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{{Incidentaloma}}
{{Incidentaloma}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{MAD}}
==Overview==
==Overview==
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the [[mass]] according to Endocrine Society. Radiological evaluation including noncontrast [[Computed tomography|CT]] attenuation value expressed in [[Hounsfield units|Hounsfield unit]] (HU) is the best tool to differentiate between [[benign]] and [[malignant]] [[Adrenal mass causes|adrenal masses.]] All patients should undergo [[hormonal]] evaluation for subclinical [[Cushing's syndrome]] and [[pheochromocytoma]], and those with [[hypertension]] should also be evaluated for primary [[Hyperaldosteronism|hyperaldosteronism.]]
 
==Diagnostic Criteria==
OR
 
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
 
OR


The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
*There are no definitive [[diagnostic criteria]] for [[adrenal incidentaloma]] management but there are guidelines to diagnose and treat the [[mass]] according to Endocrine Society.<ref name="pmid27390021">{{cite journal| author=Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A et al.| title=Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. | journal=Eur J Endocrinol | year= 2016 | volume= 175 | issue= 2 | pages= G1-G34 | pmid=27390021 | doi=10.1530/EJE-16-0467 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27390021  }}</ref>


OR
*The guidelines recommend urgent assessment of [[Adrenal mass causes|adrenal mass]] in children, adolescents, pregnant females, and adults younger than 40 years of age because of a higher likelihood of [[malignancy]].<ref name="pmid28181818">{{cite journal| author=Sahdev A| title=Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists? | journal=Br J Radiol | year= 2017 | volume= 90 | issue= 1072 | pages= 20160627 | pmid=28181818 | doi=10.1259/bjr.20160627 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28181818  }}</ref>


There are no established criteria for the diagnosis of [disease name].
*The diagnostic approach in patients with adrenal incidentalomas depends on two important questions:
==Diagnostic Criteria==
**Whether the lesion is [[malignant]], or
**Whether it is [[Hormone|hormonally]] active.
*Radiological evaluation including noncontrast [[Computed tomography|CT]] attenuation value expressed in [[Hounsfield units|Hounsfield unit]] (HU) is the best tool to differentiate between [[benign]] and [[malignant]] [[Adrenal mass causes|adrenal masses.]]
*All [[Adrenal tumor|adrenal tumors]] with suspicious radiological features, most functional [[tumors]], and all tumors more than 4 cm in size with [[malignant]] radiological features should be removed surgically.
*All patients have to perform [[hormonal]] evaluation for subclinical [[Cushing's syndrome]] and [[pheochromocytoma]], and those with [[hypertension]] should also be evaluated for primary [[Hyperaldosteronism|hyperaldosteronism.]]
*Annual [[biochemical]] follow-up of most patients with an adrenal incidentaloma (particularly if the [[tumor]] is more than 3 cm in size) for up to 5 years is sufficient.
*Patients with [[Adrenal mass causes|adrenal masses]] less than 4 cm in size and a non-contrast attenuation value greater than 10 [[Hounsfield units|HU]] should have a repeat [[Computed tomography|CT]] study in 3–6 months and then yearly for 2 years.
*[[Adrenal tumor|Adrenal tumors]] with indeterminate radiological features that grow at least 0.8 cm over 3–12 months should be considered for surgical resection once other imaging and clinical characteristics have been taken into consideration.
{{familytree/start |summary=}}
{{familytree/start |summary=}}
{{familytree |||| | | | | A01 |A01=Adrenal mass}}  
{{familytree |||| | | | | A01 |A01=Adrenal mass}}  
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=CT attenuation value< 10HU|B02=CT attenuation value> 10HU}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=CT attenuation value< 10HU*|B02=CT attenuation value> 10HU}}
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{{familytree | | |!| | | |!| | | |,|-|^|.| | | | |!| }}
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{{familytree | | D02 | | D01 | | D03| |D04||D05|D01=Surgical removal|D02=Yearly hormonal evlauation for up to 5 years|D03=Functional|D04=Nonfunctional|D05=Surgical removal}}
{{familytree | |!| | | | | | | | | |!| | |!| }}
{{familytree | | | | | | | | | | | |!| | |!| }}
{{familytree | E01 | | | | | | | | E03| |E02|E01=E01|E02=Calculate enhancement washout within 15 minutes|E03=surgical removal}}
{{familytree | | | | | | | | | | E03| |E02|E01=E01|E02=Calculate enhancement washout within 15 minutes|E03=surgical removal}}
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{{familytree | | | | | | | | | | | | |,|-|^|.| }}
{{familytree | | | | | | | | | | | | F01| |F02 |F01=<60%|F02=>60%}}
{{familytree | | | | | | | | | | | | F01| |F02 |F01=<60%|F02=>60%}}
{{familytree | | | | | | | | | | | | |!|| |,|-|^|||.|}}
{{familytree | | | | | | | | | | | | |!|| |,|-|^|-|-|.|}}
{{familytree | | | | | | | | | | | | G03| |G01||G02|G01=No change in size in 12 months|G02=>0.8 increase in size in 12 months|G03=Surgical removal}}
{{familytree | | | | | | | | | | | | G03| |G01| |G02|G01=No change in size in 12 months|G02=> 0.8cm increase in size in 12 months|G03=Surgical removal}}
{{familytree | | | | | | | | | | | | |!|| |}}
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{{familytree | | | | | | | | | | | | H01| |H01=Follow up CT image for two years}}
{{familytree | | | | | | | | | | | | H01| |H01=Follow up CT image for two years}}
{{familytree/end}}
{{familytree/end}}
<small>HU;Hounsfield unit. </small>
<br />
*Comprehensive [[history taking]] and [[physical examination]] is important to assess for features of [[hormonal]] [[hypersecretion]] followed by [[imaging]] and hormonal [[Evaluation of a bone tumor|evaluation]].
*There are two possibilities that can be found on imaging (tumor size and attenuation on unenhanced CT Additional imaging like enhanced CT, MRI, 18F-FDG PET-CT); benign features (tumor <4 cm in diameter, less than10 Hounsfield units on CT, CT contrast washout more than 40–60%, signal loss on MRI chemical-shift analysis, on 18F-FDG PET-CT, SUVmax <5 or adrenal-to-spleen or adrenal-to liver signal-intensity ratio <1), or suspicious features (Tumor more than 3 cm in diameter, >10 Hounsfield units on CT, CT contrast washout <40–60%, on MRI, hyperintense on T2 imaging or no signal loss on chemical-shift analysis, on 18F-FDG PET-CT, SUVmax more than 4 or adrenal-to-spleen or adrenal-to liver signal-intensity ratio equal or more than 1).
*In case of [[benign]] features, no further follow-up imaging needed unless symptoms or signs indicating hormone excess develop. On the other hand, in case of suspicious features, consider [[adrenalectomy]], and consider biopsy if metastasis is suspected and confirmation would change treatment plan. If [[adrenalectomy]] not performed, consider follow-up imaging in 6 months to 1 year.
*Hormonal evaluation using overnight 1-mg [[dexamethasone]] [[Suppression (eye)|suppression]] test, measurement of [[Plasma (blood)|plasma]]-free [[metanephrine]] level or fractionated [[metanephrine]] level in 24-hr [[urinary specimen]]. If hypertension or [[hypokalemia]] present, measurement of plasma [[aldosterone]] concentration and plasma [[renin]] activity.
*If the [[Hormone|hormonal]] [[Evaluation and Infection Therapy Thrombolysis In Myocardial Infarction|evaluation]] turned out to be negative, no further [[follow-up]] after hormonal evaluation unless [[Symptom|symptoms]] or [[signs]] indicating [[hormonal]] excess develop. However, if it is positive, confirmatory testing for mild [[Autonomous agent|autonomous]] [[cortisol]] excess and [[primary hyperaldosteronism]]. Positive results indicate the need for [[adrenalectomy]] for pheochromocytoma after [[alpha-blockade]] (and after beta-blockade, if necessary) and consider [[adrenalectomy]] for [[Autonomous agent|autonomous]] [[cortisol]] hypersecretion and [[primary hyperaldosteronism]].
*[[Nonfunctioning adenoma|Nonfunctioning]] [[Adrenal incidentaloma|adrenal incidentalomas]] with features that are suggestive of an [[adenoma]] on [[imaging]] (attenuation ≤10 HU on [[Computed tomography|CT]]) and their size is less than 4 cm in diameter are often [[benign]] and do not require additional [[follow-up]] [[imaging]].<ref name="pmid31234202">{{cite journal| author=Elhassan YS, Alahdab F, Prete A, Delivanis DA, Khanna A, Prokop L | display-authors=etal| title=Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis. | journal=Ann Intern Med | year= 2019 | volume= 171 | issue= 2 | pages= 107-116 | pmid=31234202 | doi=10.7326/M18-3630 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31234202  }}</ref>
==Assessment for Cancer==
*An [[adrenal incidentaloma]] can be a [[Primary central nervous system lymphoma|primary]] [[malignant]] tumor that arises from the [[adrenal cortex]] ([[adrenocortical carcinoma]]) or [[medulla]] ([[pheochromocytoma]]), or can be [[Metastasis|metastatic]] tumor in rare occasions from [[lung cancer]], [[renal cell carcinoma]], [[Gastrointestinal tract cancer|gastrointestinal cancer]], or [[melanoma]].  Imaging features and tumor size are essential for determining the probability of [[malignancy]] and also guiding treatment.
*Presence of irregular tumor margins, hemorrhage and necrosis, heterogeneity, increased vascularity, and calcification on imaging suggest cancer.
===Imaging Features of Adrenal Incidentaloma<ref name="pmid33882207">{{cite journal| author=Kebebew E| title=Adrenal Incidentaloma. | journal=N Engl J Med | year= 2021 | volume= 384 | issue= 16 | pages= 1542-1551 | pmid=33882207 | doi=10.1056/NEJMcp2031112 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33882207  }}</ref>===
====Adrenocortical Adenoma====
*Small size, less than 4 cm in diameter
*Smooth margin
*Homogenous consistency
*Usually unilateral but can be bilateral in 15% of cases
*Unenhanced [[CT-scans|CT]] attenuation: less than 10 HU
*[[Contrast-enhanced ultrasound|Contrast-enhanced]] [[Computed tomography|CT]] features: low attenuation, low [[vascularity]], and fast washout
*[[MRI]] features: isointense in relation to liver on T2-weighted image and signal drop on chemical-shift imaging
*18F-[[Fluorodeoxyglucose|FDG]] [[PET scan|PET]]-[[CT-scans|CT]] features: not avid, SUVmax less than 5, adrenal to spleen or adrenal to liver signal intensity ratio less than 1, and absent [[hemorrhage]], [[necrosis]] and [[calcification]]
====Pheochromocytoma====
*Large size
*Smooth margin
*Heterogenous consistency
*Usually unilateral but can be bilateral
*Unenhanced [[Computed tomography|CT]] attenuation: more than 10 HU
*[[Contrast-enhanced ultrasound|Contrast-enhanced]] [[CT-scans|CT]] features: high attenuation, high [[vascularity]], and slow [[washout]]
*[[Magnetic resonance imaging|MRI]] features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
*18F-[[Fluorodeoxyglucose|FDG]] [[PET scan|PET]]-[[CT]] features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and [[hemorrhage]], [[necrosis]] and [[calcification]]
====Adrenocortical Carcinoma====
*Large size, more than 6 cm
*Irregular margin
*Heterogenous consistency
*Usually [[Unilateral adrenal hyperplasia|unilateral]]
*Unenhanced CT attenuation: more than 10 HU
*[[Contrast-enhanced ultrasound|Contrast-enhanced]] [[CT-scans|CT]] features: high attenuation, high [[vascularity]], and slow washout
*[[Magnetic resonance imaging|MRI]] features: markedly hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
*18F-[[FDG]] [[PET scan|PET]]-[[CT-scans|CT]] features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and [[hemorrhage]], [[necrosis]] and [[calcification]]
====Metastasis====
*Variable size
*Irregular margin
*[[Heterogenous]] consistency
*Usually [[Unilateral adrenal hyperplasia|unilateral]] but can be bilateral
*Unenhanced [[Computed tomography|CT]] attenuation: more than 10 HU
*[[Contrast-enhanced ultrasound|Contrast-enhanced]] [[CT-scans|CT]] features: high attenuation, high [[vascularity]], and slow washout
*[[Magnetic resonance imaging|MRI]] features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
*[[18F]]-[[Fluorodeoxyglucose|FDG]] [[PET scan|PET]]-[[CT-scans|CT]] features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and [[hemorrhage]], [[necrosis]] and [[calcification]] in large tumors
<br />
==Assessment of Bilateral Adrenal Masses==
*The differential diagnosis of bilateral adrenal masses include bilateral [[macronodular]] [[adrenal hyperplasia]] or [[Adenoma|adenomas]], [[congenital adrenal hyperplasia]], bilateral [[pheochromocytoma]], bilateral [[Adrenal tumor|adrenal]] [[hyperplasia]], [[Metastasis|metastases]], partial [[glucocorticoid]] [[Drug resistance|resistance]], [[Myelolipoma|myelolipomas]], [[hemorrhage]], and [[infection]].
*[[Hormone|Hormonal]] assessments as mentioned in [[solitary]] [[adrenal incidentaloma]].
*Measurement of the serum [[17-Hydroxyprogesterone|17-hydroxyprogesterone]] level to exclude [[congenital adrenal hyperplasia]].
*If the imaging of bilateral adrenal masses shows [[hemorrhagic]] or [[Infiltrative and Metabolic Diseases Affecting the Liver|infiltrative]] features, testing for [[adrenal insufficiency]] should be performed.


<br />
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 05:10, 10 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society. Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses. All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.

Diagnostic Criteria

  • The guidelines recommend urgent assessment of adrenal mass in children, adolescents, pregnant females, and adults younger than 40 years of age because of a higher likelihood of malignancy.[2]
  • The diagnostic approach in patients with adrenal incidentalomas depends on two important questions:
  • Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses.
  • All adrenal tumors with suspicious radiological features, most functional tumors, and all tumors more than 4 cm in size with malignant radiological features should be removed surgically.
  • All patients have to perform hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.
  • Annual biochemical follow-up of most patients with an adrenal incidentaloma (particularly if the tumor is more than 3 cm in size) for up to 5 years is sufficient.
  • Patients with adrenal masses less than 4 cm in size and a non-contrast attenuation value greater than 10 HU should have a repeat CT study in 3–6 months and then yearly for 2 years.
  • Adrenal tumors with indeterminate radiological features that grow at least 0.8 cm over 3–12 months should be considered for surgical resection once other imaging and clinical characteristics have been taken into consideration.
 
 
 
 
Adrenal mass
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT attenuation value< 10HU*
 
 
 
 
 
 
 
CT attenuation value> 10HU
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nonfunctional
 
Functional
 
 
 
 
< 4cm
 
 
> 4cm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yearly hormonal evlauation for up to 5 years
 
Surgical removal
 
Functional
 
NonfunctionalSurgical removal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
surgical removal
 
Calculate enhancement washout within 15 minutes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<60%
 
>60%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical removal
 
No change in size in 12 months
 
> 0.8cm increase in size in 12 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up CT image for two years
 

HU;Hounsfield unit.


  • Comprehensive history taking and physical examination is important to assess for features of hormonal hypersecretion followed by imaging and hormonal evaluation.
  • There are two possibilities that can be found on imaging (tumor size and attenuation on unenhanced CT Additional imaging like enhanced CT, MRI, 18F-FDG PET-CT); benign features (tumor <4 cm in diameter, less than10 Hounsfield units on CT, CT contrast washout more than 40–60%, signal loss on MRI chemical-shift analysis, on 18F-FDG PET-CT, SUVmax <5 or adrenal-to-spleen or adrenal-to liver signal-intensity ratio <1), or suspicious features (Tumor more than 3 cm in diameter, >10 Hounsfield units on CT, CT contrast washout <40–60%, on MRI, hyperintense on T2 imaging or no signal loss on chemical-shift analysis, on 18F-FDG PET-CT, SUVmax more than 4 or adrenal-to-spleen or adrenal-to liver signal-intensity ratio equal or more than 1).
  • In case of benign features, no further follow-up imaging needed unless symptoms or signs indicating hormone excess develop. On the other hand, in case of suspicious features, consider adrenalectomy, and consider biopsy if metastasis is suspected and confirmation would change treatment plan. If adrenalectomy not performed, consider follow-up imaging in 6 months to 1 year.
  • Hormonal evaluation using overnight 1-mg dexamethasone suppression test, measurement of plasma-free metanephrine level or fractionated metanephrine level in 24-hr urinary specimen. If hypertension or hypokalemia present, measurement of plasma aldosterone concentration and plasma renin activity.
  • If the hormonal evaluation turned out to be negative, no further follow-up after hormonal evaluation unless symptoms or signs indicating hormonal excess develop. However, if it is positive, confirmatory testing for mild autonomous cortisol excess and primary hyperaldosteronism. Positive results indicate the need for adrenalectomy for pheochromocytoma after alpha-blockade (and after beta-blockade, if necessary) and consider adrenalectomy for autonomous cortisol hypersecretion and primary hyperaldosteronism.
  • Nonfunctioning adrenal incidentalomas with features that are suggestive of an adenoma on imaging (attenuation ≤10 HU on CT) and their size is less than 4 cm in diameter are often benign and do not require additional follow-up imaging.[3]

Assessment for Cancer

Imaging Features of Adrenal Incidentaloma[4]

Adrenocortical Adenoma

  • Small size, less than 4 cm in diameter
  • Smooth margin
  • Homogenous consistency
  • Usually unilateral but can be bilateral in 15% of cases
  • Unenhanced CT attenuation: less than 10 HU
  • Contrast-enhanced CT features: low attenuation, low vascularity, and fast washout
  • MRI features: isointense in relation to liver on T2-weighted image and signal drop on chemical-shift imaging
  • 18F-FDG PET-CT features: not avid, SUVmax less than 5, adrenal to spleen or adrenal to liver signal intensity ratio less than 1, and absent hemorrhage, necrosis and calcification

Pheochromocytoma

  • Large size
  • Smooth margin
  • Heterogenous consistency
  • Usually unilateral but can be bilateral
  • Unenhanced CT attenuation: more than 10 HU
  • Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
  • MRI features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
  • 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification

Adrenocortical Carcinoma

  • Large size, more than 6 cm
  • Irregular margin
  • Heterogenous consistency
  • Usually unilateral
  • Unenhanced CT attenuation: more than 10 HU
  • Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
  • MRI features: markedly hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
  • 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification

Metastasis

  • Variable size
  • Irregular margin
  • Heterogenous consistency
  • Usually unilateral but can be bilateral
  • Unenhanced CT attenuation: more than 10 HU
  • Contrast-enhanced CT features: high attenuation, high vascularity, and slow washout
  • MRI features: hyperintense in relation to liver on T2-weighted image and no signal drop on chemical-shift imaging
  • 18F-FDG PET-CT features: avid, SUVmax more than 5, adrenal to spleen or adrenal to liver signal intensity ratio is equal or more than than 1-1.5, and hemorrhage, necrosis and calcification in large tumors


Assessment of Bilateral Adrenal Masses


References

  1. Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A; et al. (2016). "Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors". Eur J Endocrinol. 175 (2): G1–G34. doi:10.1530/EJE-16-0467. PMID 27390021.
  2. Sahdev A (2017). "Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists?". Br J Radiol. 90 (1072): 20160627. doi:10.1259/bjr.20160627. PMID 28181818.
  3. Elhassan YS, Alahdab F, Prete A, Delivanis DA, Khanna A, Prokop L; et al. (2019). "Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis". Ann Intern Med. 171 (2): 107–116. doi:10.7326/M18-3630. PMID 31234202.
  4. Kebebew E (2021). "Adrenal Incidentaloma". N Engl J Med. 384 (16): 1542–1551. doi:10.1056/NEJMcp2031112. PMID 33882207 Check |pmid= value (help).

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