Predictive value of image-guided adrenal biopsy: analysis of results of 101 biopsies

Clinical indications, safety, and effectiveness of percutaneous image-guided adrenal mass biopsy: an 8-year retrospective analysis in 160 patients

PURPOSE

To assess indications, safety, and effectiveness of percutaneous adrenal mass biopsy in contemporary practice.

METHODS

This institutional review board-approved, retrospective study included all patients undergoing percutaneous image-guided adrenal mass biopsies at an academic health system from January 6, 2015, to January 6, 2023. Patient demographics, biopsy indications, mass size, laboratory data, pathology results, and complications were recorded. Final diagnoses were based on pathology or ≥ 1 year of imaging follow-up when biopsy specimens did not yield malignant tissue. Test performance calculations excluded repeat biopsies. Continuous variables were compared with Student's t test, dichotomous variables with chi-squared test.

RESULTS

A total of 160 patients underwent 186 biopsies. Biopsies were indicated to diagnose metastatic disease (139/186; 74.7%), for oncologic research only (27/186; 14.5%), diagnose metastatic disease and oncologic research (15/186; 8%), and diagnose an incidental adrenal mass (5/186; 2.7%). Biopsy specimens were diagnostic in 154 patients (96.3%) and non-diagnostic in 6 (3.8%). Diagnostic biopsies yielded malignant tissue (n = 136), benign adrenal tissue (n = 12), and benign adrenal neoplasms (n = 6) with sensitivity = 98.6% (136/138), specificity = 100% (16/16), positive predictive value = 100% (136/136), and negative predictive value = 88.9% (16/18). Adverse events followed 11/186 procedures (5.9%) and most minor (7/11, 63.6%). The adverse event rate was similar whether tissue was obtained for clinical or research purposes (10/144; 6.9% vs. 1/42; 2.4%, p = 0.27), despite more specimens obtained for research (5.8 vs. 3.7, p < 0.001).

CONCLUSION

Percutaneous adrenal mass biopsy is safe, accurate, and utilized almost exclusively to diagnose metastatic disease or for oncologic research. The negative predictive value is high when diagnostic tissue samples are obtained. Obtaining specimens for research does not increase adverse event risk.

ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update

The appropriate evaluation of adrenal masses is strongly dependent on the clinical circumstances in which it is discovered. Adrenal incidentalomas are masses that are discovered on imaging studies that have been obtained for purposes other than adrenal disease. Although the vast majority of adrenal incidentalomas are benign, further radiological and biochemical evaluation of these lesions is important to arrive at a specific diagnosis. Patients with a history of malignancy or symptoms of excess hormone require different imaging evaluations than patients with incidentalomas. This document reviews imaging approaches to adrenal masses and the various modalities utilized in evaluation of adrenal lesions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Adrenal biopsy, as a diagnostic method, is associated with decreased overall survival in patients with T1/T2 adrenocortical carcinoma: A propensity score-matched analysis

INTRODUCTION

The standard diagnosis for adrenocortical carcinoma (ACC) is clinical diagnosis (CD) based on radiographic and biochemical studies. Biopsy diagnosis (BD) is seldom required for the suspicion of secondary malignancy. We aim to study the impact of BD in the context of underlying T1/T2 ACC on overall survival (OS) compared with CD.

METHODS

National Cancer Database (NCDB) for endocrine malignancies was utilized. Only patients with non-metastatic ACC, whose method of diagnosis and local disease extension were reported, and received a surgical adrenalectomy with curative intent were included. Patients were divided by disease stage into T1/T2, T3, and T4 groups. A propensity score match was applied to those with T1/T2 disease who received CD versus BD and the Kaplan-Meier method was used to compare OS.

RESULTS

In total, 4000 patients with ACC were reported in the database, 1410 met selection criteria. Eight hundred and thirty patients had T1/T2, 365 had T3, and 162 had T4 ACC. Of patients with T1/T2 ACC, 742 (89.4%) received CD versus 88 (11.6%) with BD. A propensity score was calculated per a multivariable regression model with 79 patients matched from each group. Exact matching was applied for margin status and adjuvant therapies. Kaplan-Meier analysis showed a significant difference in median OS between CD versus BD patients in the matched data set (103.89 ± 15.65 vs. 54.93 ± 8.22 months; p = 0.001). In all comers, patients with T1/T2 ACC and BD had comparable median OS to that of patients with T3 ACC (52.21 ± 9.69 vs. 36.01 ± 3.33 months; p = 0.446).

CONCLUSION

BD in T1/T2 ACC could be associated with disease upstaging and worse OS outcomes.

Utility of T2-weighted MRI to Differentiate Adrenal Metastases from Lipid-Poor Adrenal Adenomas

Purpose

To evaluate T2-weighted MRI features to differentiate adrenal metastases from lipid-poor adenomas.

Materials and Methods

With institutional review board approval, this study retrospectively compared 40 consecutive patients (mean age, 66 years ± 10 [standard deviation]) with metastases to 23 patients (mean age, 60 years ± 15) with lipid-poor adenomas at 1.5- and 3-T MRI between June 2016 and March 2019. A blinded radiologist measured T2-weighted signal intensity (SI) ratio (SI_nodule/SI_{psoas muscle}), T2-weighted histogram features, and chemical shift SI index. Two blinded radiologists (radiologist 1 and radiologist 2) assessed T2-weighted SI and T2-weighted heterogeneity using five-point Likert scales.

Results

Subjectively, T2-weighted SI (P < .001 for radiologist 1 and radiologist 2) and T2-weighted heterogeneity (P < .001, for radiologist 1 and radiologist 2) were higher in metastases compared with adenomas when assessed by both radiologists. Agreement between the radiologists was substantial for T2-weighted SI (Cohen κ = 0.67) and T2-weighted heterogeneity (κ = 0.62). Metastases had higher T2-weighted SI ratio than adenomas (3.6 ± 1.7 [95% confidence interval {CI}: 0.2, 8.2] vs 2.2 ± 1.0 [95% CI: 0.6, 4.3], P < .001) and higher T2-weighted entropy (6.6 ± 0.6 [95% CI: 4.9, 7.5] vs 5.0 ± 0.8 [95% CI: 3.5, 6.6], P < .001). At multivariate analysis, T2-weighted entropy was the best differentiating feature (P < .001). Chemical shift SI index did not differ between metastases and adenomas (P = .748). Area under the receiver operating characteristic curve (AUC) for T2-weighted SI ratio and T2-weighted entropy were 0.76 (95% CI: 0.64, 0.88) and 0.94 (95% CI: 0.88, 0.99). The logistic regression model combining T2-weighted SI ratio with T2-weighted entropy yielded AUC of 0.95 (95% CI: 0.91, 0.99) and did not differ compared with T2-weighted entropy alone (P = .268). There was no difference in logistic regression model accuracy comparing the data by either field strength, 1.5- or 3-T MRI (P > .05).

Conclusion

Logistic regression models combining T2-weighted SI and T2-weighted heterogeneity can differentiate metastases from lipid-poor adenomas. Validation of these preliminary results is required.Keywords: Adrenal, MR-Imaging, UrinarySupplemental material is available for this article.© RSNA, 2020.

Uptake of 18F-FDG in Adrenal Adenomas Is Associated With Unenhanced CT Value and Constituent Cells

PURPOSE

The purposes of this study were to investigate the correlation between unenhanced CT attenuation values and F-FDG uptake in adrenal adenomas, and to clarify the mechanism of FDG uptake in adrenal adenomas based on immunohistochemical findings.

MATERIALS AND METHODS

In 57 adrenal adenomas, the correlation between SUVmax on F-FDG PET and unenhanced CT attenuation was retrospectively investigated. In the 11 surgically resected nodules, the clear cell ratio (CCR) and expression levels of glucose transporters (GLUTs) 1 to 4 were pathologically evaluated. The GLUT expression levels were scored at 0 to 3 points for each transporter, and the sum of these expression levels was defined as the GLUT score. The relationships between CCR and either the CT attenuation number or SUVmax, and between the GLUT score and each of the CT attenutation value, SUVmax, or CCR were evaluated.

RESULTS

There was a significant positive correlation between SUVmax and the CT attenuation value for the group of 57 adenomas (R = 0.44, P = 0.0007). For the 11 surgically resected cases, there was a nonsignificant trend of negative correlation between SUVmax and CCR (R = 0.57, P = 0.06). There was a significant positive correlation between GLUT score and CT attenuation value (R = 0.68, P = 0.02), and a significant negative correlation between GLUT score and CCR (R = 0.60, P = 0.003).

CONCLUSIONS

Adrenal adenomas composed of many compact cells or having high attenuation on unenhanced CT showed high FDG uptake. FDG uptake of adrenal adenomas may depend on the constituent cells.

Chemical shift imaging for evaluation of adrenal masses: a systematic review and meta-analysis

OBJECTIVES

To perform a systematic review and meta-analysis of published data to evaluate the utility of chemical shift imaging (CSI) for differentiating between adrenal adenomas and non-adenomas.

METHODS

A systematic search of the MEDLINE, Web of Science Core Collection, EMBASE and Cochrane Central Register of Controlled Trials electronic databases was performed. The methodological quality of the included studies was assessed by using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool. A bivariate random effect model was used to determine summary and subgroup sensitivity and specificity and calculate summary receiver operating characteristic curves (SROC).

RESULTS

Eighteen studies with 1138 patients and 1280 lesions (859 adenomas, 421 non-adenomas) in total were included. In addition to summary analysis, quantitative analyses of the adrenal signal intensity index (SII, 978 lesions, 14 studies), adrenal-to-spleen ratio (ASR; 394 lesions, 7 studies) and visual analysis (560 lesions, 5 studies) were performed. The resultant data showed considerable heterogeneity (inconsistency index I² of 94%, based on the diagnostic odds ratio, DOR). The pooled sensitivity of CSI for adenoma was 0.94 [95% confidence interval (CI) 0.88-0.97] and pooled specificity was 0.95 (95% CI 0.89-0.97). The area (AUC) under the SROC curve was 0.98 (95% CI 0.96-0.99). The corresponding AUCs were 0.98, 0.99 and 0.95 for SII, ASR and visual evaluation, respectively.

CONCLUSION

CSI has high sensitivity, specificity and accuracy for adrenal adenoma. Diagnostic performance does not improve when quantitative indices are used.

KEY POINTS

• Inclusion of CSI in abdominal MRI protocols provides an effective solution for classifying adrenal masses discovered on MR exams • Visual evaluation of adrenal CSI is sufficient; use of quantitative indices does not improve diagnostic accuracy.

Procedural and clinical outcomes of percutaneous adrenal biopsy in a high-risk population for adrenal malignancy

OBJECTIVE

The role of percutaneous adrenal biopsy in a high-risk population for adrenal malignancy has not been fully investigated. Our aim was to describe the clinical presentation leading to the adrenal biopsy and evaluate the diagnostic performance, complications and non diagnostic rate of adrenal biopsy.

DESIGN

Single-centre, retrospective cohort study.

PATIENTS AND MEASUREMENTS

Medical records of patients who underwent adrenal biopsy between 1994 and 2014 were reviewed. Adrenal biopsy outcome was compared to a predefined reference standard.

RESULTS

Biopsy was performed in 418 patients [62% men, median age 69 years (range, 15-91)] on 419 adrenal lesions, median size 3·1 cm (range, 0·6-24). The main indication for adrenal mass biopsy was (349/419, 83%) suspected adrenal metastasis from a known or suspected extra-adrenal primary source. Only 116 of 419, 28% of cases had prebiopsy biochemical testing for pheochromocytoma. Biopsy-related complications occurred in 4% of the patients. Histology revealed a metastasis in 231 of 419 (55%), benign adrenal tissue in 137 of 419 (33%), adrenocortical carcinoma in eight of 419 (2%), other lesions in 23 of 419 (5%) including seven cases of pheochromocytoma and six cases of infectious process. Biopsy was nondiagnostic in 20 of 419 (5%). All adrenal masses with unenhanced radiodensity ≤10 HU (42/137, 31%) proved to be benign adrenal adenomas. Adrenal biopsy diagnosed malignancy with a sensitivity of 88·5%, specificity of 91·5%, positive predictive value of 93·4% and negative predictive value of 85·5%.

CONCLUSION

When used in the appropriate clinical setting, adrenal biopsy is a powerful tool in the diagnostic algorithm of the evaluation of adrenal masses with features suspicious for malignancy. Efforts to increase awareness to perform biochemical testing for pheochromocytoma prior to adrenal biopsy are needed.

DIAGNOSIS OF ENDOCRINE DISEASE: The diagnostic performance of adrenal biopsy: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review of published literature on adrenal biopsy and to assess its performance in diagnosing adrenal malignancy.

METHODS

Medline In-Process and Other Non-Indexed Citations, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trial were searched from inception to February 2016. Reviewers extracted data and assessed methodological quality in duplicate.

RESULTS

We included 32 observational studies reporting on 2174 patients (39.4% women, mean age 59.8 years) undergoing 2190 adrenal mass biopsy procedures. Pathology was described in 1621/2190 adrenal lesions (689 metastases, 68 adrenocortical carcinomas, 64 other malignancies, 464 adenomas, 226 other benign, 36 pheochromocytomas, and 74 others). The pooled non-diagnostic rate (30 studies, 2013 adrenal biopsies) was 8.7% (95%CI: 6-11%). The pooled complication rate (25 studies, 1339 biopsies) was 2.5% (95%CI: 1.5-3.4%). Studies were at a moderate risk for bias. Most limitations related to patient selection, assessment of outcome, and adequacy of follow-up. Only eight studies (240 patients) could be included in the diagnostic performance analysis with a sensitivity and specificity of 87 and 100% for malignancy, 70 and 98% for adrenocortical carcinoma, and 87 and 96% for metastasis respectively.

CONCLUSIONS

Evidence based on small sample size and moderate risk of bias suggests that adrenal biopsy appears to be most useful in the diagnosis of adrenal metastasis in patients with a history of extra-adrenal malignancy. Adrenal biopsy should only be performed if the expected findings are likely to alter the management of the individual patient and after biochemical exclusion of catecholamine-producing tumors to help prevent potentially life-threatening complications.

Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.

18F-FDG PET/CT imaging and PET-guided biopsy in evaluation and treatment decision in adrenal histoplasmosis

Histoplasmosis is a rare opportunistic fungal infection. It is commonly seen in immunocompromised individuals from endemic areas. Adrenal glands are frequently involved in the disseminated disease. Here, we present the case of a retropositive patient with constitutional symptoms, where whole-body positron emission tomography/CT scan revealed intense ¹⁸F-fludeoxyglucose uptake in bulky adrenal glands, and subsequent positron emission tomography-guided biopsy helped in establishing the diagnosis of adrenal histoplasmosis.

Image-guided urological interventions: What the urologists must know

Advances in imaging technology, especially in the last two decades, have led to a paradigm shift in the field of image-guided interventions in urology. While the traditional biopsy and drainage techniques are firmly established, image-based stone management and endovascular management of hematuria have evolved further. Ablative techniques for renal and prostate cancer and prostate artery embolization for benign prostatic hypertrophy have evolved into viable alternative treatments. Many urologic diseases that were earlier treated surgically are now effectively managed using minimally invasive image-guided techniques, often on a day care basis using only local anesthesia or conscious sedation. This article presents an overview of the technique and status of various image-guided urological procedures, including recent emerging techniques.

Transcutaneous biopsy of adrenocortical carcinoma is rarely helpful in diagnosis, potentially harmful, but does not affect patient outcome

CONTEXT

Adrenocortical carcinoma (ACC) is a rare malignancy with high recurrence and mortality rates. The utility, sensitivity, and effect on patient outcome of transcutaneous adrenal biopsy (TAB) for single, large, adrenal masses are unclear.

OBJECTIVE

This study evaluated the utility, diagnostic sensitivity, and effect on patient outcome of TAB in patients with ACC.

DESIGN AND SETTING

We conducted a retrospective review of the electronic medical records of all ACC patients who were evaluated at the University of Michigan Health System from 1991 to 2011. We evaluated the sensitivity of TAB for tumors with the final pathological diagnosis of ACC. We compared the characteristics and survival of patients with stage I-III disease who underwent TAB with those who did not undergo TAB.

RESULTS

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 maximum sensitivity of the procedure in diagnosing ACC was 70%. For stage I-III patients, baseline characteristics, stage at diagnosis, and 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.

CONCLUSIONS

TAB of single, large, adrenal masses is usually unnecessary, exposes patients to risk, but does not affect recurrence-free or overall survival.

Imaging of adrenal incidentaloma: our experience

PURPOSE

To investigate clinical, biochemical and radiological features in 35 patients with adrenal incidentaloma found on CT and/or MRI and to define the management of patients with adrenal masses.

MATHERIAL AND METHODS

From January 2011 and May 2013, 35 patients (19F, 16M) with an adrenal mass incidentally discovered on CT and/or MRI were enrolled in a retrospective study. Thirthy-two patients underwent MDCT and eight 1.5 MRI.

RESULTS

Patients consisted in 16 males and 19 females, aged between 25 and 89 yo. Adrenal lesions were most commonly found in the sixth decade; in relation to the side of the mass, 20 were found on left side, 15 on the right. Of all the mass analyzed, 3 were <1 cm diameter, 29 between 1 and 4 cm, 3 > 4 cm. The most common finding on CT was adenoma-like appearance (19 cases in relation to size, 14 in relation to attenuation values). Hormonal analysis showed 32 cases of nonfunctional masses and 3 cases of hormone activity. Adrenalectomy was performed in ten patients having adenoma (5 cases), malignant lesions (2 cases), pheocromocitoma, cyst and myelolipoma (1 case).

CONCLUSION

Diagnostic approach to adrenal incidentaloma is focused on the definition of malignancy and hormonal activity; the characterization is needs hormonal and radiological (CT and/or MRI) evaluation, even if a fine needle aspiration is needed in selected cases. Benign and/or non-hypersecreting hormone lesion with <4 cm diameter could be sent to follow-up; active adrenal tumors or >4 cm diameter lesions with malignancy suspicious or growth during follow-up could be treated with surgical adrenalectomy.

Sonographically guided transhepatic core biopsies of right renal and adrenal masses: safety and short-term follow-up

OBJECTIVES

The purpose of this study was to retrospectively evaluate the accuracy and safety of sonographically guided transhepatic biopsies of right upper renal and adrenal masses.

METHODS

Ten sonographically guided transhepatic biopsies were performed in 10 patients with 6 right upper renal masses and 4 right adrenal masses that were invisible or inaccessible via an extrahepatic route. The control population comprised 19 sonographically guided extrahepatic biopsies that were performed in 19 patients with 18 right upper renal masses and 1 right adrenal mass. Transhepatic and extrahepatic biopsies were compared with respect to the diagnostic and complication rates. The mass sizes, biopsy distances, numbers and lengths of cores, and biopsy durations were also compared.

RESULTS

The diagnostic rates of transhepatic and extrahepatic biopsies were 90% (9 of 10) and 89% (17 of 19), respectively (P > .999). The complication rates of transhepatic and extrahepatic biopsies were 10% (1 of 10) and 21% (4 of 19; P > .999). None of these biopsies resulted in major complications. The mean mass sizes, biopsy distances, and numbers of cores ± SD for transhepatic and extrahepatic biopsies were 33.0 ± 14.3 and 46.9 ± 18.5 mm, 100.5 ± 17.9 and 76.5 ± 9.9 mm, and 2.7 ± 0.9 and 4.0 ± 0.7, respectively (P = .046, .038, and .001). However, the core lengths and biopsy durations were not significantly different between these biopsies (P = .91 and .077).

CONCLUSIONS

Sonographically guided transhepatic core biopsies appear to be feasible and safe procedures for the histologic diagnosis of right upper renal and adrenal masses that are either invisible or inaccessible via an extrahepatic route.

CT-guided adrenal biopsy: comparison of ipsilateral decubitus versus prone patient positioning for biopsy approach

OBJECTIVES

To compare ipsilateral decubitus and prone patient positioning for performing computed tomography guided adrenal biopsy using the requirements for out-of-plane approach (OOP) and the needle insertion time (NIT) as a surrogate for procedure complexity.

METHODS

The study included 106 adrenal biopsies performed in 104 patients with lesions measuring ≤ 4 cm that were divided into two groups: Ipsilateral decubitus (Group I) and prone (Group II) positions. The frequency of use of an OOP biopsy path and the NIT were recorded as well as diagnostic yield, adverse events and transgression of organs to approach the target lesion.

RESULTS

Groups I and II comprised 54 and 50 patients, respectively. The use of the OOP approach was significantly less frequent (P < 0.01) in Group I (n = 4) compared to Group II (n = 38). NIT was statistically shorter (P < 0.01) in Group I (9 min and 43 s) compared to Group II (19 min and 7 s). There were fewer organs traversed in Group I versus Group II. Diagnostic yield and post-biopsy complications were equal in both groups.

CONCLUSION

Ipsilateral adrenal biopsy approach is a less complex, equally reliable and safe compared to the prone approach based on the less frequent use of the OOP approach and the shorter NIT.

KEY POINTS

• Ipsilateral adrenal biopsy decubitus positioning provides a direct, non-transpulmonary path for sampling • Ipsilateral decubitus positioning reduces the need for potentially dangerous out-of-plane approaches (OOP) • Ipsilateral decubitus and prone positioning are equally reliable and safe techniques.

Use and usefulness of adrenal core biopsies without FNA or on-site evaluation of adequacy: a study of 204 cases for a 12-year period

While several studies have assessed the efficacy of adrenal fine-needle aspiration, there are few data regarding adrenal tissue core biopsies. We performed a retrospective study, for a 12-year period, of 204 percutaneous adrenal core biopsy specimens. A core was the only specimen obtained, and on-site evaluation was not used. About half of the cases (104/204) were diagnosed as metastatic carcinoma, with lung as the most common origin (78/204). A specificity and sensitivity of 100% for benign vs malignant was calculated, with a specificity of 88% and sensitivity of 86% for specific diagnoses. Diagnostic and sampling errors were identified. False-negatives were limited to biopsies using 20-gauge needles. Cases with a clinical history provided had specific diagnoses made at a slightly higher frequency compared with cases without an available history. Immunohistochemical workup was performed in more than half of the cases; specific diagnoses were made more frequently than in cases without immunostains.

Technical note: CT-guided paravertebral adrenal biopsy using hydrodissection--a safe and technically easy approach

The adrenal glands are an important site of both primary and secondary disease processes. Image-guided percutaneous biopsy of the adrenal gland is an accurate and safe alternative to surgical biopsy. This procedure is most often performed in patients with a suspicion of metastatic disease where an accurate pathological diagnosis plays an important role in disease staging and defining therapy. There are many different approaches to performing adrenal biopsy under CT guidance such as anterior transhepatic/transpancreatic, lateral transhepatic/transplenic or posterior transpulmonary/transpleural/paravertebral. We describe a technique in which the adrenal gland was biopsied using a CT-guided percutaneous paravertebral approach with the use of a hydrodissection manoeuver. 13 CT-guided adrenal gland percutaneous biopsies using this technique were performed at our institution between April 2009 and July 2010. All biopsies yielded sufficient material for pathological analysis and there were no complications reported after the procedure. Saline injection can expand the posterior paravertebral space and facilitate a posterior extrapleural approach with high accuracy and low complication rates, and we believe that this may be the best approach for adrenal gland biopsy.

EUS-FNA for the detection of left adrenal metastasis in patients with lung cancer

In patients with lung cancer, enlarged or (18)Fluoro-deoxyglucose positron emission tomography ((18)FDG-PET) positive left adrenal glands are suspected for distant metastases and require tissue confirmation for a definitive assessment. The aim of this study was to assess the sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for left adrenal metastases in lung cancer patients with a suspect adrenal gland based on imaging. EUS-FNA findings of patients with (suspected) lung cancer and CT enlarged or (18)FDG-PET positive left adrenal glands were retrospectively evaluated. In the absence of metastases at EUS, clinical and radiological follow-up was obtained. In 85 patients, EUS-FNA demonstrated left adrenal metastases of lung cancer in 53 (62%), benign adrenal tissue in 25 (29%), a metastasis from colon carcinoma in 1 (1%) and a primary adrenocortical carcinoma in 1 (1%) patient. In five patients (5.9%), the aspirates contained non-representative material. EUS outcomes were false negative in two patients. Sensitivity and negative predictive value (NPV) for EUS-FNA of the left adrenal gland were at least 86% (95% CI 74-93%) and 70% (95% CI 50-85%). No complications occurred. EUS-FNA is a sensitive, safe and minimally invasive technique to provide tissue proof of left adrenal metastases in patients with (suspected) lung cancer and enlarged or (18)FDG-PET positive adrenal glands. Therefore, EUS-FNA qualifies as the staging test of choice for patients with lung cancer with suspected left adrenal metastases.

Incidentally discovered adrenal mass

Adrenal masses are common incidental findings on cross-sectional imaging. Most of these masses are benign, and adenomas are the most common entity. Several imaging studies allow accurate diagnosis of these masses, separating inconsequential benign masses from the lesions that require treatment. This article discusses contemporary adrenal imaging and the optimal algorithm for the workup of incidentally detected adrenal masses.

Image-guided adrenal and renal biopsy

Image-guided biopsy is a safe and well-established technique that is familiar to most interventional radiologists. Improvements in image guidance, biopsy tools, and biopsy techniques now routinely allow for safe biopsy of renal and adrenal lesions that traditionally were considered difficult to reach or technically challenging. Image-guided biopsy is used to establish the definitive tissue diagnosis in adrenal mass lesions that cannot be fully characterized with imaging or laboratory tests alone. It is also used to establish definitive diagnosis in some cases of renal parenchymal disease and has an expanding role in diagnosis and characterization of renal masses before treatment. Although basic principles and techniques for image-guided needle biopsy are similar regardless of organ, this paper highlights some technical considerations, indications, and complications that are unique to the adrenal gland and kidney because of their anatomic location and physiological features.

A tissue microarray-based comparative analysis of novel and traditional immunohistochemical markers in the distinction between adrenal cortical lesions and pheochromocytoma

We have encountered an increasing number of image-guided adrenal mass biopsies in which the differential diagnosis is adrenal cortical lesion versus pheochromocytoma. This distinction is sometimes difficult because of confounding clinical presentations, overlapping morphologies, and some degree of immunophenotypic overlap including focal staining with markers of purported lineage specificity. Interventional radiologists commonly use narrow gauge biopsy needles in this setting, which yield scant diagnostic tissue and further complicate pathologic evaluation. In this study, a detailed immunoprofile of 63 adrenal cortical lesions (3 adrenal rests, 6 adrenal cortical hyperplasias, 43 adrenal cortical adenomas, 4 adrenal cortical neoplasms of uncertain malignant potential, and 7 adrenal cortical carcinomas) was compared with 35 pheochromocytomas using traditional (calretinin, chromogranin, inhibin, melanA, and synaptophysin) and novel [steroidogenic factor-1 (SF-1), microtubule-associated protein 2, and mammalian achaete-scute homolog-1] antibodies, using tissue microarray technology to simulate small image-guided biopsies. Staining extent and intensity were each scored semiquantitatively for each antibody. A comparison of sensitivity and specificity using different intensity thresholds required for a "positive" result (> or = 1+ vs. > or = 2+) was performed. Staining results based on a > or = 1+ and (> or = 2+) intensity threshold were as follows: calretinin-95% (89%) in adrenal cortical lesions and 14% (0%) in pheochromocytomas; chromogranin-0% in adrenal cortical lesions and 100% in pheochromocytomas; inhibin-97% (86%) in adrenal cortical lesions and 6% (0%) in pheochromocytomas; microtubule-associated protein 2-29% (16%) in adrenal cortical lesions and 100% (89%) in pheochromocytomas; mammalian achaete-scute homolog-1-0% in both adrenal cortical lesions and pheochromocytomas; melanA-94% (86%) in adrenal cortical lesions and 6% (0%) in pheochromocytomas; SF-1-87% (86%) in adrenal cortical lesions and 0% in pheochromocytomas; synaptophysin-67% (59%) in adrenal cortical lesions and 100% in pheochromocytomas. Using an antibody panel consisting of chromogranin plus the nuclear antibody SF-1 and either calretinin or inhibin, while requiring a high-staining intensity threshold, helps to eliminate interpretative issues of artifactual or background reactivity, improves diagnostic sensitivity/specificity, and makes for an effective immunohistochemical approach in distinguishing adrenal cortical lesions from pheochromocytomas.

[Adrenal incidentaloma: management approaches: CT - MRI]

The adrenal gland may be affected by several pathologies, and the detection of an adrenal nodule may occur during the work-up of a biological abnormality, oncologic work-up, or be incidental. Endocrinological and imaging work-up is required in all cases. Cross-sectional imaging has had a great impact on the diagnostic work-up of adrenal nodules. CT, without and with intravenous contrast, is the first line imaging study for evaluation of adrenal nodules. A spontaneous density below 10 HU confirms the benign nature of a nodule. When lesions cannot be characterized, postcontrast CT or MR imaging, including in and out of phase imaging, may allow diagnosis.

Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization

Incidental adrenal lesions are commonly detected at computed tomography, and lesion characterization is critical, particularly in the oncologic patient. Imaging tests have been developed that can accurately differentiate these lesions by using a variety of principles and techniques, and each is discussed in turn. An imaging algorithm is provided to guide radiologists toward the appropriate test to make the correct diagnosis.

O valor da fase sem contraste na tomografia computadorizada do abdome

OBJETIVO: Determinar o valor agregado da fase sem meio de contraste da tomografia computadorizada do abdome em pacientes sem diagnóstico determinado ou em estadiamento tumoral. MATERIAIS E MÉTODOS: Estudo prospectivo e transversal em 100 pacientes consecutivos submetidos a tomografia computadorizada abdominal sem e com meio de contraste intravenoso. Dois examinadores avaliaram todos os exames, procurando estabelecer, através da fase com meio de contraste intravenoso (primeira análise) e posteriormente através da fase sem contraste (segunda análise), o diagnóstico principal e os secundários em função da indicação clínica do exame. Mediu-se a freqüência de mudança diagnóstica decorrente da análise combinada das fases pré- e pós-contraste intravenoso. Casos que tiveram mudança diagnóstica foram avaliados por especialistas clínicos para determinar se implicaria mudanças de conduta. RESULTADOS: Diagnósticos principal e secundário foram modificados em 1 e 18 casos, respectivamente (p = 1,000; p = 0,143). Os diagnósticos modificados foram: esteatose, definição de nódulo em adrenal, nefrolitíase, classificação de cistos renais e calcificação hepática. Nos casos em que a fase sem contraste modificou o diagnóstico, os especialistas mudaram sua conduta em 14/19 (73%) dos pacientes (p = 0,038). CONCLUSÃO: A fase sem contraste não modificou significativamente o diagnóstico principal ou secundário. Porém, as mudanças nos diagnósticos secundários influenciaram na conduta adotada pelos especialistas.

Interventional uroradiology

With advances in imaging capabilities and percutaneous instruments, many urologic diseases that were once managed surgically are now managed with minimally invasive image-guided techniques. Interventional uroradiology has evolved from simple renal biopsies for diagnostic confirmation, to percutaneous management of stones, to ablation of renal and adrenal tumors. Central to this evolution is the close cooperation with the urologist and nephrologist, each of whom provides specific skill sets and knowledge that can be used to successfully manage the patient. The purpose of this article is to detail the wide range of image-guided interventional techniques, including a discussion of indications, methods, success rates, and complications.

Radiologic measurements of tumor response to treatment: practical approaches and limitations

Objective response assessment is important to describe the treatment effect of anticancer drugs. Standardization by using a "common language" is also important for comparison of results from different trials. In contrast to clinical results, which can be subjective, diagnostic imaging provides a greater opportunity for objectivity and standardization. It was generally accepted that a decrease in tumor size correlated with treatment effect; as a result, imaging was adopted for lesion measurement in the World Health Organization (WHO) criteria in 1979. However, because of some limitations of the WHO criteria, the Response Evaluation Criteria in Solid Tumors (RECIST) were introduced in 2000. In RECIST, imaging was recognized as indispensable for response evaluation of solid tumors. Nevertheless, the widespread use of multidetector computed tomography and other imaging innovations have made RECIST outdated, with a concomitant need for modifications. Meanwhile, newer anticancer agents with targeted mechanisms of action have demonstrated an inherent limitation and unsuitability of anatomic tumor evaluation that assesses only lesion size. In addition, the effect of these new drugs changes the paradigm according to which tumor response or response rate is measured. Complete and partial responses cannot be the end points in all clinical trials; in some cases, disease control or progression-free survival may be the more relevant end point.

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.

Preoperative evaluation of adrenal lesions based on imaging studies and laparoscopic adrenalectomy in patients with otherwise operable lung cancer

PURPOSE

An unsuspected adrenal mass (AM) could be discovered in patients with operable non-small-cell lung carcinoma (NSCLC), but it is difficult to determine the nature of AM. The purpose of the study is to answer the question as to which decision should be made when assessing AM in patients with NSCLC.

PATIENTS AND METHODS

From 1997 to 2005, 40 patients (31 male; mean age: 63 years) were identified to have both NSCLC and AM. We tried to determine the nature of AM based on imaging studies with or without laparoscopic adrenalectomy. When AM was considered benign on CT or PET-CT, surgical resection of NSCLC was performed (group 1, n=25). When AM was considered indeterminate on CT or PET-CT, we performed MRI to determine the operability. In eight patients, surgical resection of NSCLC was performed, because AM was considered benign on MRI (group 2). In seven patients, adrenalectomy was performed to confirm AM pathologically, because all imaging studies were indeterminate (group 3).

RESULTS

Follow-up was complete for all patients with a mean duration of 33.1 months (3-104.5). In group 1, no patients showed adrenal metastases, except one who died of adrenal metastasis. In group 2, three patients revealed that they had had adrenal metastases when staging and two died of adrenal metastasis. In group 3, one patient had an adrenal metastasis and the others had benign lesions.

CONCLUSIONS

We suggest that when AM is considered benign on CT or PET-CT, surgical resection of NSCLC is indicated. However, when AM is indeterminate on CT or PET-CT, histopathologic confirmation is needed to determine the nature of AM.

Faut-il opérer les métastases surrénaliennes isolées des cancers bronchopulmonaires non à petites cellules?

BACKGROUND

No consensus yet governs management of solitary adrenal metastasis of non-small cell lung cancer (NSCLC). Although classically considered incurable, various case reports and small series indicate that surgical treatment may improve long-term survival. The aim of this study was to review our experience and to identify factors that may affect survival.

METHODS

From January 1989 through June 2006, 26 patients (21 men and 5 women; mean age: 54+/-10 years) underwent complete resection of an isolated adrenal metastasis after surgical treatment of NSCLC. The adrenal metastasis was diagnosed at the same time as the NSCLC in 6 patients and subsequently in 20 patients. Median disease-free interval for patients with metachronous metastasis was 13.8 months (range: 4.5 to 60.1 months).

RESULTS

The overall 5- and 10-year survival rates were 31 and 21% respectively. Univariate and multivariate analysis showed that a disease-free interval longer than 6 months was a significant independent predictor of longer survival in patients after adrenalectomy. All patients with a disease-free interval of less than 6 months died within 2 years of surgery. After resection of an isolated adrenal metastasis diagnosed more than 6 months after lung resection, the 5-year survival rate was 49%. Adjuvant therapy and pathological staging of NSCLC did not affect survival.

CONCLUSION

Surgical resection of subsequent isolated adrenal metastasis with a disease-free interval longer than 6 months can lead to long-term survival in patients with previous complete resection of the primary NSCLC.

ACR Appropriateness Criteria on incidentally discovered adrenal mass

For patients without a history of malignancy, most small (less than 3 cm) incidentally discovered adrenal masses are benign, and extensive and costly workup is usually not justified. For incidentalomas from 3 to 5 cm in size, computed tomography, magnetic resonance imaging, 2-[(18)F]fluoro-2-deoxyglucose positron emission tomography, adrenal biopsy, or surgery can be considered. Lesions larger than 5 cm should be removed because of the higher risk for malignancy. For patients with histories of malignancy, incidentally discovered adrenal masses are more often malignant, and thus even smaller adrenal lesions are suspect. Adrenal biopsy should be reserved for cases in which the results of noninvasive techniques are equivocal.

Integrated PET-CT for the characterization of adrenal gland lesions in cancer patients: diagnostic efficacy and interpretation pitfalls

Integrated fluorine-18 fluorodeoxyglucose positron emission tomography (PET)-computed tomography (CT) for adrenal gland imaging in cancer patients allows early detection and accurate localization of adrenal lesions and differentiation of metastatic nodules from benign lesions, thereby facilitating treatment planning. However, false-positive findings are encountered at integrated PET-CT in approximately 5% of adrenal lesions identified as positive at PET, including adrenal adenomas, adrenal endothelial cysts, and inflammatory and infectious lesions. Moreover, false-negative findings may be seen in adrenal metastatic lesions with hemorrhage or necrosis, small-sized (<10-mm) metastatic nodules, and metastases from pulmonary bronchioloalveolar carcinoma or carcinoid tumors. An awareness of the potential pitfalls of integrated PET-CT enhances the diagnostic efficacy of this modality by allowing differentiation of metastatic adrenal lesions from other abnormalities.

An evidence-based, multidisciplinary approach to the clinical considerations, management, and surveillance of adrenal lesions in familial adenomatous polyposis: report of three cases

Adrenal masses are commonly discovered incidentally in patients with familial adenomatous polyposis, and adrenal malignancies have been rarely reported. Individuals with familial adenomatous polyposis frequently undergo abdominal CT-scan examinations for surveillance or symptoms. Adrenal lesions often are detected unexpectedly and are thus becoming a common clinical problem in this population. Adrenal lesions encompass a heterogeneous spectrum of pathologic entities, including primary adrenocortical and medullary tumors, benign or malignant lesions, hormonally active or inactive lesions, metastases, and infections. When an adrenal mass is detected, the clinician needs to address two crucial questions: 1) is the mass malignant? and 2) is it hormonally active? This article presents three new cases of incidental adrenal lesions in familial adenomatous polyposis, reviews the medical literature for this setting, and provides an overview of the diagnostic clinical approach and management of the adrenal findings in familial adenomatous polyposis patients.