review] [111 refs]. Endocrinology & Metabolism Clinics of North America. 29(1):107-25, ix, 2000 Mar.Endocrinol Metab Clin North Am. 29(1):107-25, ix, 2000 Mar. Review/Other-Dx N/A To provide an overview of the diagnostic clinical approach and management of the incidentally discovered adrenal masses No results stated in abstract. 4
29. Mantero F, Terzolo M, Arnaldi G, et al. A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. Journal of Clinical Endocrinology & Metabolism. 85(2):637-44, 2000 Feb.J Clin Endocrinol Metab. 85(2):637-44, 2000 Feb. Review/Other-Dx 420 males and 584 females To perform a national survey on occasionally discovered adrenal masses [adrenal incidentalomas (AI)] under the auspices of the Italian Society of Endocrinology. Relevant information was obtained by means of a specifically tailored questionnaire. Of the 1096 forms received, 1004 were retained for final analysis. Patients were 420 males and 584 females, aged between 15–86 yr (median, 58 yr). Mass size (computed tomography measurement) ranged from 0.5–25 cm (median, 3.0 cm). Hormonal work-up demonstrated that 85% of the masses were non hypersecretory, 9.2% were defined as subclinical Cushing’s syndrome, 4.2% were pheochromocytomas, and 1.6% were aldosteronomas. Adrenalectomy was performed in 380 patients with removal of 198 cortical adenomas (52%), 47 cortical carcinomas (12%), 42 pheochromocytomas (11%), and other less frequent tumor types. Patients with carcinoma were significantly younger than patients with adenoma (median, 46; range, 17–84; vs. 57, 16–83 yr; P 5 0.05). Adenomas were significantly smaller than carcinomas (3.5, 1–15 vs. 7.5, 2.6–25 cm; P , 0.001), and a cut-off at 4.0 cm had the highest sensitivity (93%) in differentiating between benign and malignant tumors. Hormonal work-up of patients with subclinical Cushing’s syndrome showed low baseline ACTH in 79%, cortisol unsuppressibility after 1 mg dexamethasone in 73%, above normal urinary free cortisol in 75%, disturbed cortisol rhythm in 43%, and blunted ACTH response to CRH in 55%. Only 43% of patients with pheochromocytoma were hypertensive, and 86% showed elevated urinary catecholamines. All patients with aldosteronoma were hypertensive and had suppressed upright PRA. 4
30. Terzolo M, Ali A, Osella G, Mazza E. Prevalence of adrenal carcinoma among incidentally discovered adrenal masses. A retrospective study from 1989 to 1994. Gruppo Piemontese Incidentalomi Surrenalici. Archives of Surgery. 132(8):914-9, 1997 Aug.Arch Surg. 132(8):914-9, 1997 Aug. Observational-Dx 224 cases To perform a survey of the clinical management of incidentally discovered adrenal masses (ie, adrenal incidentalomas). Most patients were in their 50s and 60s, and women were predominantly affected. The frequency of adrenocortical cancer was 13% among patients operatedon. The tumor diameter was highly correlated with the risk of cancer; a cutoff at 5 cm had a sensitivity of 93% with a specificity of 64% in discriminating betweenbenign and malignant cortical lesions. 3
31. Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. [Review] [116 refs]. Radiology. 249(3):756-75, 2008 Dec.Radiology. 249(3):756-75, 2008 Dec. Review/Other-Dx N/A To discuss the anatomic and physiologic imaging principles used for differentiating adrenal masses, present the imaging techniques available to the radiologist, and recommend an imaging algorithm that can guide the radiologist toward the correct diagnosis. No results stated in abstract 4
32. Pantalone KM, Gopan T, Remer EM, et al. Change in adrenal mass size as a predictor of a malignant tumor. Endocr Pract. 2010; 16(4):577-587. Observational-Dx 136 adrenalectomies or biopsies in 132 patients Retrospective study to assess the value of adrenal mass absolute growth, growth rate, and percentage growth rate on serial imaging for distinguishing benign from malignant adrenal masses. There were 111 benign (81.6%) and 25 malignant (18.4%) adrenal masses. With use of ROC curve analysis, all 3 aforementioned growth measures showed similar levels of discrimination for the entire study group as well as for the subgroups with 3 to 12 months of follow-up (n=75 masses) and noncontrast CT HU >10 or not reported (n=111 masses). After adjustment for other factors, the 3 growth measures remained statistically significant predictors of a malignant tumor. The absolute growth cutoff value of 0.8 cm had the highest sum of sensitivity and specificity of 72% and 81.1%, respectively. Change in adrenal mass size should be used in conjunction with other imaging and clinical characteristics when surgical resection is being considered. 2
33. Corwin MT, Navarro SM, Malik DG, et al. Differences in Growth Rate on CT of Adrenal Adenomas and Malignant Adrenal Nodules. AJR Am J Roentgenol. 1-5, 2019 Apr 30. Review/Other-Dx 105 adenomas and 26 malignant nodules To determine the differences in growth rate of adrenal adenomas and malignant adrenal nodules. There were 105 adenomas and 26 malignant nodules. Of the 105 adenomas, 34 (32.4%; 95% CI, 23.6-42.2%) grew, three (2.9%; 95% CI, 0.6-8.1%) became smaller, and 68 (64.8%; 95% CI, 54.8-73.8%), were unchanged in size. All 26 (100%; 95% CI, 89.1-100%) malignant nodules grew. The mean (± SD) growth rate of adenomas was 1.0 ± 0.67 mm/year (range, 0.3-2.8 mm/year), compared with 58.4 ± 78.5 mm/year (range, 5.8-395.4 mm/year) for malignant nodules (p < 0.001). A growth rate of 3 mm/year distinguished adenomas from malignant nodules with a sensitivity of 100% (95% CI, 86.8-100%) and a specificity of 100% (95% CI, 96.6-100%). 4
34. Boland GW, Lee MJ, Gazelle GS, Halpern EF, McNicholas MM, Mueller PR. Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature. AJR. 1998; 171(1):201-204. Review/Other-Dx 10 CT reports; 495 adrenal lesions (272 benign, 223 malignant) To establish a consensus regarding optimal density threshold required to differentiate benign from malignant lesions by performing a pooled analysis of data found in the CT literature. Sensitivity for characterizing a lesion as benign ranged from 47% at a threshold of 2 H to 88% at a threshold of 20 H. Similarly, specificity varied from 100% at a threshold of 2 H to 84% at a threshold of 20 H. The attempt to be absolutely certain that an adrenal lesion is benign may lead to an unacceptably low sensitivity for lesion characterization. The threshold chosen will depend on the patient population and the cost-benefit approach to patient care. 4
35. Lee MJ, Hahn PF, Papanicolaou N, et al. Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size, and observer analysis. Radiology. 1991; 179(2):415-418. Observational-Dx 55 patients: 66 adrenal masses; 3 observers Retrospective blinded study to investigate the role of CT attenuation coefficients in differentiating benign and malignant lesions in a mixed population. The mean CT attenuation coefficient for benign adrenal masses was -2.2 HU +/- 16.0 and was significantly different from the mean for malignant lesions (28.9 HU +/- 10.6). The area under the ROC curve for CT attenuation coefficients (0.91 +/- 0.04) was significantly larger than that for lesion size (0.84 +/- 0.05) or best observer interpretation (0.84 +/- 0.05). A threshold CT attenuation value of 0 HU had a sensitivity-to-specificity ratio of 47%:100% for characterizing benign adrenal masses, whereas a threshold attenuation of 10 HU had a ratio of 79%:96%. 2
36. Stadler A, Schima W, Prager G, et al. CT density measurements for characterization of adrenal tumors ex vivo: variability among three CT scanners. AJR. 2004; 182(3):671-675. Review/Other-Dx 7 patients Assess the variability of CT attenuation values for adrenal tumors with different scanning protocols and CT scanners to determine whether the establishment of a scanner-independent threshold for differentiation between adenomas and non-adenomas was possible. CT density measurements varied by 2-4 HU depending on the manufacturer. This should be considered when setting absolute threshold values for CT density. 4
37. Korobkin M, Brodeur FJ, Francis IR, Quint LE, Dunnick NR, Londy F. CT time-attenuation washout curves of adrenal adenomas and nonadenomas. AJR. 1998; 170(3):747-752. Observational-Dx 66 patients: 52 adrenal adenomas; 24 non-adenomas To determine if delayed washout CT improved differentiation of benign and malignant adrenal lesions. The mean percentage of enhancement washout for adrenal adenomas was 51% at 5 min and 70% at 15 min, compared with 8% and 20%, respectively, for nonadenomas. The sensitivity and specificity for the diagnosis of adenoma were both 96% at a threshold attenuation value of 37 H on the 15-min delayed enhanced scan. 3
38. Caoili EM, Korobkin M, Francis IR, Cohan RH, Dunnick NR. Delayed enhanced CT of lipid-poor adrenal adenomas. AJR. 2000; 175(5):1411-1415. Review/Other-Dx 18 lipid-poor adenomas; 56 lipid-rich adenomas; 40 adrenal non-adenomas Compared the delayed contrast-enhanced CT features of lipid-poor adenomas with those of lipid-rich adenomas and adrenal non-adenomas to determine whether there were differences in the washout features between these groups of lesions. A single mean attenuation value cannot differentiate lipid-poor adenomas from adrenal non-adenomas. Lipid-poor adenomas show enhancement and enhancement washout features similar to lipid-rich adenomas and can be distinguished from non-adenomas on the basis of a percentage washout threshold value of 60% and a relative percentage washout of 40%. 4
39. Kebapci M, Kaya T, Gurbuz E, Adapinar B, Kebapci N, Demirustu C. Differentiation of adrenal adenomas (lipid rich and lipid poor) from nonadenomas by use of washout characteristics on delayed enhanced CT. Abdom Imaging. 2003; 28(5):709-715. Observational-Dx 65 patients; 77 adrenal masses Describe non-enhanced, early contrast-enhanced and delayed contrast-enhanced CT features and contrast washout characteristics of adrenal adenomas (lipid rich and lipid poor) and non-adenomas to determine the role of these methods in distinguishing one type from the other. The absolute or relative percentage washout of contrast material on delayed contrast-enhanced CT is highly specific for differentiation of lipid-poor and lipid-rich adrenal adenomas from adrenal non-adenomas. 3
40. Korobkin M, Francis IR. Imaging of adrenal masses. Urol Clin North Am. 1997; 24(3):603-622. Review/Other-Dx N/A Review clinical features and imaging findings of patients with known or suspected adrenal masses. In patients with hyperfunctioning adrenal syndrome, CT is useful. In patients with a non-hyperfunctioning adrenal mass, chemical shift MRI and CT densitometry are now replacing percutaneous adrenal biopsy or serial follow-up CT as methods to establish a specific diagnosis. 4
41. Szolar DH, Kammerhuber FH. Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. Radiology. 1998; 207(2):369-375. Observational-Dx 122 patients; 135 adrenal masses To measure the changes in wash-in and washout of contrast material on contrast material-enhanced CT scans in patients with adrenal adenomas and nonadenomas. Delayed enhanced CT at 10 minutes (sensitivity 92%; specificity 95%) and 30 minutes (sensitivity 97%; specificity 100%) was more accurate for differentiation of adenomas and non-adenomas than unenhanced CT (sensitivity 82%; specificity 95%). Authors conclude that adrenal adenomas show greater washout of contrast material than adrenal non-adenomas. Recommends combining percentage change in washout of contrast material to absolute CT attenuation values in differentiation of adrenal adenomas and non-adenomas. 2
42. Park BK, Kim CK, Kim B, Lee JH. Comparison of delayed enhanced CT and chemical shift MR for evaluating hyperattenuating incidental adrenal masses. Radiology. 2007; 243(3):760-765. Observational-Dx 34 patients; 43 adrenal masses Retrospective study to compare the accuracy of delayed enhanced CT and chemical shift MRI for characterizing hyperattenuating adrenal masses at CT, with either follow-up imaging or pathologic review as the reference standard. Sensitivity, specificity, and accuracy for adenoma at CT were 97% (36/37), 100% (6/6), and 98% (42/43), respectively, and at MR were 86% (32/37), 50% (3/6), and 49% (21/43), respectively. CT helped confirm 5 more adenomas and 3 more metastatic tumors than did MRI. However, there was no significant difference for diagnostic accuracy between the two imaging modalities (P>.05). 2
43. Koo HJ, Choi HJ, Kim HJ, Kim SO, Cho KS. The value of 15-minute delayed contrast-enhanced CT to differentiate hyperattenuating adrenal masses compared with chemical shift MR imaging. Eur Radiol. 24(6):1410-20, 2014 Jun. Observational-Dx 478 adrenal masses in 453 patients examined with 15-DECT and 235 masses in 217 patients examined with CSMR To investigate the diagnostic performance of 15-min delayed contrast-enhanced computed tomography (15-DECT) compared with that of chemical shift magnetic resonance (CSMR) imaging in differentiating hyperattenuating adrenal masses and to perform subgroup analysis in underlying malignancy and non-malignancy. RPW calculated from 15-DECT showed the highest diagnostic performance for characterising hyperattenuating adrenal masses regardless of underlying malignancy, and the sensitivity, specificity and accuracy were 91.7 %, 74.8 % and 88.1 %, respectively in all patients. The risk of non-adenoma increased approximately threefold asmass size increased 1 cm or as its attenuation value increased by 10 Hounsfield units. 2
44. Tessonnier L, Sebag F, Palazzo FF, et al. Does 18F-FDG PET/CT add diagnostic accuracy in incidentally identified non-secreting adrenal tumours? Eur J Nucl Med Mol Imaging. 2008; 35(11):2018-2025. Observational-Dx 37 patients with 41 adrenal masses To evaluate the ability of FDG-PET to distinguish benign from malignant adrenal masses when CT or MRI results had been inconclusive. The final diagnosis was 12 malignant, 17 benign tumors, and 12 tumors classified as benign on follow-up. The visual interpretation was more accurate than SUVmax alone, tumor diameter or unenhanced density, with a sensitivity of 100% (12/12), a specificity of 86% (25/29) and a NPV of 100% (25/25). The use of 1.8 as the threshold for tumor/liver SUVmax ratio, retrospectively established, demonstrated 100% sensitivity and specificity. FDG-PET/CT accurately characterizes adrenal tumors, with an excellent sensitivity and NPVs. Thus, a negative PET may predict a benign tumor that would potentially prevent the need for surgery of adrenal tumors with inconclusive conventional imaging. 2
45. Gillams A, Roberts CM, Shaw P, Spiro SG, Goldstraw P. The value of CT scanning and percutaneous fine needle aspiration of adrenal masses in biopsy-proven lung cancer. Clin Radiol. 1992; 46(1):18-22. Review/Other-Dx 16 patients had FNA To review the accuracy of CT and percutaneous FNA of adrenal masses in biopsy-proven lung cancer. 19% of samples were insufficient. 5 patients with positive FNA died within 24 months but 2/5 with negative biopsies died with metastatic disease within 11 months. Lesions <2 cm were benign. Biopsy was necessary for diagnosis since the CT appearances of many adrenal lesions were insufficiently distinctive to exclude malignancy. 4
46. Silverman SG, Mueller PR, Pinkney LP, Koenker RM, Seltzer SE. Predictive value of image-guided adrenal biopsy: analysis of results of 101 biopsies. Radiology. 1993; 187(3):715-718. Observational-Dx 97 patients; 101 biopsies To review the accuracy of biopsy performed in a mixed population. Diagnostic samples were obtained in 86%. Biopsy had sensitivity of 93%, NPV of 91% and accuracy of 96%. Three small masses <3 cm proved to be malignant. Biopsy is an accurate procedure, however if benign tissue is not obtained then repeat biopsy or surgery is indicated. 8% complications. 3
47. Tikkakoski T, Taavitsainen M, Paivansalo M, Lahde S, Apaja-Sarkkinen M. Accuracy of adrenal biopsy guided by ultrasound and CT. Acta Radiol. 1991; 32(5):371-374. Observational-Dx 56 patients To review the results of FNA of the adrenal glands guided by US or CT and determine its accuracy. Sufficient material was obtained in 96%. Overall accuracy to differentiate benign and malignant disease was 85.7% with 2 false negatives and one false positive. No complications. 4
48. Mazzaglia PJ, Monchik JM. Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: a decade of experience. Archives of Surgery. 144(5):465-70, 2009 May.Arch Surg. 144(5):465-70, 2009 May. Review/Other-Dx 154 patients, 163 biopsies To determine the value of percutaneous adrenal biopsy in the evaluation of adrenal neoplasm. There were 163 biopsies performed on 154 patients. Mean (SD) age was 66 (12.5) years. Eighty-eight biopsies (53.4%) were performed in patients with a priordiagnosis of cancer. Forty-five (26.4%) were performed when imaging study results suggested previously undiagnosed cancer with a simultaneous adrenal metastasis. Thirty (20.2%) were performed for isolated adrenal incidentalomas. Rates of positive biopsy results in these 3 groups were 70.6%, 69.0%, and 16.7%, respectively. Prebiopsy evaluation for pheochromocytoma was performed in less than 5% of patients with established or suspected nonadrenal malignancies and 32% of patients with incidentalomas. In patients with isolated adrenal incidentaloma, a radiology report recommended biopsy 33% of the time for characteristics inconsistent with benign adenoma. Benign incidentalomas measured mean (SD) 4.2 (2.1) cm (range, 1.4-10.7 cm), and malignancies measured mean (SD) 9.3 (3.3) cm (range, 5.3-14 cm) (P<.05). All incidentalomas 5 cm or less (n=18) were benign. There were 4 false-negative biopsy results: 3 adrenocortical carcinomas and 1 pheochromocytoma. 4
49. Williams AR, Hammer GD, Else T. Transcutaneous biopsy of adrenocortical carcinoma is rarely helpful in diagnosis, potentially harmful, but does not affect patient outcome. European Journal of Endocrinology. 170(6):829-35, 2014 Jun.EUR. J. ENDOCRINOL.. 170(6):829-35, 2014 Jun. Observational-Dx 75 patients To evaluate the utility, diagnostic sensitivity, and effect on patient outcome of transcutaneous adrenal biopsy (TAB) in patients with Adrenocortical carcinoma (ACC). A total of 75 ACC patients with TAB were identified. Complications occurred in at least 11% of patients and were mainly associated with bleeding. The sensitivity of the procedure in diagnosing ACC was maximally 70%. For stage I-III patients, baseline characteristics, stage at diagnosis, adjuvant treatment with mitotane or radiation were not significantly different between the TAB (n = 36) and the non-TAB (n = 254) groups. There was no significant difference in recurrence-free (p = 0.7) or overall survival (p = 0.7) between patients who underwent TAB and those who did not. 3
50. Leroy-Willig A, Bittoun J, Luton JP, et al. In vivo MR spectroscopic imaging of the adrenal glands: distinction between adenomas and carcinomas larger than 15 mm based on lipid content. AJR. 1989; 153(4):771-773. Review/Other-Dx 20 patients; 22 adrenal tumors To investigate the role of chemical shift MRI in differentiating benign and malignant adrenal masses in a mixed population. Lipid percentage was higher for adenomas (n=15) than for metastatic (n=7). One adenoma had a lipid percentage overlapping with malignant (96% correct). In vivo MR spectroscopic imaging of adrenal tumors is useful. 4
51. Mitchell DG, Crovello M, Matteucci T, Petersen RO, Miettinen MM. Benign adrenocortical masses: diagnosis with chemical shift MR imaging. Radiology. 1992; 185(2):345-351. Observational-Dx 31 patients; 45 adrenal masses To investigate the role of chemical shift MRI in differentiating benign and malignant adrenal masses in a mixed population. Both myelolipomas and 26/27 benign cortical masses showed a loss of SI on at least one chemical shift image. Opposed-phase images were slightly more sensitive than fat-suppressed images in depicting lipid within benign cortical masses. All masses had higher SI than that of the liver on standard T2-weighted MR images. Chemical shift MRI can demonstrate lipid within benign adrenocortical masses and thus increase specificity, potentially obviating biopsy and aggressive follow-up. 4
52. Tsushima Y, Ishizaka H, Matsumoto M. Adrenal masses: differentiation with chemical shift, fast low-angle shot MR imaging. Radiology. 1993; 186(3):705-709. Observational-Dx 46 patients; 53 adenomas Prospective study to investigate the role of chemical shift MRI in differentiating benign and malignant adrenal masses in a mixed population. The signal-intensity indexes of adrenal masses ([SI on IP - SI on OP]/[SI on IP x 100]), where IP = in-phase image and OP = out-of-phase image, were calculated. All adenomas had SI indexes >5%, while SI indexes of metastatic tumors and pheochromocytomas were <5%, with accuracy of 100%. Chemical shift MRI was superior to the calculated T2. 3
53. Mayo-Smith WW, Lee MJ, McNicholas MM, Hahn PF, Boland GW, Saini S. Characterization of adrenal masses (< 5 cm) by use of chemical shift MR imaging: observer performance versus quantitative measures. AJR. 1995; 165(1):91-95. Observational-Dx 43 patients: 46 adrenal lesions; 3 observers To evaluate the ability of chemical shift MRI to differentiate <5 cm adrenal adenomas from metastases and to compare subjective interpretation with several different quantitative measures. Mean SI was significantly different between adenomas and metastases on out-of-phase images (64 vs 98) (P<.0005) but not in-phase images (130 vs 122) (P=.47). The adrenal-spleen ratio discriminated between adenomas and metastases better than did the adrenal-liver ratio, the adrenal-muscle ratio, or the SI index. No significant difference in interpretation among the three observers was evident (areas under the ROC curves, 0.93, 0.95, and 0.96). The performance of the observers was comparable to the results obtained with the adrenal-spleen ratio measurement (area under the ROC curve, 0.97). 3
54. McNicholas MM, Lee MJ, Mayo-Smith WW, Hahn PF, Boland GW, Mueller PR. An imaging algorithm for the differential diagnosis of adrenal adenomas and metastases. AJR. 1995; 165(6):1453-1459. Review/Other-Dx 33 patients; 37 adrenal masses Prospective study to develop an algorithm using CT and chemical-shift MRI for the characterization of adrenal masses in patients with a primary cancer and no other evidence of metastatic disease. Lesions =0 H may be benign and further work-up is not required. Lesions with density >20 H may be malignant and should be biopsied when the result will influence management. Study recommends chemical-shift MRI for CT-indeterminate lesions. An adrenal-spleen ratio threshold of 70 indicates a benign lesion, and no further workup is required in these patients. Lesions with adrenal-spleen ratio >70 should have a biopsy performed, depending on the clinical situation. 4
55. Outwater EK, Siegelman ES, Radecki PD, Piccoli CW, Mitchell DG. Distinction between benign and malignant adrenal masses: value of T1-weighted chemical-shift MR imaging. AJR. 1995; 165(3):579-583. Observational-Dx 50 patients: 58 adrenal; masses; 3 observers Blinded study to determine value of T1-weighted chemical-shift MRI for distinction between benign and malignant adrenal masses. The 3 readers had mean sensitivity of 87%, specificity of 92%, and PPV of 95% for diagnosis of benign lesion. At the highest (definite) confidence of a benign lesion, the mean PPV was 99%, with lower sensitivity (54%). Areas under ROC curves for the 3 radiologists were .98 (95% CI: .94-1.00), .96 (CI: .91-1.00), and .95 (CI: .89-1.00). Inter-observer variation for the diagnosis of a benign mass was low (kappa = .79). Authors conclude that chemical-shift imaging using breath-hold opposed-phase T1-weighted MRI is a reliable and reproducible technique for the diagnosis of most benign adrenal masses at the highest threshold of confidence. 2
56. Fujiyoshi F, Nakajo M, Fukukura Y, Tsuchimochi S. Characterization of adrenal tumors by chemical shift fast low-angle shot MR imaging: comparison of four methods of quantitative evaluation. AJR. 2003; 180(6):1649-1657. Observational-Dx 88 patients; 102 adrenal masses Retrospective study to compare and assess 4 quantitative methods of distinguishing adenomas from malignant adrenal lesions using chemical shift fast low-angle shot MRI. The SI index was the best method of distinguishing benign and malignant lesions. In this study 100% were identified correctly using a SI index of 11.2% to 16.5%. 3
57. Shinozaki K, Yoshimitsu K, Honda H, et al. Metastatic adrenal tumor from clear-cell renal cell carcinoma: a pitfall of chemical shift MR imaging. Abdom Imaging. 2001; 26(4):439-442. Review/Other-Dx 1 patient A case of adrenal metastasis from clear-cell renal cell carcinoma in which presence of a small amount of fat was shown on chemical shift gradient-echo MRI is presented. Radiologists should be aware that signal loss of the adrenal tumor on out-of-phase gradient-echo images does not always suggest the diagnosis of benign adenoma, particularly in patients with a history of renal cell carcinoma. 4
58. Sydow BD, Rosen MA, Siegelman ES. Intracellular lipid within metastatic hepatocellular carcinoma of the adrenal gland: a potential diagnostic pitfall of chemical shift imaging of the adrenal gland. AJR. 2006; 187(5):W550-551. Review/Other-Dx 1 patient A case is presented of a 48-year-old man with a history of hepatitis C, hepatic cirrhosis, and hepatocellular carcinoma who was being treated with chemotherapy. A baseline MRI examination revealed a 2.5 cm hepatocellular carcinoma of the right lobe and normal adrenal glands. An adrenal mass was discovered during an MR examination performed 3 months later. The adrenal mass was isointense to the spleen on both in-phase gradient-echo T1- and T2-weighted fast spin-echo images but lost signal relative to spleen on opposed-phase imaging. 4
59. Haider MA, Ghai S, Jhaveri K, Lockwood G. Chemical shift MR imaging of hyperattenuating (>10 HU) adrenal masses: does it still have a role? Radiology. 2004; 231(3):711-716. Observational-Dx 36 patients; 38 masses Retrospective study to determine whether chemical shift MRI can characterize hyperattenuating adrenal masses. 89% (17/19 masses) of adrenal adenomas >10HU were detected by chemical shift MRI. Authors conclude that for some circumstances, chemical shift MRI is a reasonable second imaging test for further characterization of a hyperattenuating adrenal mass. 3
60. Gabriel H, Pizzitola V, McComb EN, Wiley E, Miller FH. Adrenal lesions with heterogeneous suppression on chemical shift imaging: clinical implications. J Magn Reson Imaging. 2004; 19(3):308-316. Review/Other-Dx 242 patients Retrospective study to determine the frequency and value of adrenal lesions that demonstrate heterogeneous suppression on chemical shift MRI. Heterogeneous suppression was seen in 14% of patients. Imaging or pathologic follow-up was available for 18 of the heterogeneously suppressing lesions. 18/18 cases were benign. Therefore, heterogeneous suppression has the same significance as homogeneous suppression. 4
61. Miller FH, Wang Y, McCarthy RJ, et al. Utility of diffusion-weighted MRI in characterization of adrenal lesions. AJR. 2010; 194(2):W179-185. Observational-Dx 160 adrenal lesions in 156 patients To retrospectively evaluate the utility of ADC values for characterizing adrenal lesions and determine if DWI can distinguish lipid-rich from lipid-poor adenomas. ADCs of adrenal malignancies (median, 1.67 x 10(-3) mm(2)/s; interquartile range, 1.41-1.84 x 10(-3) mm(2)/s) were not different compared with those of benign lesions (1.61 x 10(-3) mm(2)/s; 1.27-1.96 x 10(-3) mm(2)/s; p > 0.05). Cysts (2.93 x 10(-3) mm(2)/s; 2.70-3.09 x 10(-3) mm(2)/s) showed higher ADCs than the remaining adrenal lesions (P<0.05). The median ADCs of lipid-rich adenomas did not differ from those of lipid-poor ones (P>0.05). The CT attenuation had no negative or positive correlation with the ADCs of adrenal adenomas (r = -0.05, P=0.97). Unlike lesion size and percentage decrease in SI, the ADCs were not useful in distinguishing benign from malignant adrenal lesions. Lipid-poor adenomas could not be distinguished from lipid-rich adenomas and all other nonfatty lesions of the adrenal gland with DWI. 3
62. Tsushima Y, Takahashi-Taketomi A, Endo K. Diagnostic utility of diffusion-weighted MR imaging and apparent diffusion coefficient value for the diagnosis of adrenal tumors. J Magn Reson Imaging. 2009; 29(1):112-117. Observational-Dx 42 patients with 43 adrenal tumors Retrospective study to determine the utility of DWI-MRI for the diagnosis of adrenal tumors. There was no difference in ADC values between adenomas (1.09 +/- 0.29*10(-3) mm(2)/s; range, 0.52-1.64) and metastatic tumors (0.85 +/- 0.26*10(-3); 0.51-1.23; P=0.14). Pheochromocytomas showed the higher mean ADC value (1.59 +/- 0.34*10(-3); 1.04-1.96) compared with those of adenomas or metastatic tumors (P<0.05 and P<0.005, respectively). The mean SI index of adenomas (62.1 +/- 17.9%; 14.5-88.4) was significantly higher than those of pheochromocytomas (4.0 +/- 10.0%; -19.6-3.3; P<0.005) or metastatic tumors (-1.5 +/- 11.7%; -18.3-8.2; P<0.01). There was no correlation between ADC values and SI index. Although pheochromocytomas showed higher ADC values, we did not find that ADC value had diagnostic utility for differentiating adenomas and metastatic tumors. 3
63. Pena CS, Boland GW, Hahn PF, Lee MJ, Mueller PR. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology. 217(3):798-802, 2000 Dec.Radiology. 217(3):798-802, 2000 Dec. Observational-Dx 86 patients, 101 adrenal lesions To determine whether computed tomographic (CT) scans and attenuation measurements on contrast material–enhanced and nonenhanced CT scanscould be used to characterize adrenal masses, in particular, to characterize these lesions by using adrenal washout characteristics at contrast-enhanced CT. Ninety-nine of 101 lesions were correctly characterized as benign or malignant with a relative percentage washout threshold of 50% on delayed scans;benign lesions demonstrated more than 50% washout; and malignant lesions, less than 50% washout. Two benign lesions demonstrating less than 50% washout were characterized as benign by using conventional CT. 3
64. Minn H, Salonen A, Friberg J, et al. Imaging of adrenal incidentalomas with PET using (11)C-metomidate and (18)F-FDG. J Nucl Med. 2004; 45(6):972-979. Review/Other-Dx 21 patients To examine imaging of adrenal incidentalomas with PET using (11) C-metomidate and FDG. FDG detected 2/3 noncortical malignancies but failed to detect adrenal metastases from renal cell carcinoma. Authors conclude that (11)C-Metomidate is a promising PET tracer to identify incidentalomas of adrenocortical origin. FDG is recommended for patients with a moderate to high likelihood of neoplastic disease. 4
65. Zettinig G, Mitterhauser M, Wadsak W, et al. Positron emission tomography imaging of adrenal masses: (18)F-fluorodeoxyglucose and the 11beta-hydroxylase tracer (11)C-metomidate. Eur J Nucl Med Mol Imaging. 2004; 31(9):1224-1230. Observational-Dx 16 patients Study aimed to: Evaluate (11)C-metomidate. Point out possible advantages in comparison with FDG. Examine in vivo the expression of 11beta-hydroxylase in patients with primary aldosteronism. (11)C-metomidate is an excellent imaging tool to distinguish adrenocortical and non-cortical lesionsThe in vivo expression of 11beta-hydroxylase is lower in Cushing’s syndrome than in Conn’s syndrome, and there is no suppression of the contralateral gland in primary aldosteronism. FDG is the tracer of choice for discriminating between benign and malignant lesions. 3
66. Bharwani N, Rockall AG, Sahdev A, et al. Adrenocortical carcinoma: the range of appearances on CT and MRI. [Review]. AJR. American Journal of Roentgenology. 196(6):W706-14, 2011 Jun.AJR Am J Roentgenol. 196(6):W706-14, 2011 Jun. Review/Other-Dx N/A To review the range of appearances of adrenocortical carcinoma on CT and MRI No results stated in abstract. 4
67. van Erkel AR, van Gils AP, Lequin M, Kruitwagen C, Bloem JL, Falke TH. CT and MR distinction of adenomas and nonadenomas of the adrenal gland. J Comput Assist Tomogr. 1994; 18(3):432-438. Observational-Dx 37 patients; 44 adrenal masses To determine which of these: size, CT attenuation values, MRI SI ratios on T1- and T2-weighted sequences, calculated T2 relaxation times, or T2 relaxation time ratios provide better distinction of adenomas and non-adenomas of the adrenal gland. Using a threshold of 15 HU they found no malignancies although there were some cysts. The optimal size threshold was 3.1 cm but it did not discriminate all lesions (93%). Attenuation values on non-contrast-enhanced CT are recommended in discriminating adrenal adenomas from non-adenomas. 3
68. Barry MK, van Heerden JA, Farley DR, Grant CS, Thompson GB, Ilstrup DM. Can adrenal incidentalomas be safely observed? World J Surg. 1998; 22(6):599-603; discussion 603-594. Review/Other-Dx 231 patients To determine the clinical outcome of a well-defined population of patients with incidentalomas followed without operative intervention. Most adrenal tumors were unilateral (right 113; left 98); 20 were bilateral. Mean tumor size was 2 cm (range 1-6 cm). In 9 (4%) patients the tumor was =4 cm. Follow-up [mean 7 years; range 1 month (patient died) to 11.7 years] was complete in 224 (97%) patients. 91 (39%) patients had one or more additional CT scans performed during the follow-up period, with only 4 patients demonstrating a >1 cm increase in the size of the adrenal mass. Surgical excision of these 4 lesions identified benign pathology. 81 (35%) patients died of conditions unrelated to adrenal pathology. No patient developed subsequent adrenal hyperfunction or adrenal malignancy. Conservative management of adrenal incidentalomas considered benign or nonfunctioning at diagnosis is appropriate. Additional information provided by repeat CT scanning appears to confer limited benefit. This study does not support laparoscopic removal of small, nonfunctional adrenal tumors, as has been suggested. 4
69. Ho LM, Paulson EK, Brady MJ, Wong TZ, Schindera ST. Lipid-poor adenomas on unenhanced CT: does histogram analysis increase sensitivity compared with a mean attenuation threshold? AJR. 2008; 191(1):234-238. Observational-Dx 104 patients; 132 adrenal nodules To compare histogram analysis with mean attenuation threshold to determine the value of CT histogram analysis for further characterization of lipid-poor adenomas on unenhanced CT. Unenhanced CT mean attenuation threshold <10 histogram yielded a sensitivity of 68% and specificity of 100% for the diagnosis of an adenoma. Unenhanced CT threshold >10% negative pixels yielded a sensitivity of 84% and specificity of 100% for the diagnosis of an adenoma. Authors conclude that CT histogram analysis is superior to mean CT attenuation analysis for the evaluation of adrenal nodules and may help decrease referrals for additional imaging or biopsy. 3
70. Remer EM, Motta-Ramirez GA, Shepardson LB, Hamrahian AH, Herts BR. CT histogram analysis in pathologically proven adrenal masses. AJR Am J Roentgenol. 187(1):191-6, 2006 Jul. Observational-Dx 187 patients: 208 adenomas; 2 observers Retrospective review to evaluate if a CT histogram analysis method can distinguish adrenal adenomas from metastases, pheochromocytomas and adrenal cortical carcinomas. Compared adenomas on unenhanced CT with enhanced CT. Specificity for a 10% negative pixel threshold was approximately 88% for unenhanced CT scans and 99% for enhanced CT scans, with sensitivities of 71% and 12%, respectively. Although the specificity for adenoma diagnosis on enhanced CT is high using a histogram analysis method with a 10% negative threshold, low sensitivity limits clinical usefulness. 4
71. Young WF, Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med. 2007; 356(6):601-610. Review/Other-Dx N/A Review article that presents recommendations for the evaluation of patients with adrenal incidentalomas. A patient is described in a vignette. A thorough history should be obtained and a physical examination performed to assess the evidence of adrenal hormone excess for the patient presented in the vignette. 4
72. Schteingart DE, Doherty GM, Gauger PG, et al. Management of patients with adrenal cancer: recommendations of an international consensus conference. Endocr Relat Cancer. 2005; 12(3):667-680. Review/Other-Dx N/A Consensus conference to examine management of patients with adrenal cancer. In addition to setting up guidelines in specific areas of the diagnosis and treatment of adrenal cancer, the conference recommended and initiated the planning of an international prospective trial for treatment of patients with adrenal cancer in stages III and IV. 4
73. Kutikov A, Mallin K, Canter D, Wong YN, Uzzo RG. Effects of increased cross-sectional imaging on the diagnosis and prognosis of adrenocortical carcinoma: analysis of the national cancer database. J Urol. 2011; 186(3):805-810. Review/Other-Dx 4,275 patients To assess whether incidental screening due to imaging performed for other purposes has resulted in earlier detection or better outcomes in patients with adrenocortical carcinoma. Median survival for 4,275 patients was 24 months. Localized adrenocortical carcinoma accounted for 43.9% of cases. No stage migration was noted with time. No statistical trends were noted in tumor size changes during the years in patients who underwent surgery for localized disease (P=0.32). No improvement was observed in 5-year survival during the period (P>0.1). Better risk stratification of patients with adrenal incidentaloma, while improving treatment efficacy for those with proven adrenocortical carcinoma, is an essential clinical and epidemiological task. 4
74. Song JH, Grand DJ, Beland MD, Chang KJ, Machan JT, Mayo-Smith WW. Morphologic features of 211 adrenal masses at initial contrast-enhanced CT: can we differentiate benign from malignant lesions using imaging features alone?. AJR Am J Roentgenol. 201(6):1248-53, 2013 Dec. Observational-Dx Two hundred eleven adrenal masses To determine whether morphologic features of adrenal masses detected at initial contrast-enhanced MDCT can differentiate benign from malignant disease. There were 171 (81%) benign and 40 (19%) malignant adrenal masses. All malignant masses were metastases diagnosed in patients with known extraadrenal malignancy. For individual morphologic features in diagnosing malignancy, irregular margins had 30–33% sensitivity and 95–96% specificity and an enhancing rim had 5–13% sensitivity and 98–99% specificity. None of the imaging features was reliable in predicting benignity. When an adrenal mass was deemed suspicious by a reader, the sensitivities for malignancy ranged from 54% to 74% and specificities from 96% to 97%. Notably, no malignant lesions occurred in patients without a known history of cancer. 2
75. Boland GW, Blake MA, Holalkere NS, Hahn PF. PET/CT for the characterization of adrenal masses in patients with cancer: qualitative versus quantitative accuracy in 150 consecutive patients. AJR. American Journal of Roentgenology. 192(4):956-62, 2009 Apr.AJR Am J Roentgenol. 192(4):956-62, 2009 Apr. Observational-Dx 150 patients To evaluate a large cohort of patients with PET/CT to determine whether qualitative (visual) assessment, quantitative standardized uptakevalue (SUV), or standardized uptake ratio (SUR) techniques should be used when attempting to characterize adrenal masses in patients with cancer. Of the 139 benign lesions, 109 were considered benign by CT densitometry measurements and 135 by qualitative PET data. Qualitative PET characterized 28 of 30 benign lesions that were considered indeterminate by unenhanced CT. All 26 malignant lesions were characterized by PET: All showed qualitative and quantitative signal intensity greater than the liver. By combining unenhanced and qualitative CT data with the retrospective PET data, the analysis yielded a sensitivity of 100% for the detection of malignancy, a specificity of 99%, a positive predictive value (PPV) of 93%, a negative predictive value (NPV) of 100%, and an accuracy of 99% (Table 1). Conversely, for the detection of benignity, the sensitivity, specificity, PPV, NPV, and accuracy were 99%, 100%, 100%, 93%, and 99%, respectively. 2
76. Choi YA, Kim CK, Park BK, Kim B. Evaluation of adrenal metastases from renal cell carcinoma and hepatocellular carcinoma: use of delayed contrast-enhanced CT. Radiology. 266(2):514-20, 2013 Feb. Observational-Dx 36 patients To retrospectively compare absolute and relative washout of adrenal metastases in patients with renal cell carcinoma (RCC) and hepatocellular carcinoma (HCC) to that of adrenal adenoma. The mean absolute percentage washout (APW) of the metastases (observer 1, 67% ± 11 [standard deviation]; observer 2, 63% ± 12) was not significantly different from that of adenomas (observer 1, 73% ± 9; observer 2, 72% ± 12) for observer 1 (P = .143) and was significantly different for observer 2 (P = .029). The mean RPW of the metastases (observer 1, 46% ± 11; observer 2, 43% ± 12) was significantly lower than that of adenomas (observer 1, 62% ± 19; observer 2, 60% ± 17) (all P < .001 for each observer). With a threshold of 60% for APW or 40% for RPW, 95% (18 of 19) and 89% (17 of 19), respectively, of the metastases were falsely diagnosed as lipid-poor adenomas by each observer. All nine metastases that were followed up at CT had a substantial growth in size. 4
77. Hoh CK, Schiepers C, Seltzer MA, et al. PET in oncology: will it replace the other modalities? Semin Nucl Med.1997; 27(2):94-106. Review/Other-Dx N/A Review literature over last 3 years to examine role of PET in relation to other tumor imaging modalities. Currently, PET is used in characterizing tumor lesions, differentiating recurrent disease from treatment effects, staging tumors, evaluating the extent of disease, and monitoring therapy. In the future, PET may be used in molecular medicine and genetics. 4
78. Kutlu CA, Pastorino U, Maisey M, Goldstraw P. Selective use of PET scan in the preoperative staging of NSCLC. Lung Cancer. 1998; 21(3):177-184. Observational-Dx 21 patients To evaluate the place of PET scanning for the characterisation of additional abnormalities discovered on routine, preoperative CT evaluation of patients with proven NSCLC. Accuracy of PET in assessment of nonpulmonary lesions found on CT in operable NSCLC was 96% with sensitivity of 93% and specificity of 100%. Results show PET is useful in small cell lung cancer. 4
79. Yun M, Kim W, Alnafisi N, Lacorte L, Jang S, Alavi A. 18F-FDG PET in characterizing adrenal lesions detected on CT or MRI. J Nucl Med. 2001; 42(12):1795-1799. Observational-Dx 41 patients; 50 adrenal masses Retrospective analysis to evaluate the ability of FDG-PET to characterize adrenal lesions in patients with proven or suspected cancers. FDG-PET for characterization of adrenal lesions showed a sensitivity of 100%, a specificity of 94%, and an accuracy of 96%. FDG-PET has the additional advantage of evaluating the primary lesions as well as metastases, it could be cost-effective and the modality of choice for the characterization of adrenal lesions, especially in patients with malignancy. 3
80. Vikram R, Yeung HD, Macapinlac HA, Iyer RB. Utility of PET/CT in differentiating benign from malignant adrenal nodules in patients with cancer. AJR. 2008; 191(5):1545-1551. Observational-Dx 112 adrenal nodules in 96 patients To determine the sensitivity and specificity of combined PET/CT in differentiating benign from malignant adrenal nodules measuring at least 1 cm in diameter in patients with cancer. 12/82 benign nodules were PET positive with a sensitivity of 83.3% and specificity of 85.4%. Patients with 4/5 malignant nodules with negative PET results had received previous therapy. The PPV for detection of malignant lesions was 67%, and the NPV was 93%. Adrenal masses that are not FDG avid are likely to be benign with a high NPV. Especially in patients undergoing therapy, however, there is a small but statistically significant false-negative rate. A considerable proportion of benign nodules have increased FDG activity. 3
81. Paulsen SD, Nghiem HV, Korobkin M, Caoili EM, Higgins EJ. Changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies. AJR. 2004; 182(4):1033-1037. Review/Other-Dx 50 adrenal biopsies Retrospective study to assess the effect of dedicated adrenal imaging with CT and MRI on the rate of percutaneous imaging-guided biopsies of adrenal masses. Only 6/50 (12%) of adrenal biopsied were adenomas. The number of adrenal adenomas biopsied has declined markedly with the introduction of dedicated adrenal CT and MRI for adrenal adenomas. Percutaneous imaging-guided biopsy is useful in confirming the presence and nature of suspected adrenal metastases. 4
82. Outwater EK, Bhatia M, Siegelman ES, Burke MA, Mitchell DG. Lipid in renal clear cell carcinoma: detection on opposed-phase gradient-echo MR images. Radiology. 205(1):103-7, 1997 Oct. Observational-Dx 43 patients To determine if comparison of in-phase and opposed-phase gradient-echo magnetic resonance (MR) images enables detection of lipid in renal clear cell carcinoma. The mean OIR of clear cell carcinomas was significantly different from that of other renal masses (P < .0002); in 16 (59%) of 27 patients with clear cell carcinoma, the OIR was less than 2 standard deviations below the mean OIR of other masses. In cases of clear cell carcinoma, focal signal intensity on opposed-phase images was less than that on in-phase images. 3
83. Yoshimitsu K, Honda H, Kuroiwa T, et al. Fat detection in granular-cell renal cell carcinoma using chemical-shift gradient-echo MR imaging: another renal tumor that contains fat. Abdom Imaging. 25(1):100-2, 2000 Jan-Feb. Review/Other-Dx 1 case To present a case of granular cell renal cell carcinoma (RCC) that had been shown to have fat on the preoperative chemical-shift gradient-echo MR images and was proven to have fat containing foamy histiocytic infiltration in the interstitium of the tumor. The surgical specimen showed a granular-cell renal cell carcinoma with papillary architecture, associated with abundant fat-containing foamy histiocytes in the interstitium. 4
84. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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