Incidentaloma CT scan: Difference between revisions
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{{Incidentaloma}} | {{Incidentaloma}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}} {{MAD}} | ||
==Overview== | |||
Abdominal CT scan may be helpful in the diagnosis of [disease name]. Differentiation between [[benign]] and [[malignant]] incidentaloma is important. [[Malignancy]] is suggested on [[Computed tomography|CT]] by a large diameter more than 6 cms, irregular border, inhomogeneity, a “washout” of contrast after 15 min of less than 40%, and [[Calcification|calcifications]]. [[Contrast medium|Contrast]]-enhanced washout [[Computed tomography|CT]] utilizes the unique perfusion pattern of [[adenomas]]. [[Adenomas]] take up intravenous [[Computed tomography|CT]] contrast rapidly, but also have a rapid loss of [[Contrast medium|contrast]] – a phenomenon termed ‘[[contrast]] enhancement washout’. It is assumed that [[malignant]] [[Adrenal gland|adrenal]] lesions usually enhance rapidly but demonstrate a slower washout of [[Contrast medium|contrast]] medium. | |||
== | ==CT scan== | ||
* On a [[Computed tomography|CT scan]], differentiation between [[benign]] and [[malignant]] incidentaloma is important. | |||
* [[Malignancy]] is suggested on [[Computed tomography|CT]] by below features: | |||
** Large diameter more than 6 cm, | |||
** Irregular border, | |||
** Non-homogenous, | |||
** Washout of contrast after 15 min of less than 40%, | |||
** Calcifications.<ref name="pmid19011181">{{cite journal| author=Boland GW, Blake MA, Hahn PF, Mayo-Smith WW| title=Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. | journal=Radiology | year= 2008 | volume= 249 | issue= 3 | pages= 756-75 | pmid=19011181 | doi=10.1148/radiol.2493070976 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19011181 }}</ref> | |||
* Many malignant lesions may look benign. | |||
* A large diameter is not diagnostic; only about 25% of masses larger than 4 cm were [[Adrenal gland|adrenal]] [[cancer]]. | |||
* | |||
=== The '''Hounsfield unit differentiation''' === | === The '''Hounsfield unit differentiation''' === | ||
* CT has a high | * [[Computed tomography|CT]] has a high quantitative contrast resolution, which allows assessment of tissue density by measuring [[X-ray]] absorption of tissues. | ||
* This allows calculation of tissue attenuation or tissue density values, which are measured in [[Hounsfield units]] (HU). | |||
* The '''Hounsfield | * The '''[[Hounsfield units|Hounsfield unit]] (HU)''' is a quantity commonly used in [[computed tomography]] (CT) scanning to express [[Computed tomography|CT]] numbers in a standardized and convenient form. | ||
* Hounsfield units are obtained from a linear transformation of the measured attenuation coefficients. | * Hounsfield units are obtained from a linear transformation of the measured attenuation coefficients. | ||
* The | * The intra-cytoplasmic [[fat]] in [[adenomas]] results in low attenuation on non-enhanced [[Computed tomography|CT]] in contrast to non-adenomas have higher attenuation in non-enhanced CT.<ref name="pmid20823463">{{cite journal| author=Nieman LK| title=Approach to the patient with an adrenal incidentaloma. | journal=J Clin Endocrinol Metab | year= 2010 | volume= 95 | issue= 9 | pages= 4106-13 | pmid=20823463 | doi=10.1210/jc.2010-0457 | pmc=2936073 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20823463 }}</ref> | ||
* Typical | * Typical pre-contrast [[Hounsfield units|Hounsfield unit]] (HU) values are as below measures: | ||
** [[adipose tissue]] = -20 to -150 HU | |||
** [[kidney]] = 20 to 150 HU. | |||
* If an adrenal mass measures <10 HU on | * If an [[Adrenal mass causes|adrenal mass]] measures <10 HU on un-enhanced [[Computed tomography|CT]], the likelihood that it is a [[benign]] [[adenoma]] is nearly 100 percent. | ||
* Up to 30 percent of adenomas do not contain large amounts of lipid. | * Up to 30 percent of [[adenomas]] do not contain large amounts of [[lipid]]. | ||
* A homogeneous adrenal mass with a smooth border and an attenuation value <10 HU on | * A homogeneous [[Adrenal gland|adrenal]] mass with a smooth border and an attenuation value <10 HU on un-enhanced CT is likely to be a [[benign]] [[adenoma]].<ref name="pmid12614096">{{cite journal| author=Grumbach MM, Biller BM, Braunstein GD, Campbell KK, Carney JA, Godley PA et al.| title=Management of the clinically inapparent adrenal mass ("incidentaloma"). | journal=Ann Intern Med | year= 2003 | volume= 138 | issue= 5 | pages= 424-9 | pmid=12614096 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12614096 }}</ref> | ||
* The only patients in the | * The only patients in the non-adenoma groups with a non-contrast CT HU <10 were those with [[Myelolipoma|myelo-lipomas]]. | ||
=== Contrast-enhanced washout CT === | === Contrast-enhanced washout CT === | ||
*Contrast-enhanced washout | *Contrast-enhanced washout [[Computed tomography|CT]] utilizes the unique [[perfusion]] pattern of [[adenomas]]. [[Adenomas]] take up intravenous [[Computed tomography|CT]] contrast rapidly, but also have a rapid loss of contrast – a phenomenon termed ‘[[contrast]] enhancement washout’.<ref name="pmid11110946">{{cite journal| author=Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR| title=Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. | journal=Radiology | year= 2000 | volume= 217 | issue= 3 | pages= 798-802 | pmid=11110946 | doi=10.1148/radiology.217.3.r00dc29798 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11110946 }}</ref> | ||
*It is assumed that malignant adrenal lesions usually enhance rapidly but demonstrate a slower washout of contrast medium.<ref name="pmid9577483">{{cite journal| author=Szolar DH, Kammerhuber FH| title=Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. | journal=Radiology | year= 1998 | volume= 207 | issue= 2 | pages= 369-75 | pmid=9577483 | doi=10.1148/radiology.207.2.9577483 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9577483 }}</ref> | *It is assumed that [[malignant]] [[Adrenal gland|adrenal]] lesions usually enhance rapidly but demonstrate a slower washout of contrast medium.<ref name="pmid9577483">{{cite journal| author=Szolar DH, Kammerhuber FH| title=Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. | journal=Radiology | year= 1998 | volume= 207 | issue= 2 | pages= 369-75 | pmid=9577483 | doi=10.1148/radiology.207.2.9577483 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9577483 }}</ref> | ||
* Fifteen minutes after administration of contrast, an absolute contrast medium washout of more than 40 percent was reported to be 100 percent sensitive and specific for adenoma when patients with adenomas were compared with carcinomas, pheochromocytomas, and metastases.<ref name="pmid25246052">{{cite journal| author=Song JH, Mayo-Smith WW| title=Current status of imaging for adrenal gland tumors. | journal=Surg Oncol Clin N Am | year= 2014 | volume= 23 | issue= 4 | pages= 847-61 | pmid=25246052 | doi=10.1016/j.soc.2014.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25246052 }}</ref> | * Fifteen minutes after administration of contrast, an absolute contrast medium washout of more than 40 percent was reported to be 100 percent sensitive and specific for adenoma when patients with adenomas were compared with [[carcinomas]], [[Pheochromocytoma|pheochromocytomas]], and [[metastases]].<ref name="pmid25246052">{{cite journal| author=Song JH, Mayo-Smith WW| title=Current status of imaging for adrenal gland tumors. | journal=Surg Oncol Clin N Am | year= 2014 | volume= 23 | issue= 4 | pages= 847-61 | pmid=25246052 | doi=10.1016/j.soc.2014.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25246052 }}</ref> | ||
[[File:Incidentaloma.gif|left|300px|thumb|CT without contrast showing adrenal adenoma with HU less than 10, source: Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 26]] | |||
[[File:Angiomyolipoma.gif|left|300px|thumb|CT shows cortical mass fungating from the lower pole of the left kidney, predominantly of fat density, with areas of soft tissue component and prominent vascularity within. most ommonly angiomyolipoma, source: Case courtesy of Dr Abdallah Khateeb , Radiopaedia.org, rID: 44940]] | |||
[[File:Adrenal carcinoma.gif|left|300px|thumb|MRI shows adrenal carcinoma, source: Case courtesy of Dr Natalie Yang, Radiopaedia.org, rID: 676]] | |||
<br style="clear:left"> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 00:35, 8 November 2017
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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
Abdominal CT scan may be helpful in the diagnosis of [disease name]. Differentiation between benign and malignant incidentaloma is important. Malignancy is suggested on CT by a large diameter more than 6 cms, irregular border, inhomogeneity, a “washout” of contrast after 15 min of less than 40%, and calcifications. Contrast-enhanced washout CT utilizes the unique perfusion pattern of adenomas. Adenomas take up intravenous CT contrast rapidly, but also have a rapid loss of contrast – a phenomenon termed ‘contrast enhancement washout’. It is assumed that malignant adrenal lesions usually enhance rapidly but demonstrate a slower washout of contrast medium.
CT scan
- Malignancy is suggested on CT by below features:
- Large diameter more than 6 cm,
- Irregular border,
- Non-homogenous,
- Washout of contrast after 15 min of less than 40%,
- Calcifications.[1]
- Many malignant lesions may look benign.
The Hounsfield unit differentiation
- CT has a high quantitative contrast resolution, which allows assessment of tissue density by measuring X-ray absorption of tissues.
- This allows calculation of tissue attenuation or tissue density values, which are measured in Hounsfield units (HU).
- The Hounsfield unit (HU) is a quantity commonly used in computed tomography (CT) scanning to express CT numbers in a standardized and convenient form.
- Hounsfield units are obtained from a linear transformation of the measured attenuation coefficients.
- The intra-cytoplasmic fat in adenomas results in low attenuation on non-enhanced CT in contrast to non-adenomas have higher attenuation in non-enhanced CT.[2]
- Typical pre-contrast Hounsfield unit (HU) values are as below measures:
- adipose tissue = -20 to -150 HU
- kidney = 20 to 150 HU.
- If an adrenal mass measures <10 HU on un-enhanced CT, the likelihood that it is a benign adenoma is nearly 100 percent.
- A homogeneous adrenal mass with a smooth border and an attenuation value <10 HU on un-enhanced CT is likely to be a benign adenoma.[3]
- The only patients in the non-adenoma groups with a non-contrast CT HU <10 were those with myelo-lipomas.
Contrast-enhanced washout CT
- Contrast-enhanced washout CT utilizes the unique perfusion pattern of adenomas. Adenomas take up intravenous CT contrast rapidly, but also have a rapid loss of contrast – a phenomenon termed ‘contrast enhancement washout’.[4]
- It is assumed that malignant adrenal lesions usually enhance rapidly but demonstrate a slower washout of contrast medium.[5]
- Fifteen minutes after administration of contrast, an absolute contrast medium washout of more than 40 percent was reported to be 100 percent sensitive and specific for adenoma when patients with adenomas were compared with carcinomas, pheochromocytomas, and metastases.[6]
References
- ↑ Boland GW, Blake MA, Hahn PF, Mayo-Smith WW (2008). "Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization". Radiology. 249 (3): 756–75. doi:10.1148/radiol.2493070976. PMID 19011181.
- ↑ Nieman LK (2010). "Approach to the patient with an adrenal incidentaloma". J Clin Endocrinol Metab. 95 (9): 4106–13. doi:10.1210/jc.2010-0457. PMC 2936073. PMID 20823463.
- ↑ Grumbach MM, Biller BM, Braunstein GD, Campbell KK, Carney JA, Godley PA; et al. (2003). "Management of the clinically inapparent adrenal mass ("incidentaloma")". Ann Intern Med. 138 (5): 424–9. PMID 12614096.
- ↑ Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR (2000). "Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT". Radiology. 217 (3): 798–802. doi:10.1148/radiology.217.3.r00dc29798. PMID 11110946.
- ↑ Szolar DH, Kammerhuber FH (1998). "Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT". Radiology. 207 (2): 369–75. doi:10.1148/radiology.207.2.9577483. PMID 9577483.
- ↑ Song JH, Mayo-Smith WW (2014). "Current status of imaging for adrenal gland tumors". Surg Oncol Clin N Am. 23 (4): 847–61. doi:10.1016/j.soc.2014.06.002. PMID 25246052.