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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.]] | 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== | ==Diagnostic Criteria== | ||
* | *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> | ||
* The diagnostic approach in patients with adrenal incidentalomas | *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> | ||
** Whether the lesion is [[malignant]], or | |||
** Whether it is [[Hormone|hormonally]] active. | *The diagnostic approach in patients with adrenal incidentalomas depends on two important questions: | ||
* 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.]] | **Whether the lesion is [[malignant]], or | ||
* 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. | **Whether it is [[Hormone|hormonally]] active. | ||
* All patients | *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.]] | ||
* Annual [[biochemical]] follow-up of most patients with an adrenal incidentaloma ( | *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. | ||
* 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. | *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.]] | ||
* [[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. | *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}} | ||
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{{familytree/end}} | {{familytree/end}} | ||
<small>HU;Hounsfield unit. </small> | <small>HU;Hounsfield unit. </small> | ||
<br /> | |||
== 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 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-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 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-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-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 | |||
==References== | ==References== | ||
Revision as of 06:21, 9 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
- There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society.[1]
- 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:
- Whether the lesion is malignant, or
- Whether it is hormonally active.
- 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 | Nonfunctional | Surgical 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.
Assessment for Cancer
- An adrenal incidentaloma can be a primary malignant tumor that arises from the adrenal cortex (adrenocortical carcinoma) or medulla (pheochromocytoma), or can be metastatic tumor in rare occasions from lung cancer, renal cell carcinoma, 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[3]
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
References
- ↑ 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.
- ↑ 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.
- ↑ Kebebew E (2021). "Adrenal Incidentaloma". N Engl J Med. 384 (16): 1542–1551. doi:10.1056/NEJMcp2031112. PMID 33882207 Check
|pmid=value (help).