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Kwak MH, Yun JS, Kim JN, Lee YR, Kim CK, Kang KA. Validation of the modified CT criteria for identifying non-adenomas. Abdom Radiol (NY) 2024; 49:1603-1614. [PMID: 38411694 DOI: 10.1007/s00261-024-04206-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/30/2023] [Accepted: 01/12/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Although adrenal computed tomography (CT) percentage washout is a potentially powerful imaging technique for differentiating adrenal adenomas from non-adenomas, its application to non-adenomas can be problematic. Recently, modified criteria for diagnosing pheochromocytomas using adrenal CT were developed based on data from 199 patients with surgically proven pheochromocytomas and adenomas. However, these criteria have not been thoroughly validated. The purpose of this study was to validate the performance of the modified criteria for diagnosing non-adenomas including pheochromocytomas. METHODS The conventional and modified criteria were applied to 266 patients from two cohorts who had surgically proven lipid-poor adenomas (155/266, 58.3%) and non-adenomas (111/266, 41.7%) and underwent adrenal CT. Two radiologists calculated the attenuation on each dynamic phase and percentage washout of adrenal masses. The final assessments based on the conventional and modified criteria were categorized into adenomas or non-adenomas. The diagnostic performance of each criterion for diagnosing non-adenomas was evaluated using the area under the receiver operating characteristic curve (AUC). False negatives and positives were also compared. RESULTS The AUC for the diagnosis of non-adenomas was 0.806 for conventional criteria and 0.858 for modified criteria (p = 0.047). The false-negative rate of conventional criteria for the diagnosis of non-adenomas was 29.7%. Use of modified criteria could have reduced the false-negative rate by to 7.2%. The false-positive rate increased from 9% to 21.3% when using the modified criteria. CONCLUSION The utilization of modified criteria has the potential to identify additional non-adenomas that would otherwise be misdiagnosed as adenomas using conventional criteria alone.
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Affiliation(s)
- Min Hwan Kwak
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Ji-Sup Yun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Na Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Rae Lee
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Kyo Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
| | - Kyung A Kang
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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Kocic S, Vukomanovic V, Djukic A, Saponjski J, Saponjski D, Aleksic V, Ignjatovic V, Vuleta Nedic K, Markovic V, Vojinovic R. Can MDCT Enhancement Patterns Be Helpful in Differentiating Secretory from Non-Functional Adrenal Adenoma? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:72. [PMID: 38256333 PMCID: PMC10819253 DOI: 10.3390/medicina60010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Primary adrenal tumors (AT) are a heterogeneous group of neoplasms due to their functional heterogeneity, which results in the diverse clinical presentation of these tumors. The purpose of this study was to examine cross-sectional imaging characteristics using multi-detector computed tomography (MDCT) to provide insight into the lesion characterization and functional status of these tumors. The radionuclide imaging using Technetium-99m radiolabeled hydrazinonicotinylacid-d-phenylalanyl1-tyrosine3-octreotide (99mTc-HYNIC-TOC), was also used in the diagnostic evaluation of these tumors. Materials and Methods: This cross-sectional study included 50 patients with confirmed diagnoses of AT (21 hormone-secreting and 29 non-functional) at the University Clinical Center, Kragujevac, Serbia, during the 2019-2022 year period. The morphological and dynamic characteristics using MDCT were performed, using qualitative, semi-quantitative, and quantitative analysis. Absolute washout (APW) and relative washout (RPW) values were also calculated. A semi-quantitative analysis of all visual findings with 99mTc-HYNIC-TOC was performed to compare the tumor to non-tumor tracer uptake. Results: A statistically significant difference was found in the MDCT values in the native phase (p < 0.05), the venous phase (p < 0.05), and the delayed phase (p < 0.001) to detect the existence of adrenal tumors. Most of these functional adrenocortical lesions (n = 44) can be differentiated using the delayed phase (p < 0.05), absolute percentage washout (APW) (p < 0.05), and relative percentage washout (RPW) (p < 0.001). Furthermore, 99mTc-HYNIC-TOC could have a high diagnostic yield to detect adrenal tumor existence (p < 0.001). There is a positive correlation between radionuclide imaging scan and APW to detect all AT (p < 0.01) and adrenocortical adenomas as well (p < 0.01). Conclusions: The results can be very helpful in a diagnostic algorithm to quickly and precisely diagnose the expansive processes of the adrenal glands, as well as to learn about the advantages and limitations of the mentioned imaging modalities.
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Affiliation(s)
- Svetlana Kocic
- Department of Radiology, Clinical Hospital Center Zemun, 11070 Belgrade, Serbia;
| | - Vladimir Vukomanovic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Aleksandar Djukic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Pathophysiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Jovica Saponjski
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.S.); (D.S.)
- University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Dusan Saponjski
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (J.S.); (D.S.)
- University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Vuk Aleksic
- Department of Neurosurgery, Clinical Hospital Center Zemun, 11070 Belgrade, Serbia;
| | - Vesna Ignjatovic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Katarina Vuleta Nedic
- Department of Nuclear Medicine, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia; (V.I.); (K.V.N.)
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
| | - Vladan Markovic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Radiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Radisa Vojinovic
- University Clinical Center Kragujevac, 34000 Kragujevac, Serbia; (A.D.); (V.M.); (R.V.)
- Department of Radiology, Faculty of Medical Science, University of Kragujevac, 34000 Kragujevac, Serbia
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Park SS, Kim JH. Recent Updates on the Management of Adrenal Incidentalomas. Endocrinol Metab (Seoul) 2023; 38:373-380. [PMID: 37583083 PMCID: PMC10475962 DOI: 10.3803/enm.2023.1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023] Open
Abstract
Adrenal incidentalomas represent an increasingly common clinical conundrum with significant implications for patients. The revised 2023 European Society of Endocrinology (ESE) guideline incorporates cutting-edge evidence for managing adrenal incidentalomas. This paper provides a concise review of the updated contents of the revised guideline. In the 2023 guideline, in patients without signs and symptoms of overt Cushing's syndrome, a post-dexamethasone cortisol level above 50 nmol/L (>1.8 μg/dL) should be considered as mild autonomous cortisol secretion. Regarding the criteria of benign adrenal adenomas, a homogeneous adrenal mass with ≤10 Hounsfield units on non-contrast computed tomography requires no further follow-up, irrespective of its size. The updated guideline also discusses steroid metabolomics using tandem mass spectrometry to discriminate malignancy. It underscores the importance of high-volume surgeons performing adrenalectomy and emphasizes the pivotal role of a multidisciplinary team approach in deciding the treatment plan for indeterminate adrenal masses. The guideline advocates for more proactive surgical treatment for indeterminate adrenal masses in young patients (<40 years) and pregnant women. This review of the 2023 ESE guideline underscores the ongoing evolution of the adrenal incidentaloma management landscape, emphasizing the need for further research and adaptation of diagnostic and therapeutic strategies.
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Affiliation(s)
- Seung Shin Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Herndon J, Bancos I. Diagnosing and managing adrenal incidentalomas. JAAPA 2023; 36:12-18. [PMID: 37043721 DOI: 10.1097/01.jaa.0000923528.75127.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
ABSTRACT Adrenal incidentalomas are commonly encountered because of the widespread use of high-resolution cross-sectional imaging. Adrenal incidentalomas may be benign or malignant, and also may demonstrate hormonal hypersecretion, so all patients with adrenal masses should undergo further assessment. Clinicians should have a basic understanding of adrenal incidentalomas, their workup, and when follow-up and referral are warranted.
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Affiliation(s)
- Justine Herndon
- At the Mayo Clinic in Rochester, Minn., Justine Herndon practices in the Division of Endocrinology, Diabetes, and Nutrition, and Irina Bancos practices in the Division of Endocrinology, Diabetes, and Nutrition and the Department of Laboratory Medicine and Pathology. Dr. Bancos reports advisory board participation and/or consulting with Lantheus, Sparrow Pharmaceuticals, Spruce Biosciences, Recordati Rare Disease, Corcept Therapeutics, Adrenas Therapeutics, and HRA Pharma. She also is partly supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) under awards K23DK121888 and R03DK132121. The views expressed are those of the authors and not necessarily those of the NIH. The authors have disclosed no other potential conflicts of interest, financial or otherwise
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Vogg N, Müller T, Floren A, Dandekar T, Riester A, Dischinger U, Kurlbaum M, Kroiss M, Fassnacht M. Simplified urinary steroid profiling by LC-MS as diagnostic tool for malignancy in adrenocortical tumors. Clin Chim Acta 2023; 543:117301. [PMID: 36948238 DOI: 10.1016/j.cca.2023.117301] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Preoperative identification of malignant adrenal tumors is challenging. 24-h urinary steroid profiling by LC-MS/MS and machine learning has demonstrated high diagnostic power, but the unavailability of bioinformatic models for public use has limited its routine application. We here aimed to increase usability with a novel classification model for the differentiation of adrenocortical adenoma(ACA) and adrenocortical carcinoma(ACC). METHODS Eleven steroids (5-pregnenetriol, dehydroepiandrosterone, cortisone, cortisol, α-cortolone, tetrahydro-11-deoxycortisol, etiocholanolone, pregnenolone, pregnanetriol, pregnanediol, and 5-pregnenediol) were quantified by LC-MS/MS in 24-h urine samples from 352 patients with adrenal tumor (281 ACA,71 ACC). Random forest modelling and decision tree algorithms were applied in training (n=188) and test sets (n=80) and independently validated in 84 patients with paired 24-h and spot urine. RESULTS After examining different models, a decision tree using excretions of only 5-pregnenetriol and tetrahydro-11-deoxycortisol classified three groups with low, intermediate, and high risk for malignancy. 148/217 ACA were classified as being at low, 67 intermediate, and 2 high risk of malignancy. Conversely, none of the ACC demonstrated a low-risk profile leading to a negative predictive value of 100% for malignancy. In the independent validation cohort, the negative predictive value was again 100% in both 24-h urine and spot urine with a positive predictive value of 87.5% and 86.7%, respectively. CONCLUSIONS This simplified LC-MS/MS-based classification model using 24-h-urine provided excellent results for exclusion of ACC and can help to avoid unnecessary surgeries. Analysis of spot urine led to similarly satisfactory results suggesting that cumbersome 24-h urine collection might be dispensable after future validation.
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Affiliation(s)
- Nora Vogg
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany
| | - Tobias Müller
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Andreas Floren
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Thomas Dandekar
- Department of Bioinformatics, Biocenter, Am Hubland, University of Würzburg, Germany
| | - Anna Riester
- Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany; Central Laboratory, Core Unit Clinical Mass Spectrometry, University Hospital Würzburg, Germany.
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Wang G, Kang B, Cui J, Deng Y, Zhao Y, Ji C, Wang X. Two nomograms based on radiomics models using triphasic CT for differentiation of adrenal lipid-poor benign lesions and metastases in a cancer population: an exploratory study. Eur Radiol 2023; 33:1873-1883. [PMID: 36264313 DOI: 10.1007/s00330-022-09182-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVES To investigate the effectiveness of CT-based radiomics nomograms in differentiating adrenal lipid-poor benign lesions and metastases in a cancer population. METHODS This retrospective study enrolled 178 patients with cancer history from three medical centres categorised as those with adrenal lipid-poor benign lesions or metastases. Patients were divided into training, validation, and external testing cohorts. Radiomics features were extracted from triphasic CT images (unenhanced, arterial, and venous) to establish three single-phase models and one triphasic radiomics model using logistic regression. Unenhanced and triphasic nomograms were established by incorporating significant clinico-radiological factors and radscores. The models were evaluated by the receiver operating characteristic curve, Delong's test, calibration curve, and decision curve. RESULTS Lesion side, diameter, and enhancement ratio resulted as independent factors and were selected into nomograms. The areas under the curves (AUCs) of unenhanced and triphasic radiomics models in validation (0.878, 0.914, p = 0.381) and external testing cohorts (0.900, 0.893, p = 0.882) were similar and higher than arterial and venous models (validation: 0.842, 0.765; testing: 0.814, 0.806). Unenhanced and triphasic nomograms yielded similar AUCs in validation (0.903, 0.906, p = 0.955) and testing cohorts (0.928, 0.946, p = 0.528). The calibration curves showed good agreement and decision curves indicated satisfactory clinical benefits. CONCLUSION Unenhanced and triphasic CT-based radiomics nomograms resulted as a useful tool to differentiate adrenal lipid-poor benign lesions from metastases in a cancer population. They exhibited similar predictive efficacies, indicating that enhanced examinations could be avoided in special populations. KEY POINTS • All four radiomics models and two nomograms using triphasic CT images exhibited favourable performances in three cohorts to characterise the cancer population's adrenal benign lesions and metastases. • Unenhanced and triphasic radiomics models had similar predictive performances, outperforming arterial and venous models. • Unenhanced and triphasic nomograms also exhibited similar efficacies and good clinical benefits, indicating that contrast-enhanced examinations could be avoided when identifying adrenal benign lesions and metastases.
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Affiliation(s)
- Gongzheng Wang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, China
| | - Bing Kang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, China
| | - Jingjing Cui
- United Imaging Intelligence (Beijing) Co., Ltd., Beijing, 100094, China
| | - Yan Deng
- Department of Radiology, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China
| | - Yun Zhao
- Department of Radiology, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, China
| | - Congshan Ji
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, China. .,Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
| | - Ximing Wang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, China. .,Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
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Wang YL, Liu XL, Liao ZB, Lu XM, Chen LL, Lei Y, Zhang HW, Lin F. Dual-energy spectral detector computed tomography differential diagnosis of adrenal adenoma and pheochromocytoma: Changes in the energy level curve, a phenomenon caused by lipid components? Front Endocrinol (Lausanne) 2023; 13:998154. [PMID: 36686431 PMCID: PMC9854128 DOI: 10.3389/fendo.2022.998154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023] Open
Abstract
Background and objectives Pheochromocytoma and adrenal adenoma are common space-occupying lesions of the adrenal gland, and incorrect surgery may lead to adrenal crisis. We used a new method, dual-energy spectral detector computed tomography (SDCT), to differentiate between the two. Materials and methods We analysed the imaging images of patients with SDCT scans and pathologically confirmed adrenal adenomas (n=70) and pheochromocytomas (n=15). The 40, 70, and 100 KeV virtual monoenergetic images (VMIs) were reconstructed based on the SCDT arterial phase, and the correlation between the arterial/venous phase iodine concentration (AP-IC/VP-IC), the effective atomic number (Z-effect), the slope of the Hounsfield unit attenuation plot (VMI slope) and the pathological results was tested. The Shapiro-Wilk test was used to determine whether the above data conformed to a normal distribution. For parameters with P greater than 0.05, Student's t test was used, and the Mann-Whitney test was used for the remaining parameters. A ROC curve was drawn based on the results. Results Student's t test showed that the 40 KeV VMI and the VMI slope were both statistically significant (P<0.01). The Mann-Whitney U test showed that ID-A was statistically significant (P=0.004). ROC curve analysis showed that 40 keV VMI (AUC=0.818), AP-IC (AUC=0.736), difference (AUC=0.817) and VMI-Slope (0.817) could be used to differentiate adrenal adenoma from pheochromocytoma. Conclusion The effect of lipid components on SDCT parameters can be used to differentiate adrenal adenoma from pheochromocytoma.
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Affiliation(s)
- Yu-li Wang
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Xiao-lei Liu
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Ze-bing Liao
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Xiao-mei Lu
- CT Clinical Science, Philips Healthcare, Shenyang, China
| | - Ling-lin Chen
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Yi Lei
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Han-wen Zhang
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Fan Lin
- Department of Radiology, the First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen, China
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Savoie PH, Murez T, Neuville P, Van Hove A, Rocher L, Fléchon A, Camparo P, Ferretti L, Branger N, Rouprêt M. French AFU Cancer Committee Guidelines Update 2022-2024: Adrenal tumor - Assessment of an adrenal incidetaloma and oncological management. Prog Urol 2022; 32:1040-1065. [PMID: 36400477 DOI: 10.1016/j.purol.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The objective of this publication is to recall the initial work-up when faced with an adrenal incidentaloma and, if necessary, to establish the oncological management of an adrenal malignant tumor. MATERIAL AND METHODS The multidisciplinary working group updated French urological guidelines about oncological assessment of the adrenal incidentaloma, established by the CCAFU in 2020, based on an exhaustive literature review carried out on PubMed. RESULTS Although the majority of the adrenal masses are benign and non-functional, it is important to investigate them, as a percentage of these can cause serious endocrine diseases or be cancers. Malignant adrenal tumors are mainly represented by adrenocortical carcinomas (ACC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). The malignancy assessment of an adrenal incident includes a complete history, a physical examination, a biochemical/hormonal assessment to look for subclinical hormonal secretion. Diagnostic hypotheses are sometimes available at this stage, but it is the morphological and functional imaging and the histological analysis, which will make it possible to close the malignancy assessment and make the oncological diagnosis. CONCLUSIONS ACC and MPC are mainly sporadic but a hereditary origin is always possible. ACC is suspected preoperatively but the diagnosis of certainty is histological. The diagnosis of MPC is more delicate and is based on clinic, biology and imagery. The diagnosis of certainty of AM requires a percutaneous biopsy. At the end, the files must be discussed within the COMETE - adrenal cancer network (Appendix 1).
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Affiliation(s)
- P H Savoie
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie urologique, hôpital d'instruction des armées Sainte-Anne, 2, boulevard Sainte-Anne, BP 600, 83800 Toulon cedex 09, France.
| | - T Murez
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et de transplantation rénale, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - P Neuville
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - A Van Hove
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Hôpital européen, 6, rue Désirée-Clary, 13003 Marseille, France
| | - L Rocher
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Saclay, BIOMAPS, 63, avenue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - A Fléchon
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P Camparo
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut de pathologie des Hauts-de-France, 51, rue Jeanne-d'Arc, 80000 Amiens, France
| | - L Ferretti
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; MSP Bordeaux Bagatelle, 203, route de Toulouse, 33401 Talence, France
| | - N Branger
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille, France
| | - M Rouprêt
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
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Yan F, Zeng J, Chen Y, Cheng Y, Pei Y, Zang L, Chen K, Gu W, Du J, Guo Q, Wang X, Ba J, Lyu Z, Dou J, Yang G, Mu Y. Clinical analysis of the etiological spectrum of bilateral adrenal lesions: A large retrospective, single-center study. Endocrine 2022; 77:372-379. [PMID: 35606576 DOI: 10.1007/s12020-022-03077-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the clinical characteristics, endocrinological function, and etiology of bilateral adrenal lesions in hospitalized patients. METHODS A retrospective study of 777 patients with bilateral adrenal lesions was conducted at the Chinese People's Liberation Army General Hospital between January 2013 and January 2018. Patients' demographic features, hormonal profiles, imaging findings, and histopathological findings were reviewed from database records. RESULTS Of the 777 patients with bilateral adrenal lesions, 495 were men. The mean age at diagnosis was 52.0 ± 13.0 years. Overall, 511 (65.8%) cases were benign, followed by adrenal metastases (n = 224, 28.8%), pheochromocytoma (n = 26, 3.3%), adrenal lymphoma (n = 9, 1.2%), and adrenal corticocarcinoma (ACC; n = 7, 0.9%). Hormonal evaluation revealed that 34.3% of bilateral adrenal lesions were functional. The primary etiologies of functional lesions were primary aldosteronism (16.6%, 129/777), and primary bilateral macronodular adrenocortical hyperplasia (PBMAH; 8.8%, 68/777). Patients with lymphoma and metastases were significantly older than those with benign nonfunctional lesions (60.4 ± 11.0 years vs. 54.5 ± 10.4 years and 57.9 ± 10.8 years vs. 54.5 ± 10.4 years, respectively; both P < 0.001). Lesions in patients with adrenal lymphoma, ACC, pheochromocytoma, metastases, congenital adrenal hyperplasia, tuberculosis, and Cushing's syndrome were significantly larger than benign nonfunctional lesions (all P < 0.001). CONCLUSION Benign adrenal lesions and metastases from the lungs are the most common causes of bilateral adrenal lesions. Primary aldosteronism and PBMAH are the most prevalent functional lesions. Moreover, patients with lymphoma or metastases are older and their masses are larger.
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Affiliation(s)
- Fangfang Yan
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jinyang Zeng
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yulong Chen
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yu Cheng
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yu Pei
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Li Zang
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Kang Chen
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Weijun Gu
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jin Du
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Qinghua Guo
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xianling Wang
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jianming Ba
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhaohui Lyu
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Guoqing Yang
- Department of Endocrinology, Hainan Branch of Chinese People's Liberation Army General Hospital, Sanya, Hainan, China.
| | - Yiming Mu
- Department of Endocrinology, Chinese People's Liberation Army General Hospital, Beijing, China.
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Olmos R, Mertens N, Vaidya A, Uslar T, Fernandez P, Guarda FJ, Zúñiga Á, San Francisco I, Huete A, Baudrand R. Discriminative Capacity of CT Volumetry to Identify Autonomous Cortisol Secretion in Incidental Adrenal Adenomas. J Clin Endocrinol Metab 2022; 107:e1946-e1953. [PMID: 35020922 PMCID: PMC9272424 DOI: 10.1210/clinem/dgac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 01/12/2023]
Abstract
CONTEXT Incidentally discovered adrenal adenomas are common. Assessment for possible autonomous cortisol excess (ACS) is warranted for all adrenal adenomas, given the association with increased cardiometabolic disease. OBJECTIVE To evaluate the discriminatory capacity of 3-dimensional volumetry on computed tomography (CT) to identify ACS. METHODS Two radiologists, blinded to hormonal levels, prospectively analyzed CT images of 149 adult patients with unilateral, incidentally discovered, adrenal adenomas. Diameter and volumetry of the adenoma, volumetry of the contralateral adrenal gland, and the adenoma volume-to-contralateral gland volume (AV/CV) ratio were measured. ACS was defined as cortisol ≥ 1.8 mcg/dL after 1-mg dexamethasone suppression test (DST) and a morning ACTH ≤ 15. pg/mL. RESULTS We observed that ACS was diagnosed in 35 (23.4%) patients. Cortisol post-DST was positively correlated with adenoma diameter and volume, and inversely correlated with contralateral adrenal gland volume. Cortisol post-DST was positively correlated with the AV/CV ratio (r = 0.46, P < 0.001) and ACTH was inversely correlated (r = -0.28, P < 0.001). The AV/CV ratio displayed the highest odds ratio (1.40; 95% CI, 1.18-1.65) and area under curve (0.91; 95% CI, 0.86-0.96) for predicting ACS. An AV/CV ratio ≥ 1 (48% of the cohort) had a sensitivity of 97% and a specificity of 70% to identify ACS. CONCLUSION CT volumetry of adrenal adenomas and contralateral adrenal glands has a high discriminatory capacity to identify ACS. The combination of this simple and low-cost radiological phenotyping can supplement biochemical testing to substantially improve the identification of ACS.
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Affiliation(s)
| | | | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Thomas Uslar
- Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
- Program for Adrenal Disorders, CETREN UC, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Paula Fernandez
- Program for Adrenal Disorders, CETREN UC, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Francisco J Guarda
- Department of Endocrinology, Pontificia Universidad Catolica de Chile, Santiago, 8330077, Chile
| | - Álvaro Zúñiga
- Department of Urology, Pontificia Universidad Catolica de Chile, Santiago 8330077, Chile
| | - Ignacio San Francisco
- Department of Urology, Pontificia Universidad Catolica de Chile, Santiago 8330077, Chile
| | | | - René Baudrand
- Correspondence: René Baudrand, M.D., Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 4th FL, RM, Santiago, Chile, 8330077, USA.
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11
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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12
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Berke K, Constantinescu G, Masjkur J, Kimpel O, Dischinger U, Peitzsch M, Kwapiszewska A, Dobrowolski P, Nölting S, Reincke M, Beuschlein F, Bornstein SR, Prejbisz A, Lenders JWM, Fassnacht M, Eisenhofer G. Plasma Steroid Profiling in Patients With Adrenal Incidentaloma. J Clin Endocrinol Metab 2022; 107:e1181-e1192. [PMID: 34665854 DOI: 10.1210/clinem/dgab751] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Indexed: 01/13/2023]
Abstract
CONTEXT Most patients with adrenal incidentaloma have nonfunctional lesions that do not require treatment, while others have functional or malignant tumors that require intervention. The plasma steroid metabolome may be useful to assess therapeutic need. OBJECTIVE This work aimed to establish the utility of plasma steroid profiling combined with metanephrines and adrenal tumor size for the differential diagnosis of patients with adrenal incidentaloma. METHODS This retrospective cross-sectional study, which took place at 7 European tertiary-care centers, comprised 577 patients with adrenal incidentaloma, including 19, 77, 65, 104 and 312 respective patients with adrenocortical carcinoma (ACC), pheochromocytoma (PHEO), primary aldosteronism (PA), autonomous cortisol secretion (ACS), and nonfunctional adrenal incidentaloma (NFAI). Mesaures of diagnostic performance were assessed (with [95% CIs]) for discriminating different subgroups of patients with adrenal incidentaloma. RESULTS Patients with ACC were characterized by elevated plasma concentrations of 11-deoxycortisol, 11-deoxycorticosterone, 17-hydroxyprogesterone, androstenedione, and dehydroepiandrosterone-sulfate, whereas patients with PA had elevations of aldosterone, 18-oxocortisol, and 18-hydroxycortisol. A selection of those 8 steroids, combined with 3 others (cortisol, corticosterone, and dehydroepiandrosterone) and plasma metanephrines, proved optimal for identifying patients with ACC, PA, and PHEO at respective sensitivities of 83.3% (66.1%-100%), 90.8% (83.7%-97.8%), and 94.8% (89.8%-99.8%); and specificities of 98.0% (96.9%-99.2%), 92.0% (89.6%-94.3%), and 98.6% (97.6%-99.6%). With the addition of tumor size, discrimination improved further, particularly for ACC (100% [100%-100%] sensitivity, 99.5% [98.9%-100%] specificity). In contrast, discrimination of ACS and NFAI remained suboptimal (70%-71% sensitivity, 89%-90% specificity). CONCLUSION Among patients with adrenal incidentaloma, the combination of plasma steroid metabolomics with routinely available plasma free metanephrines and data from imaging studies may facilitate the identification of almost all clinically relevant adrenal tumors.
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Affiliation(s)
- Kristina Berke
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Otilia Kimpel
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, 04-828 Warsaw, Poland
| | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8057 Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Martin Reincke
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8057 Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80539 Munich, Germany
| | - Stefan R Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, 04-828 Warsaw, Poland
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, 6500 HB Nijmegen, the Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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13
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Crimì F, Quaia E, Cabrelle G, Zanon C, Pepe A, Regazzo D, Tizianel I, Scaroni C, Ceccato F. Diagnostic Accuracy of CT Texture Analysis in Adrenal Masses: A Systematic Review. Int J Mol Sci 2022; 23:ijms23020637. [PMID: 35054823 PMCID: PMC8776161 DOI: 10.3390/ijms23020637] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 12/19/2022] Open
Abstract
Adrenal incidentalomas (AIs) are incidentally discovered adrenal neoplasms. Overt endocrine secretion (glucocorticoids, mineralocorticoids, and catecholamines) and malignancy (primary or metastatic disease) are assessed at baseline evaluation. Size, lipid content, and washout characterise benign AIs (respectively, <4 cm, <10 Hounsfield unit, and rapid release); nonetheless, 30% of adrenal lesions are not correctly indicated. Recently, image-based texture analysis from computed tomography (CT) may be useful to assess the behaviour of indeterminate adrenal lesions. We performed a systematic review to provide the state-of-the-art of texture analysis in patients with AI. We considered 9 papers (from 70 selected), with a median of 125 patients (range 20–356). Histological confirmation was the most used criteria to differentiate benign from the malignant adrenal mass. Unenhanced or contrast-enhanced data were available in all papers; TexRAD and PyRadiomics were the most used software. Four papers analysed the whole volume, and five considered a region of interest. Different texture features were reported, considering first- and second-order statistics. The pooled median area under the ROC curve in all studies was 0.85, depicting a high diagnostic accuracy, up to 93% in differentiating adrenal adenoma from adrenocortical carcinomas. Despite heterogeneous methodology, texture analysis is a promising diagnostic tool in the first assessment of patients with adrenal lesions.
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Affiliation(s)
- Filippo Crimì
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Institute of Radiology, University-Hospital of Padova, 35128 Padua, Italy
| | - Emilio Quaia
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Institute of Radiology, University-Hospital of Padova, 35128 Padua, Italy
| | - Giulio Cabrelle
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Institute of Radiology, University-Hospital of Padova, 35128 Padua, Italy
| | - Chiara Zanon
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Institute of Radiology, University-Hospital of Padova, 35128 Padua, Italy
| | - Alessia Pepe
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Institute of Radiology, University-Hospital of Padova, 35128 Padua, Italy
| | - Daniela Regazzo
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Endocrine Disease Unit, University-Hospital of Padova, 35128 Padua, Italy
| | - Irene Tizianel
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Endocrine Disease Unit, University-Hospital of Padova, 35128 Padua, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Endocrine Disease Unit, University-Hospital of Padova, 35128 Padua, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, 35128 Padua, Italy; (F.C.); (E.Q.); (G.C.); (C.Z.); (A.P.); (D.R.); (I.T.); (C.S.)
- Endocrine Disease Unit, University-Hospital of Padova, 35128 Padua, Italy
- Correspondence: ; Tel.: +39-049-8211323; Fax: +39-049-657391
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14
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Schloetelburg W, Ebert I, Petritsch B, Weng AM, Dischinger U, Kircher S, Buck AK, Bley TA, Deutschbein T, Fassnacht M. Adrenal wash-out CT: moderate diagnostic value in distinguishing benign from malignant adrenal masses. Eur J Endocrinol 2021; 186:183-193. [PMID: 34813495 PMCID: PMC8679842 DOI: 10.1530/eje-21-0650] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/23/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Reliable results of wash-out CT in the diagnostic workup of adrenal incidentalomas are scarce. Thus, we evaluated the diagnostic accuracy of delayed wash-out CT and determined thresholds to accurately differentiate adrenal masses. DESIGN Retrospective, single-center cohort study including 216 patients with 252 adrenal lesions who underwent delayed wash-out CT. Definitive diagnoses based on histopathology (n = 92) or comprehensive follow-up. METHODS Size, average attenuation values of the adrenal lesions in all CT scan phases, and absolute and relative percentage wash-out (APW/RPW) were determined by an expert radiologist blinded for clinical data. Adrenal lesions with unenhanced attenuation values >10 Hounsfield units (HU) built a subgroup (n = 142). Diagnostic accuracy was calculated. RESULTS The study group consisted of 171 adenomas, 32 other benign tumors, 11 pheochromocytomas, 9 adrenocortical carcinomas, and 29 other malignant tumors. All (potentially) malignant and 46% of benign lesions showed unenhanced attenuation values >10 HU. In this most relevant subgroup, the established thresholds of 60% for APW and 40% for RPW misclassified 35.9 and 35.2% of the masses, respectively. When we applied optimized cutoffs (APW >83%; RPW >58%) and excluded pheochromocytomas, we missed only one malignant tumor by APW and none by RPW. However, only 11 and 15% of the benign tumors were correctly identified. CONCLUSIONS Wash-out CT with the established thresholds for APW and RPW is insufficient to reliably diagnose adrenal masses. Using the proposed cutoff of 58% for RPW, malignant tumors will be correctly identified, but the added value is limited, namely 15% of patients with benign tumors can be prevented from additional imaging or even unnecessary surgery.
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Affiliation(s)
- Wiebke Schloetelburg
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Department of Nuclear Medicine, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ines Ebert
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Bernhard Petritsch
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Andreas Max Weng
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefan Kircher
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Andreas Konrad Buck
- Department of Nuclear Medicine, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Radiology, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Correspondence should be addressed to M Fassnacht;
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Ceccato F, Tizianel I, Voltan G, Maggetto G, Merante Boschin I, Quaia E, Crimì F, Scaroni C. Attenuation Value in Adrenal Incidentalomas: A Longitudinal Study. Front Endocrinol (Lausanne) 2021; 12:794197. [PMID: 34925247 PMCID: PMC8678594 DOI: 10.3389/fendo.2021.794197] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/12/2021] [Indexed: 12/19/2022] Open
Abstract
Context A tendency to grow has been reported in adrenal incidentalomas. However, long-term data regarding attenuation value, a measure of lipid content, are not available. Aim This study aims to collect radiological data (diameter in mm and attenuation value in Hounsfield units, HU) with computed tomography (CT) in adrenal incidentalomas, in order to compare baseline characteristics with the last follow-up imaging. Design This is a longitudinal study which included patients with a new diagnosis of adrenal incidentaloma, evaluated from January 2002 to June 2020. Setting Referral University-Hospital center. Patients Two hundred seventy-seven patients with 355 different cortical adenomas (baseline group) were evaluated at the first outpatient visit; the follow-up cohort consists of 181 patients with 234 adenomas (12-175 months after baseline). Inclusion criteria were conservative management and radiological features able to minimize malignancy or risk of progression. Main Outcome Measure CT modification according to endocrine function: autonomous cortisol secretion (ACS) if cortisol >50 nmol/L after 1-mg dexamethasone test (DST). Results At baseline CT, mean diameter was 18.7 mm and attenuation value was 0.8 HU (higher in ACS, 66 cases >10 HU), without modification in early imaging (12-36 months). The size increased over time (r = 0.289), achieving the largest differences after at least 60 months of follow-up (mean diameter, +2 mm; attenuation value, -4 HU), combined with a reduction in the attenuation value (r = -0.195, especially in patients with ACS). Lipid-poor adenomas (>10 HU) presented a reduced cortisol suppression after 1-mg DST, an increase in size and the largest decrease in attenuation value during follow-up. Univariate analysis confirmed that larger adenomas presented reduced suppression after DST and increase in size during follow-up. Conclusions Growth is clinically modest in adrenal incidentaloma: the first follow-up CT 5 years after baseline is a reasonable choice, especially in ACS. Mean density is increased in patients with ACS and overt hypercortisolism. Mean density reduces during follow-up in all adrenal adenomas, suggesting an increase in lipid content, especially in those with ACS.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
| | - Irene Tizianel
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Giacomo Voltan
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | | | - Isabella Merante Boschin
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Surgical Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Padova, Italy
| | - Emilio Quaia
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Institute of Radiology, University-Hospital of Padova, Padova, Italy
| | - Filippo Crimì
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Institute of Radiology, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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16
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Viëtor CL, Creemers SG, van Kemenade FJ, van Ginhoven TM, Hofland LJ, Feelders RA. How to Differentiate Benign from Malignant Adrenocortical Tumors? Cancers (Basel) 2021; 13:cancers13174383. [PMID: 34503194 PMCID: PMC8431066 DOI: 10.3390/cancers13174383] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Adrenocortical carcinoma is a rare cancer with a poor prognosis. Adrenal tumors are, however, commonly identified in clinical practice. Discrimination between benign and malignant adrenal tumors is of great importance to determine the appropriate treatment and follow-up strategy. This review summarizes the current diagnostic strategies and challenges to distinguish benign from malignant adrenal lesions. We will focus both on radiological and biochemical assessments, enabling diagnosis of the adrenal lesion preoperatively, and on histopathological and a wide variety of molecular assessments that can be done after surgical removal of the adrenal lesion. Furthermore, new non-invasive strategies such as liquid biopsies, in which blood samples are used to study circulating tumor cells, tumor DNA and microRNA, will be addressed in this review. Abstract Adrenocortical carcinoma (ACC) is a rare cancer with a poor prognosis. Adrenal incidentalomas are, however, commonly identified in clinical practice. Discrimination between benign and malignant adrenal tumors is of great importance considering the large differences in clinical behavior requiring different strategies. Diagnosis of ACC starts with a thorough physical examination, biochemical evaluation, and imaging. Computed tomography is the first-level imaging modality in adrenal tumors, with tumor size and Hounsfield units being important features for determining malignancy. New developments include the use of urine metabolomics, also enabling discrimination of ACC from adenomas preoperatively. Postoperatively, the Weiss score is used for diagnosis of ACC, consisting of nine histopathological criteria. Due to known limitations as interobserver variability and lack of accuracy in borderline cases, much effort has been put into new tools to diagnose ACC. Novel developments vary from immunohistochemical markers and pathological scores, to markers at the level of DNA, methylome, chromosome, or microRNA. Molecular studies have provided insights into the most promising and most frequent alterations in ACC. The use of liquid biopsies for diagnosis of ACC is studied, although in a small number of patients, requiring further investigation. In this review, current diagnostic modalities and challenges in ACC will be addressed.
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Affiliation(s)
- Charlotte L. Viëtor
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, 3015GD Rotterdam, The Netherlands; (C.L.V.); (T.M.v.G.)
| | - Sara G. Creemers
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
| | - Folkert J. van Kemenade
- Department of Pathology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands;
| | - Tessa M. van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, 3015GD Rotterdam, The Netherlands; (C.L.V.); (T.M.v.G.)
| | - Leo J. Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
| | - Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, 3015GD Rotterdam, The Netherlands; (S.G.C.); (L.J.H.)
- Correspondence:
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17
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Sundin A, Hindié E, Avram AM, Tabarin A, Pacak K, Taïeb D. A Clinical Challenge: Endocrine and Imaging Investigations of Adrenal Masses. J Nucl Med 2021; 62:26S-33S. [PMID: 34230070 DOI: 10.2967/jnumed.120.246066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
Incidentalomas are reported in 3%-4% of patients who undergo abdominal anatomic imaging, making adrenal mass evaluation a common occurrence. An adrenal mass can be caused by a variety of pathologies, such as benign cortical and medullary tumors, malignant tumors (primary or secondary), cysts, hyperplasia, hemorrhage, or more rarely infection/inflammation processes. Functioning tumors usually have increased hormonal production but they are less common. Regardless of their functional status, some tumors have the potential to behave aggressively. Anatomic and functional imaging together with biologic evaluation play a vital role in adrenal pathology subtyping. Most patients are initially evaluated by CT or MRI, which allows for tumor characterization (to a certain extent) and can rule out malignant behavior based on the absence of tumor growth during longitudinal follow-up. In the remaining patients for whom CT or MRI fail to characterize the pathogenesis of adrenal tumors, the use of specialized molecular imaging techniques should be performed after hormonal screening. This review emphasizes well-established and emerging nuclear medicine imaging modalities and describes their use across various clinical scenarios.
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Affiliation(s)
- Anders Sundin
- Section of Radiology & Molecular Imaging, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Elif Hindié
- Department of Nuclear Medicine, University Hospital of Bordeaux, Bordeaux, France
| | - Anca M Avram
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Antoine Tabarin
- Department of Endocrinology, University Hospital of Bordeaux, Bordeaux, France
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health, Bethesda, Maryland; and
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, France
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18
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Torresan F, Crimì F, Ceccato F, Zavan F, Barbot M, Lacognata C, Motta R, Armellin C, Scaroni C, Quaia E, Campi C, Iacobone M. Radiomics: a new tool to differentiate adrenocortical adenoma from carcinoma. BJS Open 2021; 5:6157086. [PMID: 33677483 PMCID: PMC7937424 DOI: 10.1093/bjsopen/zraa061] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/01/2020] [Indexed: 01/06/2023] Open
Abstract
Background The main challenge in the management of indeterminate incidentally discovered adrenal tumours is to differentiate benign from malignant lesions. In the absence of clear signs of invasion or metastases, imaging techniques do not always precisely define the nature of the mass. The present pilot study aimed to determine whether radiomics may predict malignancy in adrenocortical tumours. Methods CT images in unenhanced, arterial, and venous phases from 19 patients who had undergone resection of adrenocortical tumours and a cohort who had undergone surveillance for at least 5 years for incidentalomas were reviewed. A volume of interest was drawn for each lesion using dedicated software, and, for each phase, first-order (histogram) and second-order (grey-level colour matrix and run-length matrix) radiological features were extracted. Data were revised by an unsupervised machine learning approach using the K-means clustering technique. Results Of operated patients, nine had non-functional adenoma and 10 carcinoma. There were 11 patients in the surveillance group. Two first-order features in unenhanced CT and one in arterial CT, and 14 second-order parameters in unenhanced and venous CT and 10 second-order features in arterial CT, were able to differentiate adrenocortical carcinoma from adenoma (P < 0.050). After excluding two malignant outliers, the unsupervised machine learning approach correctly predicted malignancy in seven of eight adrenocortical carcinomas in all phases. Conclusion Radiomics with CT texture analysis was able to discriminate malignant from benign adrenocortical tumours, even by an unsupervised machine learning approach, in nearly all patients.
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Affiliation(s)
- F Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology DISCOG, University Hospital of Padova, Padua, Italy
| | - F Crimì
- Radiology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - F Zavan
- Radiology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - C Lacognata
- Radiology Department, University Hospital of Padua, Padua, Italy
| | - R Motta
- Radiology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - C Armellin
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology DISCOG, University Hospital of Padova, Padua, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - E Quaia
- Radiology Unit, Department of Medicine DIMED, University Hospital of Padua, Padua, Italy
| | - C Campi
- Department of Mathematics 'Tullio Levi-Civita', University of Padua, Padua, Italy
| | - M Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology DISCOG, University Hospital of Padova, Padua, Italy
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19
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Response to Comment on "A Modern Assessment of Cancer Risk in Adrenal Incidentalomas: Analysis of 2219 Patients" by Kahramangil B et al. Ann Surg 2021; 274:e888-e889. [PMID: 33605590 DOI: 10.1097/sla.0000000000004792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Yozamp N, Vaidya A. Assessment of mild autonomous cortisol secretion among incidentally discovered adrenal masses. Best Pract Res Clin Endocrinol Metab 2021; 35:101491. [PMID: 33593680 DOI: 10.1016/j.beem.2021.101491] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Incidentally discovered adrenal masses are common and mostly benign and non-functioning adenomas. However, evolving evidence suggests that a notable proportion of these adrenal adenomas may demonstrate mild autonomous cortisol secretion (MACS), which has been associated with an increased risk for hypertension, hyperglycemia, obesity, dyslipidemia, vertebral fractures, adverse cardiovascular events, and mortality. Therefore, it is advised that all patients with an incidentally discovered adrenal mass be tested for MACS. When there is convincing evidence for MACS, surgical adrenalectomy has been associated with an improvement in certain metabolic parameters and a reduction in vertebral fractures; however, conclusive evidence demonstrating decreased cardiovascular outcomes or mortality are not yet available. Future studies with adequate randomization and follow-up to assess adverse clinical endpoints are needed to determine the optimal management and follow-up of patients with MACS.
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Affiliation(s)
- Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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21
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Cambos S, Chanson P, Tabarin A. Analysis of steroid profiles by mass spectrometry: A new tool for exploring adrenal tumors? ANNALES D'ENDOCRINOLOGIE 2020; 82:36-42. [PMID: 33278379 DOI: 10.1016/j.ando.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The assay of multiple steroids by mass spectrometry coupled with chromatography, combined with data analysis using an artificial intelligence approach, has become more widely accessible in recent years. Multiple applications for this technology exist for the study of adrenocortical tumors. Taking advantage of the capacity of malignant cortical tumor secretion of non-bioactive precursors, it provides an additional diagnostic approach that can point to the nature of a tumor. These encouraging perspectives have been based to date only on pilot retrospective studies. However, this has changed in 2020 with the publication of data from the EURINE-ACT study. This very large prospective European study provided more nuanced evidence for the benefit of combining the measurement of a panel of steroids with essential imaging tools. This study also facilitated our understanding and provided more precise characterisation of autonomous steroid secretion, particularly in the case of sublinical cortisol-secreting adrenocortical adenomas. This article will focus on our current knowledge on the potential utility of mass spectrometry for diagnosis of both the nature of an adrenal tumors and their secretion.
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Affiliation(s)
- Sophie Cambos
- Service d'Endocrinologie, Diabétologie et Maladies Métaboliques, CHU de Bordeaux, Hôpital Haut Lévêque, 33600 Pessac, France.
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Le Kremlin-Bicêtre, France
| | - Antoine Tabarin
- Service d'Endocrinologie, Diabétologie et Maladies Métaboliques, CHU de Bordeaux, Hôpital Haut Lévêque, 33600 Pessac, France; Inserm U1215, Neurocentre Magendie, Université de Bordeaux, 146, Rue Leo-Saignat, 33076 Bordeaux Cedex, France
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22
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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23
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Akbulut S, Erten O, Kahramangil B, Gokceimam M, Kim YS, Li P, Remer EM, Berber E. A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas. Ann Surg Oncol 2020; 28:2756-2762. [PMID: 33210268 DOI: 10.1245/s10434-020-09329-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/22/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Contrast-enhanced computed tomography (CT) with washout has emerged as an option to distinguish lipid-poor adenomas from non-adenomas. OBJECTIVE The aim of this study was to assess the utility of CT washout in characterizing indeterminate lipid-poor adrenal incidentalomas. METHODS From an Institutional Review Board-approved database, patients with adrenal incidentalomas who had adrenal protocol CT scans with a 15-min washout between 2003 and 2019 were identified. Non-contrast CT attenuation and washout patterns of different tumor types were compared. RESULTS Overall, 156 patients with 175 adrenal lesions were included. Average tumor size was 3.0 cm, non-contrast CT density was 24.7 Hounsfield units (HU), and absolute washout was 52.6%. In 102 lesions (58.3%), CT washout was ≥ 60%; 94 (92.2%) of these were benign adrenocortical adenomas, 7 (6.9%) were pheochromocytomas, and 1 (0.9%) was an adrenal hematoma. Furthermore, in 73 tumors (41.7%), CT washout was < 60%; diagnosis was benign adrenocortical adenoma in 45 (61.6%) lesions, pheochromocytoma in 8 (11%) lesions, metastasis in 9 (12.3%) lesions, adrenocortical cancer in 6 (8.2%) lesions, and 'others' in 5 (6.9%) lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of > 60% absolute CT washout for detecting an adrenal adenoma was 67.6%, 77.8%, 92.2%, 38.4%, and 69.7%, respectively. CONCLUSION CT washout should be incorporated into the management algorithm of indeterminate adrenal incidentalomas with a high non-contrast CT attenuation to 'rule-in' benign tumors. For small tumors with mild elevation of plasma metanephrines, it should be kept in mind that adenomas and pheochromocytomas may have similar imaging and washout characteristics.
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Affiliation(s)
- Serkan Akbulut
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Ozgun Erten
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Bora Kahramangil
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Mehmet Gokceimam
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Yoo Seok Kim
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Pengpeng Li
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA
| | - Erick M Remer
- Imaging Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA.
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Vassiliadi DA, Partsalaki E, Tsagarakis S. Approach to patients with bilateral adrenal incidentalomas. Curr Opin Endocrinol Diabetes Obes 2020; 27:125-131. [PMID: 32209820 DOI: 10.1097/med.0000000000000536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW The current review provides a summary on the most recent developments regarding the cause, work-up and management of bilateral adrenal incidentalomas (BAI). RECENT FINDINGS The recent ENS@T/ESE guidelines provide comprehensive directions on the evaluation and management of patients with adrenal incidentalomas with special focus on those with bilateral tumours. Intraadrenal ACTH synthesis that may locally stimulate cortisol secretion challenging the traditionally used term 'ACTH-independent'. Inactivating mutations of a new tumour suppressor gene, armadillo repeat containing 5 (ARMC5), are implicated in a number of patients, especially those with multiple macronodules (bilateral macronodular hyperplasia) and evidence of hypercortisolism. Loss-of-function mutations of the glucocorticoid receptor gene (NR3C1) consist a new possible genetic cause of BAIs. Regarding management an increasing number of studies provide data on the benefits and safety of unilateral rather than bilateral adrenalectomy. There is also emerging data on the beneficial use of steroidogenesis inhibitors in a dosing schedule that aims to mimic the normal cortisol rhythm with promising short-term results, but the long-term clinical benefits of this approach remain to be demonstrated. SUMMARY The diagnostic approach consists of imaging and hormonal evaluation. Imaging characterization should be done separately for each lesion. Hormonal evaluation includes testing for primary aldosteronism, pheochromocytoma and evaluation for autonomous cortisol secretion, using the 1-mg overnight dexamethasone suppression test. Midnight cortisol or 24-h urinary-free cortisol may aid in establishing the degree of cortisol excess. In patients with hypercortisolism ACTH levels should be measured to establish ACTH-independency. The appropriate management of BAI associated with cortisol excess remains controversial. Bilateral adrenalectomy results in lifetime steroid dependency and is better reserved only for patients with overt and severe hypercortisolism. Unilateral adrenalectomy might be considered in selected patients. Medical therapy is not an established approach yet but it may be considered when control of hypercortisolism is desired, but surgery is not an option.
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Affiliation(s)
- Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes, and Metabolism, National Expertise Center for Rare Endocrine Disorders, Evangelismos Hospital, Athens, Greece
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Abstract
The European society of endocrinology, in association with the European network for the study of adrenal tumors, published recommendations for the diagnosis and treatment of adrenal incidentalomas in 2016. A thorough and critical analysis of the literature was performed to establish evidence-based recommendations and expert suggestions with the aim of avoiding 'over-diagnosis' and 'over-treatment' and to reduce unnecessary investigations, surgery and follow-up. The purpose of this review is to reconsider several recommendations that are open to debate, such as imaging of adrenal incidentalomas, diagnosis of pheochromocytoma, diagnosis and treatment of autonomous cortisol-secreting tumors, investigations of bilateral AI and follow-up of non-operated AIs, based on studies published after the release of the recommendations.
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Affiliation(s)
- Sophie Cambos
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France; Inserm U1215, Neurocentre Magendie, University of Bordeaux, 146 Rue Leo Saignat, 33076 Bordeaux Cedex, France.
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26
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Gruber LM, Strajina V, Bancos I, Murad MH, Dy BM, Young WF, Farley DR, Lyden ML, Thompson GB, McKenzie TJ. Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis. Gland Surg 2020; 9:362-371. [PMID: 32420260 DOI: 10.21037/gs.2020.03.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma. Methods We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU). Results In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I2=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU. Conclusions Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Veljko Strajina
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - William F Young
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Melanie L Lyden
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Geoffrey B Thompson
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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27
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Buitenwerf E, Berends AMA, van Asselt ADI, Korteweg T, Greuter MJW, Veeger NJM, Links TP, Dullaart RPF, Kerstens MN. Diagnostic Accuracy of Computed Tomography to Exclude Pheochromocytoma: A Systematic Review, Meta-analysis, and Cost Analysis. Mayo Clin Proc 2019; 94:2040-2052. [PMID: 31515105 DOI: 10.1016/j.mayocp.2019.03.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the diagnostic accuracy of unenhanced computed tomography (CT) attenuation values to exclude a pheochromocytoma in the diagnostic work-up of patients with an adrenal incidentaloma and to model the associated difference in diagnostic costs. METHODS The MEDLINE and Embase databases were searched from indexing to September 27, 2018, and studies reporting the proportion of pheochromocytomas on either side of the 10-Hounsfield unit (HU) threshold on unenhanced CT were included. The pooled proportion of pheochromocytomas with an attenuation value greater than 10 HU was determined, as were the modeled financial costs of the current and alternative diagnostic approaches. RESULTS Of 2957 studies identified, 31 were included (N=1167 pheochromocytomas). Overall risk of bias was low. Heterogeneity was not observed between studies (Q=11.5, P=.99, I2=0%). The pooled proportion of patients with attenuation values greater than 10 HU was 0.990 (95% CI, 0.984-0.995). The modeled financial costs using the new diagnostic approach were €55 (∼$63) lower per patient. CONCLUSION Pheochromocytomas can be reliably ruled out in the case of an adrenal lesion with an unenhanced CT attenuation value of 10 HU or less. Therefore, determination of metanephrine levels can be restricted to adrenal tumors with an unenhanced CT attenuation value greater than 10 HU. Implementing this novel diagnostic strategy is cost-saving.
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Affiliation(s)
- Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Annika M A Berends
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Antoinette D I van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tijmen Korteweg
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel J W Greuter
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nic J M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
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28
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Fassnacht M, Dekkers O, Else T, Baudin E, Berruti A, de Krijger R, Haak H, Mihai R, Assie G, Terzolo M. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2018; 179:G1-G46. [PMID: 30299884 DOI: 10.1530/eje-18-0608] [Citation(s) in RCA: 463] [Impact Index Per Article: 77.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.
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Affiliation(s)
- Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Olaf Dekkers
- Department of Clinical Epidemiology
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Baudin
- Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France
- INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pathology, Reinier de Graaf Hospital, Delft, the Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Harm Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guillaume Assie
- Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Reference Center dor Rare Adrenal Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Institut Cochin, Institut National de la Santé et de la Recherche Médicale U1016, Centre National de la Recherche Scientifique UMR8104, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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29
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Hao M, Lopez D, Luque-Fernandez MA, Cote K, Newfield J, Connors M, Vaidya A. The Lateralizing Asymmetry of Adrenal Adenomas. J Endocr Soc 2018; 2:374-385. [PMID: 29644340 PMCID: PMC5887332 DOI: 10.1210/js.2018-00034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/13/2018] [Indexed: 12/18/2022] Open
Abstract
CONTEXT It is presumed that the incidence of adrenal adenomas is symmetric between the left and right adrenal gland; however, anecdotal observations suggest a potential lateralizing asymmetry. OBJECTIVE To investigate the symmetry in detection of adrenal adenomas and relevance to patient care. DESIGN Cross-sectional and longitudinal studies. POPULATION AND SETTING One thousand three hundred seventy-six patients with abdominal computed tomography or magnetic resonance imaging demonstrating benign-appearing adrenal adenomas. MAIN OUTCOME Location and size of adrenal adenomas. RESULTS Left-sided adenomas were discovered in 65% of patients, right-sided in 21%, and bilateral adenomas in 14%. Among unilateral adenomas, 75% were left-sided. Left-sided adenomas were more prevalent than right-sided adenomas in each size category except the largest: <10 mm, 87%; 10 to 19 mm, 74%; 20 to 29 mm, 72%; ≥30 mm, 56% (P < 0.0001 for each category, except P = 0.19 when ≥30 mm). Among those with bilateral adenomas, the left-sided adenoma was significantly larger than the right one in 61% of patients (P < 0.001). There were no significant differences in the baseline prevalence or incidence of cardiometabolic diseases between patients with left-sided vs right-sided adenomas during 5.10 (4.2) years of follow-up. CONCLUSIONS Adrenal adenomas are substantially more likely to be identified on the left adrenal than the right. This observation may be due to detection bias attributed to the location of the right adrenal, which may preclude identification of right-sided adenomas until they are substantially larger. These findings suggest the potential for an underrecognition of right-sided adenomas that may also impair the accurate detection of bilateral adrenal diseases.
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Affiliation(s)
- Meng Hao
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Diana Lopez
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Miguel Angel Luque-Fernandez
- Harvard School of Public Health, Boston, Massachusetts
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kathryn Cote
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica Newfield
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Molly Connors
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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