Detection of the adrenal glands by endoscopic or transabdominal ultrasound

A Brief Look at Hashimoto's Disease, Adrenal Incidentalomas, Obesity and Insulin Resistance-Could Endocrine Disruptors Be the Other Side of the Same Coin?

Hashimoto's disease (HD) is the most common cause of hypothyroidism in developed countries. The exact pathomechanism behind it has not been clearly established; however, an interplay of genetic susceptibility, environmental triggers (including diet) and epigenetic factors seems to be involved. Among the latter, increasingly more attention has been paid to some hormonally active substances, known as endocrine disruptors, which are commonly used worldwide. HD has become a condition widely reported in the media, acting as a culprit for inexplicable weight gain, chronic fatigue or weakness. Nevertheless, the recognition of HD is undeniably increasing and represents a major public health burden. At the same time, improving access to imaging tests has increased the number of incidentally diagnosed adrenal tumors. Above all, the widespread use of chest computed tomography (CT) due to the COVID-19 pandemic has contributed to frequent incidental detection of adrenal lesions. Fortunately, a vast majority of these findings are asymptomatic benign tumors with no excessive hormonal activity, and therefore, they are defined as adrenal incidentalomas (AIs). Interestingly, recent studies have indicated that patients with AIs are more prone to obesity and insulin resistance. Although mutual relationships between the thyroid and the adrenal glands have been studied widely, still, little is known about the possible pathophysiological associations between thyroid autoimmunity and the occurrence of adrenal incidentalomas. This article presents a brief review of the common endocrine disorders with a special focus on the frequently coexisting insulin resistance and/or obesity. Furthermore, in response to the recent growing interest in endocrine disruptors, with their transgenerational epigenetic effects that influence hormonal system function, a concise overview of the topic has also been included.

Approach to Fine Needle Aspiration of Adrenal Gland Lesions

Adrenal gland lesions are present in 1% to 5% of patients and are most commonly identified incidentally on abdominal imaging. Fine needle aspiration (FNA) cytology plays an important role in the initial workup of adrenal gland nodules, especially in patients with a known history of malignancy. The most common reason for adrenal gland FNA is to differentiate benign adrenal lesions, such as adrenal cortical adenoma, from metastatic malignancy. However, there is a significant cytomorphologic overlap between primary and metastatic adrenal neoplasms. This review focuses on the current state of adrenal gland FNA cytology, with an emphasis on distinguishing adrenocortical adenoma from carcinoma and adrenal cortical neoplasms from metastatic malignancies. The role of immunohistochemistry in specifically diagnosing adrenal neoplasms is discussed. Proposed diagnostic classification systems for adrenal gland FNA cytology are also described.

[Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?]

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?

Rare Presentation of Right Adrenal Mass: Extramedullary Haematopoiesis in a Patient with Thalassaemia Intermedia

Extramedullary hematopoiesis (EMH) is a rare cause of adrenal mass. We present a 44-year-old woman who has thalassaemia intermedia, referred to Endocrinology clinic for huge adrenal mass. Along with a paraspinal lesion discovered in this patient, the leading diagnosis was EMH. The patient was treated with hypertransfusion and hydroxyurea, which led to a reduction in the size of the right adrenal mass and paraspinal mass.

This case highlights the challenges in managing this rare condition. Although EMH is a rare cause of adrenal mass, the diagnosis must be considered in any patient with a history of a congenital hemolytic disorder, to avoid unnecessary surgical procedures.

Diagnosis and staging of lung cancer with the use of one single echoendoscope in both the trachea and the esophagus: A practical guide

Accurate staging of non-small cell lung cancer (NSCLC) is crucial for allocation to surgical, medical or multimodal treatment. EUS and endobronchial ultrasound (EBUS) have gained ground in the diagnosis and staging of lung cancer in addition to radiological imaging (e.g., computed tomography, fluoroscopy, and magnetic resonance imaging), nuclear medicine techniques (e.g. positron emission tomography, PET), combined techniques (e.g., fluorodesoxyglucosepositron emission tomography scanning), and sonographic imaging including conventional transcutaneous mediastinal and lung ultrasound. By using one single echoendoscope in both the trachea and the esophagus, surgical staging procedures (e.g. mediastinoscopy and video assisted thoracoscopy) can be avoided in a considerable proportion of patients with NSCLC.

[Postmortem sonography helpful in death of unknown origin]

Postmortem imaging has been used primarily in forensic medicine since 1895. Conventional x‑ray, computed tomography (CT), and magnetic resonance imaging (MRI) are used. In studies, sonography is not considered to be of particular value, especially because of postmortem gas formation in adults. We report three cases in which postmortem sonography within three hours of death allowed clarification of a previously unclear cause of death.

Pitfalls and differential diagnosis on adrenal lesions: current concepts in CT/MR imaging: a narrative review

The purpose of this pictorial essay is to review the imaging findings of adrenal lesions. Adrenal lesions could be divided into functioning or non-functioning masses, primary or metastatic, and benign or malignant. Imaging techniques have undergone significant advances in recent years. The most significant objective of adrenal imaging is represented by the detection and, when possible, characterization of adrenal lesions in order to direct patient management correctly. The detection and management of adrenal lesions is based on cross-sectional imaging obtained with non-contrast CT (tumour density), contrast-enhanced CT including delayed washout (either absolute percentage washout or relative percentage one) and finally with MR chemical shift analysis (loss of signal intensity between in-phase and out-of-phase images including both qualitative and quantitative estimates of signal loss). The small incidental adrenal nodules are benign, in most of cases; some tumors such as lipid-rich adenoma and myelolipoma have characteristic features that can be diagnosed accurately in CT. On contrary, if the presenting contrast-enhanced CT shows an adrenal mass with uncertain or malignant morphologic features, particularly in patients with a known history of malignancy, further evaluations should be considered. The most significative implications for radiologists are represented by how to assess risk of malignancy on imaging and what follow-up to indicate if an adrenal incidentaloma is not surgically removed.

The Role of Endoscopic Ultrasound for Esophageal Varices

Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care.

Comparison between the clinical characteristics of patients with adrenal incidentalomas and those with hypertension-associated adrenal tumors in a single center in Japan

In the largest retrospective study of adrenal incidentalomas (AIs) in Japan between 1999 and 2004, adrenal tumors detected during secondary hypertension (HT) screening were included. The characteristics of patients with adrenal tumors detected during HT screening may differ from those of patients with AIs. This study aimed to compare the characteristics of patients with AIs with those of patients with adrenal tumors detected during HT screening. We retrospectively analyzed patients referred to our division for detailed examination of adrenal tumors between April 2009 and April 2017. When the purposes of imaging tests included HT screening, we defined adrenal tumors as HT associated, otherwise as strictly defined AIs. We reviewed data on age, sex, purpose and modality of imaging, location of tumor, tumor diameter, and hormonal evaluation. We identified 104 patients with HT-associated adrenal tumors and 413 with AIs. Patients with HT-associated adrenal tumors were younger (54.2 years vs. 61.7 years, p < 0.001) and had smaller tumor diameters (1.3 cm vs. 1.9 cm, p < 0.001), lower prevalence of nonfunctioning tumors (24.0% vs. 67.6%, p < 0.001), and higher prevalence of primary aldosteronism (58.7% vs. 4.8%, p < 0.001) than those with AIs. There were no differences in terms of tumor location and prevalence of subclinical Cushing's syndrome, Cushing's syndrome, and pheochromocytoma (18.3% vs. 16.0%, 7.7% vs. 8.0%, and 2.9% vs. 4.6%, respectively). In conclusion, patients with HT-associated tumors were younger and had a smaller tumor with higher prevalence of primary aldosteronism than those with AIs.

[Not Available]

Adrenal glands are often not examined in abdominal ultrasound because it is thought that the adrenal glands cannot be visualized. The normal right adrenal gland can be represented in most cases and the left one very often. Sonography makes an important contribution to the diagnosis of adrenal diseases. In addition to bleeding and tuberculosis, there are benign tumors (adrenal adenomas), pheochromocytomas, and adrenal carcinomas. There are also adrenal metastases and lymphomas.

Renal Cell Carcinoma Follow-Up - Is it Time to Abandon Ultrasound?

Background

We wished to compare the efficacy of ultrasound versus intravenous contrast-enhanced computed tomography (CT) for detecting recurrent renal cell carcinoma (RCC) by identifying patients presenting with such tumor burden and to evaluate the utility of these imaging modalities in these circumstances.

Methods

Patients who developed local and/or distant recurrences following surgical intervention for RCC were identified. The imaging regimen utilized during post-operative surveillance was analyzed to determine whether recurrent disease was identifiable on ultrasound or CT or both.

Results

Of the 22 patients with recurrent RCC, 16 had previously undergone radical nephrectomy and 6 had undergone partial nephrectomy. Median duration to RCC recurrence was 28.5 months (range 2-66 months). Fourteen patients (64%) underwent ultrasound during their follow-up surveillance protocol and 1 case of disease recurrence was detected by ultrasound before subsequent con-frmation with CT. All 22 patients underwent CT as a routine component of their follow-up surveillance protocol and all recurrences were detected by this modality. Six patients had recurrence in their ipsilateral kidney after partial nephrec-tomy - five had undergone ultrasound in their surveillance protocol and this modality failed to detect a recurrence in four of these patients.

Conclusion

Ultrasound is inferior to CT for detecting recurrent RCC. CT should be recognized as the standard diagnostic modality during post-operative surveillance, in contradiction to what is recommended in many guidelines.

WFUMB position paper on the management incidental findings: adrenal incidentaloma

Focal lesions of the adrenal glands are incidentally detected in approximately 5% of cases by modern imaging techniques. Fewer than 5% of these adrenal incidentalomas are malignant and approximately 10% have endocrine activity. Reliable differentiation of malignant versus benign and hormonally active versus nonfunctional adrenal incidentalomas significantly influences therapeutic management and the outcome of affected individuals. Therefore, each adrenal incidentaloma should undergo a standardized diagnostic work-up to exclude malignancy and endocrine activity. This position statement of the World Federation of Ultrasound in Medicine and Biology (WFUMB) summarizes the available evidence on the management of adrenal incidentaloma and describes efficient management strategies with particular reference to the role of ultrasound techniques.

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

What should be known prior to performing EUS exams? (Part II)

In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

Role of Endoscopic Ultrasound-guided Fine-needle Aspiration in Adrenal Lesions: Analysis of 32 Patients

Objective:

Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) is a precise and safe technique that provides both radiological and pathological diagnosis with a better diagnostic yield and minimal adverse events. EUS-FNAC led to the remarkable increase in the detection rate of incidentaloma found during radiologic staging or follow-up in various malignancy or unrelated conditions.

Aims:

We did this preliminary study with an aim to evaluate the role of EUS-FNA in diagnosing and classifying adrenal lesions, clinical impact, and compare the outcome with the previously published literature.

Materials and Methods:

We included 32 consecutive cases (both retrospective and prospective) of EUS-guided adrenal aspirate performed over a period of 3.3 years. The indications for the aspirate in decreasing order were metastasis (most common carcinoma gall bladder) > primary adrenal mass > disseminated tuberculosis > pyrexia of unknown origin. On EUS, 28 cases revealed space occupying lesion or mass (two cases bilateral) and four cases revealed diffuse enlargement (two cases bilateral) with a mean size of 21 mm.

Results:

The cytology reports were benign adrenal aspirate (43.8%), metastatic adenocarcinoma (15.6%), histoplasmosis (9.4%), tuberculosis (9.4%), round cell tumor (6.2%), adrenocortical carcinoma (3.1%), and descriptive (3.1%). Three cases (9.4%) yielded inadequate sample. The TNM staging was altered in 22.23% of the cases by result of adrenal aspirate.

Conclusions:

EUS-FNA of the adrenal gland is a safe, quick, and sensitive and real-time diagnostic technique, which requires an integrated approach of clinician, endoscopist, and cytopathologist for high precision in diagnosis. Although the role of EUS-FNA for right adrenal is not much described, we found adequate sample yield in all the four patients that underwent the procedure.

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

Right adrenal gland prospective evaluation through transgastric endoscopic ultrasound: an alternative approach

Background and aims: Endoscopic ultrasound (EUS) guided right adrenal gland (RAG) evaluation is frequently unsuccessful and, when feasible, requires a cumbersome maneuver through the duodenum. In our experience, the use of a recent ultrasound platform has enabled transgastric detection of the RAG with a simple maneuver. The aim of this study was to determine the RAG transgastric EUS detection rate and identify predictive factors for failure. Methods: Consecutive patients referred to EUS in a single center were prospectively included over a 6-month period. Success was defined as RAG transgastric EUS detection within 180 seconds. Logistic regression analysis was used to assess factors associated with failure. Results: Among 100 patients, the success rate for RAG transgastric EUS detection was 75 %, with a median maneuver duration of 45 seconds [interquartile range, 25 - 70 seconds]. Two incidental RAG lesions were detected. Of possible demographic and anthropometric predictive factors for failure, only age (OR 1.04; P = 0.04) was statistically significant on multivariate analysis. Conclusions: The transgastric EUS approach for RAG detection is simple, fast and effective.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of adrenal lesions

The use of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) appears to be a safe and feasible means of confirming or excluding malignancy in the adrenal glands. EUS-FNA with biopsy of suspicious masses in either adrenal gland allows for assessment of these lesions while keeping complications relatively rare. The main advantages of EUS-FNA are that it can be done as an outpatient procedure, with good results, minimal morbidity, and a short hospital stay. Nevertheless, EUS-FNA of adrenal masses should be indicated only in selected cases, in which there is potential to either decrease unnecessary treatment or guide therapy in cancer patients by aiding in either staging of malignancy or treatment of recurrence.v.

Standards of ultrasound imaging of the adrenal glands

Adrenal glands are paired endocrine glands located over the upper renal poles. Adrenal pathologies have various clinical presentations. They can coexist with the hyperfunction of individual cortical zones or the medulla, insufficiency of the adrenal cortex or retained normal hormonal function. The most common adrenal masses are tumors incidentally detected in imaging examinations (ultrasound, tomography, magnetic resonance imaging), referred to as incidentalomas. They include a range of histopathological entities but cortical adenomas without hormonal hyperfunction are the most common. Each abdominal ultrasound scan of a child or adult should include the assessment of the suprarenal areas. If a previously non-reported, incidental solid focal lesion exceeding 1 cm (incidentaloma) is detected in the suprarenal area, computed tomography or magnetic resonance imaging should be conducted to confirm its presence and for differentiation and the tumor functional status should be determined. Ultrasound imaging is also used to monitor adrenal incidentaloma that is not eligible for a surgery. The paper presents recommendations concerning the performance and assessment of ultrasound examinations of the adrenal glands and their pathological lesions. The article includes new ultrasound techniques, such as tissue harmonic imaging, spatial compound imaging, three-dimensional ultrasound, elastography, contrast-enhanced ultrasound and parametric imaging. The guidelines presented above are consistent with the recommendations of the Polish Ultrasound Society.

Endoscopic ultrasound elastography: Current status and future perspectives

Elastography is a new ultrasound modality that provides images and measurements related to tissue stiffness. Endoscopic ultrasound (EUS) has played an important role in the diagnosis and management of numerous abdominal and mediastinal diseases. Elastography by means of EUS examination can assess the elasticity of tumors in the proximity of the digestive tract that are hard to reach with conventional transcutaneous ultrasound probes, such as pancreatic masses and mediastinal or abdominal lymph nodes, thus improving the diagnostic yield of the procedure. Results from previous studies have promised benefits for EUS elastography in the differential diagnosis of lymph nodes, as well as for assessing masses with pancreatic or gastrointestinal (GI) tract locations. It is important to mention that EUS elastography is not considered a modality that can replace biopsy. However, it may be a useful adjunct, improving the accuracy of EUS-fine needle aspiration biopsy (EUS-FNAB) by selecting the most suspicious area to be targeted. Even more, it may be useful for guiding further clinical management when EUS-FNAB is negative or inconclusive. In the present paper we will discuss the current knowledge of EUS elastography, including the technical aspects, along with its applications in the differential diagnosis between benign and malignant solid pancreatic masses and lymph nodes, as well as its aid in the differentiation between normal pancreatic tissues and chronic pancreatitis. Moreover, the emergent indication and future perspectives are summarized, such as the benefit of EUS elastography in EUS-guided fine needle aspiration biopsy, and its uses for characterization of lesions in liver, biliary tract, adrenal glands and GI tract.

Ultrasound techniques in the evaluation of the mediastinum, part 2: mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node (MLN) staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [endoscopic ultrasound fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all MLNs can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review in two integrative parts is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part 1 deals with an introduction into ultrasound techniques, MLN anatomy and diagnostic reach of ultrasound techniques and part 2 with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Early detection of sporadic pancreatic cancer: strategic map for innovation--a white paper

Innovation leading to significant advances in research and subsequent translation to clinical practice is urgently necessary in early detection of sporadic pancreatic cancer. Addressing this need, the Early Detection of Sporadic Pancreatic Cancer Summit Conference was conducted by Kenner Family Research Fund in conjunction with the 2014 American Pancreatic Association and Japan Pancreas Society Meeting. International interdisciplinary scientific representatives engaged in strategic facilitated conversations based on distinct areas of inquiry: Case for Early Detection: Definitions, Detection, Survival, and Challenges; Biomarkers for Early Detection; Imaging; and Collaborative Studies. Ideas generated from the summit have led to the development of a Strategic Map for Innovation built upon 3 components: formation of an international collaborative effort, design of an actionable strategic plan, and implementation of operational standards, research priorities, and first-phase initiatives. Through invested and committed efforts of leading researchers and institutions, philanthropic partners, government agencies, and supportive business entities, this endeavor will change the future of the field and consequently the survival rate of those diagnosed with pancreatic cancer.

Application of parametric ultrasound contrast agent perfusion studies for differentiation of hyperplastic adrenal nodules from adenomas-Initial study

OBJECTIVES

To evaluate the possibilities of differentiation of non-malignant adrenal masses with the application of the new technique for the evaluation of enhancement after administration of an ultrasound contrast agent: parametric imaging.

PATIENTS AND METHODS

34 non-malignant adrenal masses in 29 patients were evaluated in a dynamic examination after the administration of ultrasound contrast agent with parametric imaging. Patterns on parametric imaging of arrival time were evaluated. The final diagnosis was based on CT, MRI, biochemical studies, follow up and/or histopathology examination.

RESULTS

The study included: 12 adenomas, 10 hyperplastic nodules, 7 myelolipomas, 3 pheochromocytomas, hemangioma with hemorrhage and cyst. The pattern of peripheral laminar inflow of Sonovue on parametric images of arrival time of was 100% sensitive for hyperplastic nodules and 83% specific in regard to adenomas.

CONCLUSIONS

Parametric contrast enhanced ultrasound may accurately differentiate hyperplastic adrenal nodules from adenomas and could be complementary to CT or MRI. Incorporation of perfusion studies to CT or MRI could possibly enable one-shop complete characterization of adrenal masses. This could deliver additional information in diagnostics of patients with Conn Syndrome and warrants further studies in this cohort of patients.

Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: analysis of 21 patients

Background/Aims

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology of adrenal masses helps in etiological diagnosis. The aim of this study was to evaluate the diagnostic yield of EUS-FNA of adrenal masses in cases where other imaging methods failed and/or were not feasible.

Methods

Twenty-one consecutive patients with adrenal masses, in whom adrenal FNA was performed because conventional imaging modalities failed and/or were not feasible, were prospectively evaluated over a period of 3 years.

Results

Of the 21 patients (mean age, 56±12.2 years; male:female ratio, 2:1), 12 had pyrexia of unknown origin and the other nine underwent evaluation for metastasis. The median lesion size was 2.4×1.6 cm. Ten patients were diagnosed with tuberculosis (shown by the presence of caseating granulomas [n=10] and acid-fast bacilli [n=4]). Two patients had EUS-FNA results suggestive of histoplasmosis. The other patients had metastatic lung carcinoma (n=6), hepatocellular carcinoma (n=1), and adrenal lipoma (n=1) and adrenal myelolipoma (n=1). EUS results were not suggestive of any particular etiology. No procedure-related adverse events occurred.

Conclusions

EUS-FNA is a safe and effective method for evaluating adrenal masses, and it yields diagnosis in cases where tissue diagnosis is impossible or has failed using conventional imaging modalities.

Can elastography replace fine needle aspiration?

Endoscopic ultrasound (EUS) is one of the best diagnostic methods for diseases of the digestive tract and surrounding organs. Whereas EUS-guided fine needle aspiration (FNA) has been very useful for providing histological confirmation for previously hard to reach lesions, elastography is aiming to obtain a “virtual biopsy” by assessing differences in elasticity between the normal and pathological – usually malignant – tissue. A question that arises is whether EUS-elastography has reached a stage where it might successfully supplant the use of EUS-FNA in some of its clinical indications. The main indications of EUS-guided FNA are listed in this article and published data on the usage of elastography in these settings is reviewed for each one. In some of the indications, a plethora of studies have been published, notably for the evaluation of solid pancreatic masses and lymph nodes, while in others there is little relevant data (submucosal masses, left liver lesions, left adrenal masses), or elastography simply is not suitable as a diagnostic means (cystic lesions). Our conclusion is that elastography is not yet ready to replace EUS-FNA in its indications, but should complement it in various settings, especially for the assessment of lymph nodes. It can only be considered an alternative on a case-by-case basis, in situations where FNA is regarded as a contraindication. Furthermore, it could be used in conjunction with other imaging techniques, such as contrast-enhanced EUS, in order to further improve the accuracy of non-invasive EUS assessment, possibly making the case for a more limited or targeted use of EUS-FNA in selected cases.

Adrenal incidentaloma imaging - the first steps in therapeutic management

The term “adrenal incidentaloma” refers to clinically unapparent adrenal mass detected during imaging examination performed for reasons other than the evaluation of adrenal glands. These tumors must be carefully examined in order to assess the indications for surgical treatment. The main method of finding evidence of potential malignancy in these lesions is computed tomography (CT), before and after i.v. contrast media enhancement. Density of a malignant lesion is higher than 10 HU and the relative percentage washout is less than 40% at 10 min. Other useful methods utilized in tumor assessment, include magnetic resonance imaging (MRI), scintigraphy techniques (SPECT) and PET. Basal hormonal investigations include urine and plasma catecholamines with their metabolites, plasma cortisol before and after dexamethasone administration, plasma renin activity and aldosterone level. Cases not suitable for surgery should be followed with repeat imaging techniques and hormonal testing at the recommended 6, 12, and 24 months. Surgery should be performed when tumor growth rate exceeds 0,8 cm per year.

Real time elastography endoscopic ultrasound (RTE-EUS), a comprehensive review

Real-time elastography (RTE) performed during endoscopic ultrasound (EUS) is a relatively new technique which allows the evaluation of tissue stiffness, with the intent of better characterising lesions during EUS examinations. The aim of this comprehensive review was to describe the technique of RTE-EUS, as well as the clinical applications, including the study of pancreatic lesions, but also hepatobiliary, gastrointestinal (GI) tract pathology (including anal canal), lymph nodes, adrenal glands, lung and mediastinum, as well as urogenital applications. One of the advantages of the RTE-EUS technique is especially the possibility to be used in various locations accessible from the GI tract. Future developments are also briefly discussed, as elastography is a tissue characterising technique that will certainly not replace biopsy, but will rather be an adjunct during EUS examinations, due to its ease of use and low cost.

Bilateral adrenal lesions

Bilateral adrenal lesions include a spectrum of disorders: neoplastic disorders (metastases, lymphoma, bilateral phaeochromocytoma, adrenocortical carcinoma and myelolipoma); longstanding congenital adrenal hyperplasia and macronodular adrenal hyperplasia; infections such as tuberculosis, histoplasmosis and blastomycosis; adrenal haemorrhage; adrenals in hypoperfusion complex and paediatric masses. Bilateral distribution in addition to other imaging characteristics can help narrow differential diagnoses in case of adrenal masses. We present a pictorial review highlighting the adrenal lesions that can present bilaterally.

Clinical impact of endoscopic ultrasound-fine needle aspiration of left adrenal masses in established or suspected lung cancer

INTRODUCTION

Correct lung cancer staging is pivotal for optimal allocation to surgical and nonsurgical treatment. A left adrenal gland (LAG) mass is found in 5 to 16%, and malignancy preclude surgery. Endoscopic ultrasound (EUS) is superior to other imaging procedures in visualizing LAG, but the impact of EUS-fine needle aspiration (FNA) on tumor, node, metastasis (TNM)-staging, treatment, and survival is unknown.

METHODS

The impact of EUS-FNA of the LAG on TNM staging, treatment, and survival was evaluated retrospectively in all patients (n = 40) referred to EUS during 2000-2006 for known or suspected lung cancer and where EUS disclosed an enlarged LAG. Conventional workup had preceded EUS.

RESULTS

EUS-FNA of an enlarged LAG altered the TNM staging in 70% (downstaged: 26 of 28 patients) and treatment in 48% (gained surgery 25%, avoided surgery 5%, surgically verified benign disease 5%, no cancer and no further workup 5%, and no cancer, control computed tomography, and then no further workup 8%). A malignant LAG lesion was found in 28% and was significantly associated with shorter survival.

CONCLUSION

EUS-FNA of an enlarged LAG in patients with known or suspected lung cancer had a significant impact on TNM staging, treatment, and survival. The impact of routine visualization of the LAG in lung cancer workup needs to be prospectively validated.

Contrast-enhanced sonography of adrenal masses: differentiation of adenomas and nonadenomatous lesions

OBJECTIVE

The aim of this proof-of-principle study was to evaluate contrast-enhanced sonography in the characterization of adrenal masses.

SUBJECTS AND METHODS

Thirty-five consecutively registered patients with newly detected adrenal masses underwent hormonal evaluation and duplex and Doppler sonography followed by contrast-enhanced sonography and CT or MRI. The dynamics of contrast enhancement were analyzed with time-intensity curves. CT and MRI were used as the reference methods for the diagnosis of adenoma and myelolipoma. Metastasis was diagnosed with fine-needle biopsy, and all other adrenal masses were diagnosed at adrenalectomy. Fisher's exact test was used to evaluate the criteria for diagnosis of malignant adrenal masses.

RESULTS

Size greater than 4 cm and hypervascularization were found significantly more often in malignant than in benign lesions (71% vs 21% for size; 57% vs 7% for hypervascularization). At contrast-enhanced sonography, early arterial or arterial contrast enhancement and rapid washout were seen in all patients with primary or secondary malignant lesions of the adrenal gland and in only 22% of patients with benign adrenal masses (p < 0.05). All primary malignant lesions were confirmed at histologic examination. In 32 of 35 patients (91%), findings at CT or MRI were congruent with those at contrast-enhanced sonography in regard to characterization of adenoma versus nonadenomatous lesion (p < 0.001). In two of the 35 cases, however, all imaging methods favored the diagnosis of nonadenomatous lesion, but the histologic result after adrenalectomy was adrenal adenoma. The sensitivity and specificity of contrast-enhanced sonography in the diagnosis of malignant adrenal mass were 100% and 82%.

CONCLUSION

Contrast-enhanced sonography can be used to differentiate adenomas and nonadenomatous lesions with a sensitivity comparable with that of CT and MRI and may be a cost-effective method for preselection of patients with adrenal masses.

Imaging of hyperfunctioning adrenal masses

Adrenal imaging not only aims to detect hyperfunctioning adrenal lesions responsible for distinct clinical syndromes (pheochromocytoma, Cushing's syndrome or primary aldosteronism) but also to differentiate malignant from benign disease. Computed tomography (CT), MRI and high-resolution ultrasound imaging methods are available for detection of adrenal masses with high sensitivities. Although the risk of malignancy increases with the size of the adrenal mass, this criterion does not discriminate malignant from benign disease with sufficient specificity. Attenuation values on unenhanced CT, contrast washout characteristics on CT and chemical-shift imaging on MRI help differentiate adrenal adenomas and nonadenomas. Adrenal lesions with equivocal results on CT and MRI can be characterized further by functional nuclear medicine imaging. Radiopharmaceutical agents specifically detect masses derived from the adrenal cortex (e.g.,¹³¹I-6-iodomethyl-norcholesterol) and from the adrenal medulla (e.g., ¹²³I- and ¹³¹I-meta-iodobenzylguanidine). Unspecific tracers, such as ¹⁸F-fluorodeoxyglucose, are very useful in discriminating malignant and benign adrenal tumors.

Transduodenal EUS-guided FNA of the right adrenal gland

BACKGROUND

EUS-guided FNA is commonly performed to sample peri-intestinal targets such as the pancreas, lymph nodes, and the left adrenal gland. To our knowledge, EUS-guided FNA of the right adrenal gland has not been reported.

OBJECTIVE

Our purpose was to determine the feasibility and success in sampling an enlarged right adrenal gland.

STUDY DESIGN

Observational study.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients that underwent EUS-guided FNA of the right adrenal gland.

RESULTS

Over a span of 3.5 years, 4 patients underwent transduodenal EUS-guided FNA of the right adrenal gland with a curvilinear echoendoscope. Four passes were performed in all cases, and the diagnosis was rendered on the first pass. The posterior wall of the descending duodenum was the port of entry of the needle. Three of the patients had metastatic lung cancer to the right adrenal gland; one was proven by surgical histopathologic examination. One patient had a benign aspirate consistent with angiomyolipoma. None of the patients had any minor or major complications.

LIMITATIONS

Observational study, small sample size.

CONCLUSIONS

Transduodenal EUS-guided FNA of the right adrenal gland is feasible and safe. Future large-scale studies are needed to replicate our findings and to determine the rate of successful identification and sampling of the right adrenal gland with the curvilinear echoendoscope.

Endoscopic ultrasound-guided fine-needle aspiration of right adrenal masses: report of 2 cases

OBJECTIVE

Although transgastric endoscopic ultrasound (EUS)-guided biopsy is a safe and accurate method for sampling of the left adrenal gland, only 2 reports describing EUS-guided fine-needle aspiration (FNA) of the right adrenal gland have been published to date. The aim of this series was to report 2 additional successful cases of EUS-FNA of right adrenal masses.

METHODS

In this retrospective single-center case series, prospectively updated cytology and EUS databases between January 1997 and September 2007 were reviewed to identify all patients who underwent attempted EUS-FNA of either adrenal gland. Those who underwent EUS-FNA of the right adrenal gland were identified and reviewed.

RESULTS

Of 52 consecutive patients who underwent EUS-FNA of either adrenal gland, 2 had attempted biopsy of the right adrenal gland and constituted the study population. The first patient had a history of colon cancer and was found to have a right adrenal mass during workup of jaundice. The second patient also had a history of colon cancer and was found to have an enlarging right adrenal mass and a subcarinal mass during follow-up computed tomography. Endoscopic ultrasound-guided FNA showed a pheochromocytoma in the first patient and metastatic colon cancer in the second patient. No complications were encountered during either procedure.

CONCLUSIONS

This series further shows that EUS-FNA of right adrenal masses is feasible and may be an option for sampling of these lesions. Prospective studies comparing EUS with percutaneous FNA of adrenal masses are indicated to help delineate the indications and limitations of each technique.

EUS-FNA of the Left Adrenal Gland is Safe and Useful

Introduction: There are limited data on the use of endosonography-guided fine-needle aspiration (EUS-FNA) to determine the nature of left adrenal lesions. We described our experience in performing EUS-FNA of left adrenal lesions. Clinical Picture: During a 20-week period, data on consecutive patients who underwent EUS with or without EUS-FNA were prospectively captured. Patients with a left adrenal mass and who underwent EUS-FNA formed our study population. Treatment: EUS-FNA. Outcome: A total of 119 consecutive patients underwent diagnostic EUS +/- FNA, during which the left adrenal gland was routinely examined. Twelve of these patients underwent EUS as part of lung cancer staging and among these 12 lung cancer patients, 2 had left adrenal masses detected by computed tomography (CT). EUS detected left adrenal nodules in 2 other patients which were not visualised by CT. The overall prevalence of a left adrenal mass was 3.4%; in the subgroup with confirmed lung cancer, the prevalence was 33.3%. All 4 patients were male, with a mean age of 76.3 years (range, 67 to 87). The mean size of the left adrenal lesion was 30.4 mm (range, 9 to 84.8). EUS-FNA of the left adrenal lesions was performed under Doppler guidance. The mean number of needle passes was 2 (range, 1 to 4). A cellular aspirate was obtained in all patients. No procedural complications occurred. Metastatic non-small cell lung cancer was diagnosed in 2 patients, including a lesion missed on CT. For the other 2 cases, EUS-FNA revealed benign adrenal cells. Conclusions: EUS-FNA appears safe and useful for the evaluation of left adrenal masses. Key words: Adrenal gland neoplasms, Endosonography

Endoscopic ultrasound-guided fine needle aspiration in the evaluation of suspected lung cancer

BACKGROUND AND AIM

The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and staging of lung cancer is still not fully explored. This prospective study aimed to define the effectiveness of EUS-FNA as an adjunct to computer tomography (CT) and bronchoscopy in the evaluation of suspected lung cancer in routine clinical practice.

METHODS

Over a period of 20 weeks, the data of 16 consecutive patients suspected of lung cancer on account of respiratory symptoms, and/or the findings of either a mass or mediastinal lymph nodes on helical CT, who were referred for evaluation by EUS, were prospectively collected. Fourteen of these patients underwent sequential bronchoscopy followed by EUS-FNA in the same setting.

RESULTS

Bronchoscopy was performed in 15 patients, while EUS was performed in all 16 patients. Bronchoscopy diagnosed 9 cases of non-small-cell lung cancer (NSCLC) but was falsely negative in 3 cases of malignancies, which were all established by EUS-FNA of mediastinal lymph nodes (2 cases of NSCLC and 1 case of esophageal squamous cell cancer). EUS-FNA also diagnosed advanced NSCLC in another patient who did not undergo bronchoscopy, such that eventually 13 patients were diagnosed to have malignancies. Distant metastases were diagnosed by EUS-FNA in 4 cases of NSCLC (2 cases of left adrenal gland and 2 cases of pancreatic metastases). Two patients were diagnosed to have sarcoidosis and 1 patient was diagnosed to have pneumoconiosis eventually.

CONCLUSIONS

EUS-FNA is useful as an adjunct to CT and bronchoscopy in the evaluation of suspected lung cancer.

Laparoscopic adrenalectomy for Conn's syndrome complicated by ipsilateral congenital pelvic kidney

A patient presented with hypertension, hypokalemia, and a 1.2-cm left adrenal tumor. Conn's syndrome was diagnosed, for which laparoscopic adrenalectomy is now the therapy of choice. This case was complicated by an ipsilateral ectopic pelvic kidney. A laparoscopic left adrenalectomy was performed via a lateral transabdominal approach. Without the usual anatomic landmark of the ipsilateral kidney, the left adrenal gland was difficult to identify, so intraoperative ultrasound was used to locate the lesion. Postoperatively, the patient's blood pressure and potassium normalized. This is the first documented report of a laparoscopic adrenalectomy performed for adrenal adenoma with the anatomic disruption of an ipsilateral pelvic kidney.

EUS-guided FNA of the left adrenal gland in patients with thoracic or GI malignancies

BACKGROUND

The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined.

METHODS

All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers.

RESULTS

Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (> or =3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically.

CONCLUSIONS

EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.

Evaluation and management of adrenal masses

BACKGROUND

The widespread use of abdominal imaging has led to increased detection of adrenal tumors. The significance of these masses, as well as the optimal management approach to treatment, has generated some controversy regarding further evaluation and therapy.

METHODS

The authors reviewed the literature regarding the evaluation and management of these masses, particularly adrenal incidentalomas. Based on their institutional experience, they propose a diagnostic, evaluation, and management algorithm for treating adrenal masses.

RESULTS

Appearance and clinical history should indicate how to perform the biochemical evaluation, keeping in mind that the presence of pheochromocytomas must be ruled out. Radiological evaluation by CT or MRI provides useful parameters to identify malignant lesions. Surgery is indicated for masses that are larger than 5 cm in diameter or suspected of malignancy. Fine-needle aspiration biopsy should be used when other extra-adrenal malignancies are suspected and after pheochromocytoma has been ruled out.

CONCLUSIONS

Careful analysis of each adrenal mass is essential to effectively avoid potential problems. Guidelines to manage patients with adrenal masses are needed.

Laparoscopic ultrasound imaging of adrenal tumors during laparoscopic adrenalectomy

BACKGROUND

The purpose of this study was to determine the usefulness of laparoscopic ultrasound (LUS) during laparoscopic adrenalectomy (LA) and to define the ultrasound imaging characteristics of various adrenal tumors.

METHODS

LUS was utilized in 27 patients who underwent LA (including one bilateral adrenalectomy) from May 1994 to October 1998. Tumor size ranged from 1.0 to 5.5 cm (mean 3.3 cm), and a transabdominal lateral approach to LA was used.

RESULTS

LUS localized the adrenal gland and tumor in all 28 adrenalectomies and demonstrated the relationship of the tumor to the kidney and adjacent vascular structures (renal artery/vein and inferior vena cava). The adrenal vein was visualized sonographically in only six cases (21 %). Pheochromocytomas were mild to markedly heterogenous, whereas most aldosteronomas and cortical adenomas were homogenous. LUS provided useful information to the surgeon in 11 of 28 cases (39%) by: 1) localizing the adrenal gland and tumor and/or guiding the dissection; 2) demonstrating that tumors > or =4 cm were confined to the adrenal gland; and 3) investigating suspected pathology in other organs. Mean operating time for LUS was 10.9 min (range 5 to 24 min) and calculated hospital charges were $602.

CONCLUSIONS

LUS accurately localizes adrenal tumors, helps define their relationship to adjacent structures, and provides confirmation that larger tumors are amenable to laparoscopic resection. LUS is a useful adjunct to laparoscopic adrenalectomy in selected patients.