Diagnostic accuracy of computed tomography to identify adenomas among adrenal incidentalomas in an endocrinological population

Marty, Marie; Gaye, Delphine; Perez, Paul; Auder, C.; Nunes, Marie-Laure; Ferrière, Amandine; Haissaguerre, Magalie; Tabarin, Antoine

doi:10.1530/eje-17-1056

Cited by 39 publications

(32 citation statements)

References 21 publications

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“…, potential adrenal cysts, hemorrhage, malignancy, metastatic lesions), or who had insufficient imaging data, for a final sample size of 1376 patients with benign-appearing adrenocortical adenomas. We considered an individual as having a benign-appearing adenoma when the interpreting radiologist described the nodule as having lipid-rich attenuation (<10 Hounsfield units) on unenhanced CT imaging, high-contrast washout on CT imaging (when available), a marked drop in signal intensity on MRI imaging, and/or descriptors that are suggestive of a benign entity, such as “benign” or “adenoma” or “myelolipoma” [ 11 , 12 ]. This study was conducted with the approval from the Institutional Research and Ethics Review Board of our Hospital.…”

Section: Methodsmentioning

confidence: 99%

The Lateralizing Asymmetry of Adrenal Adenomas

Hao

López

Luque-Fernandez

et al. 2018

Journal of the Endocrine Society

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ContextIt is presumed that the incidence of adrenal adenomas is symmetric between the left and right adrenal gland; however, anecdotal observations suggest a potential lateralizing asymmetry.ObjectiveTo investigate the symmetry in detection of adrenal adenomas and relevance to patient care.DesignCross-sectional and longitudinal studies.Population and SettingOne thousand three hundred seventy-six patients with abdominal computed tomography or magnetic resonance imaging demonstrating benign-appearing adrenal adenomas.Main OutcomeLocation and size of adrenal adenomas.ResultsLeft-sided adenomas were discovered in 65% of patients, right-sided in 21%, and bilateral adenomas in 14%. Among unilateral adenomas, 75% were left-sided. Left-sided adenomas were more prevalent than right-sided adenomas in each size category except the largest: <10 mm, 87%; 10 to 19 mm, 74%; 20 to 29 mm, 72%; ≥30 mm, 56% (P < 0.0001 for each category, except P = 0.19 when ≥30 mm). Among those with bilateral adenomas, the left-sided adenoma was significantly larger than the right one in 61% of patients (P < 0.001). There were no significant differences in the baseline prevalence or incidence of cardiometabolic diseases between patients with left-sided vs right-sided adenomas during 5.10 (4.2) years of follow-up.ConclusionsAdrenal adenomas are substantially more likely to be identified on the left adrenal than the right. This observation may be due to detection bias attributed to the location of the right adrenal, which may preclude identification of right-sided adenomas until they are substantially larger. These findings suggest the potential for an underrecognition of right-sided adenomas that may also impair the accurate detection of bilateral adrenal diseases.

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Section: Methodsmentioning

confidence: 99%

The Lateralizing Asymmetry of Adrenal Adenomas

Hao

López

Luque-Fernandez

et al. 2018

Journal of the Endocrine Society

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“…A recently performed meta-analysis indicated that the level of evidence is low to very low for all these imaging methods (151). In the last 2 years, some additional studies have been published (159,160,161,162,163,164,165,166,167,168,169,170,171,172). However, the panel still considers that of the available imaging modalities, only non-contrast CT is sufficiently reliable to rule-out an ACC when the adrenal lesion is homogenous and has low CT density ≤10 HU.…”

Section: Reasoningmentioning

confidence: 99%

European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors

Fassnacht

Dekkers

Else

et al. 2018

European Journal of Endocrinology

656

867

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Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.

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“…Adenomas typically enhance rapidly and show prompt washout of intravenous contrast, in contrast to malignant adrenal lesions which usually enhance rapidly but demonstrate a slower washout of contrast medium. Absolute washout values of >60% (early enhanced HU – delayed HU)/(early enhanced HU – unenhanced HU) × 100% suggest a benign adenoma ( 295 , 299 ). Relative washout can be calculated when unenhanced CT is not available (early enhanced HU – delayed HU)/enhanced HU × 100%.…”

Section: Imaging Evaluation Of An Aimentioning

confidence: 99%

Adrenal Incidentaloma

et al. 2020

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An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup and clinical symptoms and signs are required in every case. ACC remains a real concern but is restricted to <2% of all cases. Functional AI lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.

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Diagnostic accuracy of computed tomography to identify adenomas among adrenal incidentalomas in an endocrinological population

Abstract: Our study, the largest conducted in AIs recruited in an endocrinological setting, suggests safe thresholds for quantitative CT parameters to avoid false diagnoses of benignity.

Cited by 39 publications

References 21 publications

The Lateralizing Asymmetry of Adrenal Adenomas

The Lateralizing Asymmetry of Adrenal Adenomas

European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors

Adrenal Incidentaloma

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