Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant adrenal masses

Schloetelburg, Wiebke; Ebert, I.; Petritsch, Bernhard; Weng, Andreas Max; Dischinger, Ulrich; Kircher, Stefan; Buck, Andreas K.; Bley, Thorsten Alexander; Deutschbein, Timo; Fassnacht, Martin

doi:10.1530/eje-21-0650

Cited by 32 publications

(17 citation statements)

References 35 publications

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“…To conclude, the results in the study by Schloetelburg et al (13) have high impact on the management of patients with adrenal incidentalomas and support the previous ESE and ENSAT recommendations to base CT measurements for tumour characterisation on native CT and for tumours >10 HU on size and morphology comparison on imaging at least 6 months apart.…”

supporting

confidence: 78%

“…Except for the study by Schloetelburg et al, (13) there are two additional recent reports which also are likely to impact future guidelines, and therefore are appropriate to mention (14,15). In these two studies, the authors have assessed an increased threshold, set to 20 HU, on native CT for adrenal tumour characterisation, the results of which however lie outside the scope of this commentary report.…”

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confidence: 99%

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Commentary on Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant masses

Sundín

2022

European Journal of Endocrinology

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The increasing use of cross-sectional imaging, mainly computed tomography (CT), results in an accelerating number of incidental findings, for instance of adrenal tumours. Although most “adrenal incidentalomas” are benign, it is important to identify the malignant and the hormone producing (“functional”) tumours. For a small fraction of adrenal incidentalomas the diagnosis is apparent on imaging, but the large majority requires radiological characterisation. To this end, a previous joint ESE and ENSAT EJE publication recommend CT measurements of the native (non-contrast) tumour attenuation ≤ 10 Hounsfield Units (HU), consistent with a lipid-rich benign adrenocortical adenoma, and imaging at least 6 months apart, on which unchanged tumour size implies a benign tumour. Because of weak evidence, calculation of CT contrast medium washout was not recommended as a means for tumour characterisation, but this technique has nevertheless still been applied in several countries. The current EJE publication bySchloetelburg et al. is important because, in the largest study to date, the authors confirm that calculation of CT contrast medium washout with established thresholds is insufficient to reliably characterise adrenal tumours. Their results are therefor expected to impact the management of these patients.

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confidence: 78%

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confidence: 99%

Commentary on Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant masses

Sundín

2022

European Journal of Endocrinology

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“…An absolute contrast washout of >60% and a relative contrast washout of >40% characterize an adenoma with sensitivity and specificity of 98 and 92% respectively ( 26 , 27 ). It is worth to mention that more recent studies revealed that washout CT may be insufficient to reliably diagnose adrenal masses ( 28 ). Dedicated adrenal imaging including CT attenuation measurements with washout characteristic is highly recommended in patient with adrenal tumours previously treated for extra-adrenal malignancy ( 29 ).…”

Section: Discussionmentioning

confidence: 99%

Risk of malignancy in adrenal tumors in patients with a history of cancer

et al. 2023

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PurposeAdrenal gland is a common site of metastasis and on the other hand, metastases are the most frequent malignant adrenal tumors. The aim of this study was to estimate the risk of malignancy in suspicious adrenal mass in patients with a history of cancer.MethodsThis is a single-center retrospective analysis of patients with adrenal tumors treated previously for different types of cancers. Between 2004 and 2021 a hundred and six such patients were identified. Mean age of patients was 62.6 years (30-78), and mean time from oncologic treatment was 55.8 months (0-274). The most common primary cancer was kidney (RCC): 29 (27.4%), colon/rectum (CRC): 20 (18.9%) and lung (NSCLC): 20 (18.9%).ResultsOf 106 patients, 12 had hormonally active (HA) (11,3%) and 94 (88,7%) non active (HNA) tumors In group of patients with HA tumours 4 had hypercortisolaemia and 8 had elevation of urinary metanephrines. In the first group of HA patients pathology confirmed preoperative diagnosis of adrenocortical cancer and no metastasis was found. In all patients from the second group pheochromocytomas were confirmed. Primary (PM) and secondary (SM) malignancies were found in 50 patients (47.2%). In hormone inactive group only SM - 46/94 (48.9%) were diagnosed. The odds that adrenal lesion was a metastasis were higher if primary cancer was RCC (OR 4.29) and NSCLC (OR 12.3). Metastases were also more likely with high native tumor density, and bigger size in CT. The cut-off values for tumor size and native density calculated from receiver operating characteristic (ROC) curves were 37mm and 24, respectively.ConclusionRisk of malignancy of adrenal mass in a patient with a history of cancer is high (47,2%), regardless of hormonal status. 47,2% risk of malignancy. In preoperative assessment type of primary cancer, adrenal tumour size and native density on CT should be taken into consideration as predictive factors of malignancy. Native density exceeding 24 HU was the strongest risk factor of adrenal malignancy (RR 3.23), followed by history of lung or renal cancer (RR 2.82) and maximum tumor diameter over 37 mm (RR 2.14).

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“…For tumors < 6 cm the risk of malignancy is recommended to be assessed in non-enhanced CT [5]. Wash-out CT with the established thresholds for absolute and relative percentage wash-out (APW/RPW) has been shown to be insufficient to reliably diagnose adrenal masses [21]. MRI is recommended in case non-enhanced CT is inconclusive [5].…”

Section: Discussionmentioning

confidence: 99%

Adrenal Surgery in the Era of Multidisciplinary Endocrine Tumor Boards

Hartmann

2022

Horm Metab Res

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Work up of adrenal masses includes assessment of endocrine activity and malignancy risk. There is no indication for surgical removal of nonfunctional adrenal adenomas, according to the guidelines. In the present study, we aimed at evaluating the impact of a university endocrine tumor board on the quality of the indications for adrenal surgery at our institution. One hundred consecutive patients receiving primary adrenal surgery at the University Hospital of Cologne, Germany were included. Their demographics, clinic-pathologic characteristics, treatment and outcome were analyzed. In 55 (55%) cases, indication for surgery consisted in functional benign tumors, including Conn, Cushing adenomas and pheochromocytomas. Forty (40%) tumors were referred to surgery for malignancy suspicion and 5 (5%) myelolipomas were removed due to their size. Eighty-nine percent of surgeries were performed as minimally invasive procedures. Overall morbidity included two (2%) self-limiting pancreatic fistulas after left laparoscopic adrenalectomy for pheochromocytoma. All functional tumors were confirmed benign by final histology. Only 33 (82.5%) of 40 suspicious cases turned out to be malignant. Consequently, nonfunctional benign adenomas were “unnecessarily” removed in only 7 (7%) patients, with 6 (85.7%) of them having a history of extra-adrenal cancer and all of them fulfilling criteria for surgery, according to the international guidelines. In conclusion, the endocrine tumor board provided an excellent adherence to the guidelines with most surgeries being performed either for functional or malignant tumors. In nonfunctional tumors with history of extra adrenal cancer, CT guided biopsy might be considered for obviating surgery.

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Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant adrenal masses

Cited by 32 publications

References 35 publications

Commentary on Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant masses

Commentary on Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant masses

Risk of malignancy in adrenal tumors in patients with a history of cancer

Adrenal Surgery in the Era of Multidisciplinary Endocrine Tumor Boards

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