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== Assessment for Cancer ==
==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.
*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.
*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> ===
===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 ====
====Adrenocortical Adenoma====


* Small size, less than 4 cm in diameter
*Small size, less than 4 cm in diameter
* Smooth margin
*Smooth margin
* Homogenous consistency
*Homogenous consistency
* Usually unilateral but can be bilateral in 15% of cases
*Usually unilateral but can be bilateral in 15% of cases
* Unenhanced CT attenuation: less than 10 HU
*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
*[[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
*[[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  
*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 ====
====Pheochromocytoma====


* Large size
*Large size
* Smooth margin
*Smooth margin
* Heterogenous consistency
*Heterogenous consistency
* Usually unilateral but can be bilateral  
*Usually unilateral but can be bilateral
* Unenhanced CT attenuation: more than 10 HU
*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]]
*[[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
*[[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  
*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 ====
====Adrenocortical Carcinoma====


* Large size, more than 6 cm
*Large size, more than 6 cm
* Irregular margin
*Irregular margin
* Heterogenous consistency
*Heterogenous consistency
* Usually [[Unilateral adrenal hyperplasia|unilateral]]
*Usually [[Unilateral adrenal hyperplasia|unilateral]]
* Unenhanced CT attenuation: more than 10 HU
*Unenhanced CT attenuation: more than 10 HU
* [[Contrast-enhanced ultrasound|Contrast-enhanced]] [[CT-scans|CT]] features: high attenuation, high [[vascularity]], and slow washout
*[[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
*[[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  
*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 ====
====Metastasis====


* Variable size
*Variable size
* Irregular margin
*Irregular margin
* [[Heterogenous]] consistency
*[[Heterogenous]] consistency
* Usually [[Unilateral adrenal hyperplasia|unilateral]] but can be bilateral  
*Usually [[Unilateral adrenal hyperplasia|unilateral]] but can be bilateral
* Unenhanced [[Computed tomography|CT]] attenuation: more than 10 HU
*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
*[[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
*[[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  
*[[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


==References==
==References==

Revision as of 06:24, 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

  • 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.


Assessment for 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

  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. ↑ 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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