Diagnostic evaluation of the adrenal incidentaloma: decision and cost-effectiveness analyses.

UNLABELLED: The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses. METHODS: We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data. RESULTS: At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities. CONCLUSION: Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.

Implications of unsuspected pulmonary embolism detected by computed tomography.

OBJECTIVE: To describe the computed tomography (CT) findings and clinical implications of pulmonary thromboembolism noted incidentally on CT. PATIENTS AND METHODS: The authors reviewed the CT studies and medical records for nine patients in whom CT had shown clinically unsuspected pulmonary thromboembolism. The study group consisted of seven men and two women ranging in age from 51 to 75 years, who were referred for CT over a 5-year period for a variety of indications. The location of the emboli and the presence and location of parenchymal and pleural abnormalities were determined. Subsequent changes in patient care were analysed. RESULTS: The locations of the thromboemboli were described according to pulmonary zone. One case involved zone 1 (main pulmonary artery to a lung), all involved zone 2 (first-order branches), and four involved extension into zone 3 (second-order branches). No emboli were distinguished in zone 4 (beyond the segmental arteries). Four patients had pleural-based opacities characteristic of infarcts, and three had pleural effusions. Eight patients underwent confirmatory testing. A vena cava filter was placed in three patients, one of whom also received anticoagulation therapy. The other six patients were treated by anticoagulation alone. All of the patients survived and were discharged. CONCLUSION: Radiologists should watch carefully for occult pulmonary thromboembolism when interpreting CT studies of the thorax. Establishing this diagnosis can result in immediate changes to treatment and possibly a reduction in the substantial morbidity and mortality associated with untreated pulmonary emboli.

Cutaneous T-cell lymphoma: CT in evaluation and staging.

Among 63 patients with cutaneous T-cell lymphoma (CTCL), 29% (n = 18) had positive computed tomographic (CT) findings, with frequencies of 65% (n = 13) among patients thought to have stages II-IV disease at clinical examination and 12% (n = 5) among patients thought to have stage I. Among eight patients with atypical CTCL variants such as cutaneous large-cell lymphoma, only one had negative findings at CT; extracutaneous disease was not suspected in five before they underwent CT. In contrast, CT findings were positive in only 5% (n = 2) of patients with classic early mycosis fungoides-type CTCL (scaling patches, small epidermotropic CD4+ cells), and CT is unlikely to provide substantial information in this patient subgroup. Contrary to earlier reports, the authors' data suggest that body CT is extremely useful in staging and evaluating patients with CTCL. CT should be included in the evaluation of atypical CTCL variants, Sézary syndrome, advanced-stage mycosis fungoides, and cases in which the CTCL subtype is unclear.

Milk of calcium renal cyst: CT findings.

Milk of calcium in the kidney is usually found in association with hydronephrosis or caliceal diverticula. A case of milk of calcium in a renal cyst is presented. Contiguity with an adjacent rib can make it difficult to detect the dependent layered milk of calcium.

Renal trauma and retroperitoneal hematomas-indications for exploration.

One hundred nineteen patients with renal trauma documented at laparotomy or by an abnormal excretory urogram were followed up sufficiently to allow assessment of their postinjury course. One-fourth of these patients had a laparotomy and Gerota's fascia was opened; one-fourth had a laparotomy and Gerota's fascia was not opened; and one-half had no laparotomy. Gerota's fascia was opened only after vascular control of the renal pedicle was obtained. Nonetheless, the loss of renal tissue in this group was high. Twenty-three of 34 patients (68%) required nephrectomy or partial nephrectomy, indicating the severity of their renal injuries. The loss of renal tissue was low in the two groups in which Gerota's fascia was not opened. Six of 85 patients (7%) developed complications eventually requiring nephrectomy or partial nephrectomy; an additional three patients (4%) demonstrated loss of renal tissue on followup urograms, the loss being minimal in all three cases. The relatively low morbidity in these 85 patients indicates that their original renal injuries were, for the most part, less serious than the injuries in the group in which Gerota's fascia was opened. This low morbidity also indicates that retroperitoneal hematomas in the area of the kidney which are nonexpanding, contained, and nonpulsatile need not be routinely explored.