The effect of mass functionality on laparoscopic adrenalectomy outcomes.

PURPOSE: This study aimed to determine the effect of adrenal mass functionality and different hormone subtypes synthesized by the adrenal masses on laparoscopic adrenalectomy (LA) outcomes. MATERIALS AND METHODS: The study included 298 patients, 154 of whom were diagnosed with nonfunctional masses. In the functional group, 33, 62, and 59 patients had Conn syndrome, Cushing's syndrome, and pheochromocytoma, respectively. The variables were analyzed between the functional and nonfunctional groups and then compared among functional masses through subgroup analysis. RESULTS: The incidence of diabetes mellitus, hypertension, and obesity, blood loss, and length of hospital stay (LOH) were significantly higher in the functional group than in the nonfunctional group. In the subgroup analysis, patients with pheochromocytoma had significantly lower body mass index but significantly higher mass size, blood loss, and LOH than the other two groups. A positive correlation was found between mass size and blood loss in patients with pheochromocytoma (p ≤ 0.001, r = 0.761). However, no significant difference in complications was found among the groups. CONCLUSIONS: In this study, patients with functional adrenal masses had higher comorbidity rates and American Society of Anesthesiologists scores. Moreover, blood loss and LOH were longer on patients with functional adrenal masses who underwent LA. Mass size, blood loss, and LOH in patients with pheochromocytoma were significantly longer than those in patients with other functional adrenal masses. Thus, mass functionality did not increase the complications.

The level of accordance between preoperative and postoperative diagnosis in patients undergoing adrenalectomy - a study of 230 consecutive cases.

Introduction: Patients are qualified for an adrenalectomy due to endocrine or oncologic reasons. Final histopathological diagnoses include a wide spectrum of more than a dozen entities. The aim of this study was to compare preoperative and postoperative diagnoses of patients undergoing adrenalectomy to determine the level of diagnostic accuracy, as well as sex and age of patients. Material and methods: A group of 214 patients (230 specimens in total) operated on in a single center was studied and their demographic and pathological data were investigated. Results: The majority of diagnoses were characterized by both high positive predictive value and sensitivity, excluding pheochromocytoma (60.0% and 67.7%, respectively) and adrenal cyst (100% and 37.5%, respectively). Patients operated on due to Cushing's syndrome were statistically significantly more often females (p = 0.009), while those with metastases (diagnosed both pre- and postoperatively) were more often males (both p = 0.001). Patients qualified due to non-functioning tumors were older than those with Cushing's or Conn's syndrome (p = 0.044 and p = 0.002, respectively). Conclusions: The lowest diagnostic accuracy is observed in cases of pheochromocytoma and adrenal cyst. Meticulous preparation of the patient for hormonal tests, including discontinuation of certain medications, is essential for obtaining accurate results. The diagnosis of Cushing's syndrome is more prevalent in females, while metastasis syndrome is more prevalent in males. Adrenocortical carcinoma may initially be diagnosed as a non-functioning tumor (1.6% of such cases) or a recurrence of a previously resected tumor, which should always raise a suspicion of a malignant neoplasm.

Dabigatran Etexilate Related Unilateral Adrenal Hemorrhage.

A 63-year-old male presented to our clinic with computed tomography data of a large tumor of the left adrenal gland. The formation is highly suspicious for malignancy with central necrosis and hemorrhage, and a total size of 197/183/201 mm. Due to elevated D-dimer values of 7.17 mg/l (reference range <0.5 mg/l), treatment with dabigatran etexilate 2x150 mg was prescribed following a cardiology consult. On the third day of therapy, the patient noticed a large swelling in the left abdominal flank, which caused discomfort. No additional symptoms were reported. No previous abdominal surgical interventions or trauma were reported. Following a thorough physical examination, the patient was referred for a computer tomography that reported a diagnosis of a tumor of the left adrenal gland. Due to the size of the neoplasm, the suspicion of malignancy, compression of adjacent structures, and significant anemia with an Hb of 112 g/L, operative treatment was chosen as the best treatment modality. The mass was reported as a large organizing adrenal hematoma with no suspicion of malignancy on histology. Following a review of available literature, no other cases of unilateral adrenal hematoma with a size of 201x197 mm, following oral anticoagulant therapy with dabigatran etexilate, without any prior surgery or trauma have been reported. Most clinical cases report bilateral adrenal hemorrhage during the postoperative period, following prophylaxis with heparin and the development of heparin-induced thrombocytopenia. The patient underwent operative treatment, after which the patient recovered normally and was discharged from the clinic without complications.

Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study.

BACKGROUND. Adrenal washout CT is not useful for evaluating incidental adrenal masses in patients without known or suspected primary extraadrenal malignancy. OBJECTIVE. The purpose of our study was to evaluate the diagnostic utility of adrenal mass biopsy in patients without known or suspected extraadrenal primary malignancy. METHODS. This retrospective six-center study included 69 patients (mean age, 56 years; 32 men, 37 women) without known or suspected extraadrenal primary malignancy who underwent image-guided core needle biopsy between January 2004 and June 2021 of a mass suspected to be arising from the adrenal gland. Biopsy results were classified as diagnostic or nondiagnostic. For masses resected after biopsy, histopathologic concordance was assessed between diagnoses from biopsy and resection. Masses were classified as benign or malignant by resection or imaging follow-up, and all nondi-agnostic biopsies were classified as false results. RESULTS. The median mass size was 7.4 cm (range, 1.9-19.2 cm). Adrenal mass biopsy had a diagnostic yield of 64% (44/69; 95% CI, 51-75%). After biopsy, 25 masses were resected, and 44 had imaging follow-up. Of the masses that were resected after diagnostic biopsy, diagnosis was concordant between biopsy and resection in 100% (12/12). Of the 13 masses that were resected after nondiagnostic biopsy, the diagnosis from re-section was benign in eight masses and malignant in five masses. The 44 masses with imaging follow-up included one mass with diagnostic biopsy yielding benign adenoma and two masses with nondiagnostic biopsy results that were classified as malignant by imaging follow-up. Biopsy had overall sensitivity and specificity for malignancy of 73% (22/30) and 54% (21/39), respectively; diagnostic biopsies had sensitivity and specificity for malignancy of 96% (22/23) and 100% (21/21), respectively. Among nine nondi-agnostic biopsies reported as adrenocortical neoplasm, six were classified as malignant by the reference standard (resection showing adrenocortical carcinoma in four, resection showing adrenocortical neoplasm of uncertain malignant potential in one, imaging follow-up consistent with malignancy in one). CONCLUSION. Adrenal mass biopsy had low diagnostic yield, with low sensitivity and low specificity for malignancy. A biopsy result of adrenocortical neoplasm did not reliably differentiate benign and malignant adrenal masses. CLINICAL IMPACT. Biopsy appears to have limited utility for the evaluation of incidental adrenal masses in patients without primary extraadrenal malignancy.

Feasibility of spectral CT-derived extracellular volume fraction for differentiating aldosterone-producing from nonfunctioning adrenal nodules.

OBJECTIVE: To assess the feasibility of spectral CT-derived extracellular volume (ECV) for differentiating aldosterone-producing nodules (APN) from nonfunctioning adrenal nodules (NFN). METHODS: Sixty-nine patients with biochemically and histologically confirmed unilateral APN (34) and NFN (35) as well as 23 patients with bilateral APN (19) and NFN (27) confirmed biochemically and by adrenal vein sampling (AVS) were enrolled in this retrospective study from October 2020 to April 2022. All patients underwent contrast-enhanced spectral CT of the adrenal glands with a 10-min delayed phase. The haematocrit level was measured within 2 days of CT. An iodine density map was derived from the delayed CT. The ECV fractions of the APN and NFN were calculated and compared in the test cohort of 69 patients with unilateral adrenal nodules. The optimal cut-off value was determined to evaluate the diagnostic efficacy of the ECV fraction for differentiating APN from NFN in the validation cohort of 23 patients with bilateral adrenal nodules. RESULTS: The ECV fractions of the APN (11.17 ± 4.57%) were significantly lower (p < 0.001) than that of the NFN (24.79 ± 6.01%) in the test cohort. At cut-off ECV value of 17.16%, the optimal area under the receiver operating characteristic curve was 0.974 (95% confidence interval: 0.942-1) with 91.4% sensitivity, 93.9% specificity, and 92.8% accuracy in the test cohort and 89.5% sensitivity, 96.3% specificity, and 93.5% accuracy in the validation cohort for differentiating APN from NFN. CONCLUSION: The spectral CT-derived ECV fraction can differentiate APN from NFN with high diagnostic performance. CLINICAL RELEVANCE STATEMENT: Spectral CT-derived extracellular volume fraction could accurately differentiate between adrenal aldosterone-producing nodules and nonfunctioning nodules. It might serve as a noninvasive alternative to adrenal vein sampling in primary aldosteronism patients with bilateral adrenal nodules. KEY POINTS: • Conventional CT cannot differentiate aldosterone-producing adrenal nodules from nonfunctioning nodules. • Extracellular volume of adrenal aldosterone-producing nodules was significantly lower than that of nonfunctioning nodules and normal adrenal glands. It can accurately differentiate between aldosterone-producing and nonfunctioning adrenal nodules. • Extracellular volume may be a novel, noninvasive biomarker alternative to adrenal vein sampling for determining the functional status of bilateral adrenal nodules in patients with primary aldosteronism.

[Personalized treatment of pheochromocytoma]. / Personalisierte Therapie des Phäochromozytoms.

BACKGROUND: Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma. MATERIAL AND METHODS: A narrative review article based on the most recent literature is presented. RESULTS AND DISCUSSION: The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24­h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.

Dual-energy CT in the differentiation between adrenal adenomas and metastases: Usefulness of material density maps and monochromatic images.

OBJECTIVE: To evaluate the behavior of adrenal adenomas and metastases with dual-energy CT, analyzing the attenuation coefficient in monochromatic images at three different levels of energy (45, 70, and 140 keV) and the tissue concentrations of fat, water, and iodine in material density maps, with the aim of establishing optimal cutoffs for differentiating between these lesions and comparing our results against published evidence. MATERIALS AND METHODS: This retrospective case-control study included oncologic patients diagnosed with adrenal metastases in the 6-12 months prior to the study who were followed up in our hospital between January and June 2020. For each case (patient with metastases) included in the study, we selected a control (patient with an adrenal adenoma) with a nodule of similar size. All patients were studied with a rapid-kilovoltage-switching dual-energy CT scanner, using a biphasic acquisition protocol. We analyzed the concentration of iodine in paired water-iodine images, the concentration of fat in the paired water-fat images, and the concentration of water in the paired iodine-water and fat-water images, in both the arterial and portal phases. We also analyzed the attenuation coefficient in monochromatic images (at 55, 70, and 140 keV) in the arterial and portal phases. RESULTS: In the monochromatic images, in both the arterial and portal phases, the attenuation coefficient at all energy levels was significantly higher in the group of patients with metastases than in the group of patients with adenomas. This enabled us to calculate the optimal cutoffs for classifying lesions as adenomas or metastases, except for the arterial phase at 55 KeV, where the area under the receiver operating characteristic curve (AUC) for the estimated threshold (0.68) was not considered accurate enough to classify the lesions. For the arterial phase at 70 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (42.4 HU) yielded 92% sensitivity and 60% specificity. For the arterial phase at 140 keV, the AUC was 0.94 (95% CI: 0.894‒0.999); the optimal cutoff (18.9 HU) yielded 88% sensitivity and 94% specificity). For the portal phase at 55 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (95.4 HU) yielded 68% sensitivity and 84% specificity. For the portal phase at 70 keV, the AUC was 0.82 (95% CI: 0.757‒0.955); the optimal cutoff (58.4 HU) yielded 80% sensitivity and 84% specificity. For the portal phase at 140 keV, the AUC was 0.9 (95% CI: 0.834‒0.987); the optimal cutoff (16.35 HU) yielded 96% sensitivity and 84% specificity. In the material density maps, in the arterial phase, significant differences were found only for the iodine-water pair, where the concentration of water was higher in the group with metastases (1018.8 ±â€¯7.6 mg/cm3 vs. 998.6 ±â€¯8.0 mg/cm3 for the group with adenomas, p < 0.001). The AUC was 0.97 (95% CI: 0.893‒0.999); the optimal cutoff (1012.5 mg/cm3) yielded 88% sensitivity and 96% specificity. The iodine-water pair was also significantly higher in metastases (1019.7 ±â€¯12.1 mg/cm3 vs. 998.5 ±â€¯9.1 mg/cm3 in adenomas, p < 0.001). The AUC was 0.926 (95% CI: 0.807‒0.977); the optimal cutoff (1009.5 mg/cm3) yielded 92% sensitivity and 92% specificity. Although significant results were also observed for the fat-water pair in the portal phase, the AUC was insufficient to enable a sufficiently accurate cutoff for classifying the lesions. No significant differences were found in the fat-water maps or iodine-water maps in the arterial or portal phase or in the water-fat map in the arterial phase. CONCLUSIONS: Monochromatic images show differences between the behavior of adrenal adenomas and metastases in oncologic patients studied with intravenous-contrast-enhanced CT, where the group of metastases had higher attenuation than the group of adenomas in both the arterial and portal phases; this pattern is in line with the evidence published for adenomas. Nevertheless, to our knowledge, no other publications report cutoffs for this kind of differentiation in contrast-enhanced monochromatic images obtained in rapid-kilovoltage-switching dual-energy CT scanners, and this is the first new contribution of our study. Regarding the material density maps, our results suggest that the water-iodine pair is a good tool for differentiating between adrenal adenomas and metastases, in both the arterial and portal phases. We propose cutoffs for differentiating these lesions, although to our knowledge no cutoffs have been proposed for portal-phase contrast-enhanced images obtained with rapid-kilovoltage-switching dual-energy CT scanners.

A Rare Case of Myxoid Adrenocortical Carcinoma.

Myxoid adrenocortical carcinoma (myxoid ACC) is a rare subtype of adrenal cortical carcinoma with only a few cases reported in the literature. This tumor is characterized by small to large neoplastic cells in cords, diffuse sheets, or nodular architecture, which are surrounded by variable amounts of myxoid material. We are presented with an elderly female with a suprarenal mass which revealed a tumor composed of neoplastic cells surrounded by scant to abundant myxoid stroma. Expression for Melan-A, Inhibin, Synaptophysin, and Pancytokeratin, as well as a Ki-67 proliferative index of 15%, warrant a diagnosis of myxoid ACC.

A life-threatening case of pheochromocytoma crisis with hemodynamic instability.

Background: Pheochromocytoma crisis (PCC) is a fatal disease characterized by hyper and/or hypotension, hyperthermia, and encephalopathy, and its diagnosis and treatment are challenging. Case presentation: A 50-year-old woman presented with hypertension, and computed tomography showed an adrenal tumor. Fever, shock, and impaired consciousness were observed, and PCC was diagnosed clinically. Systolic blood pressure fluctuated from 40-220 mmHg within a few minutes, and circulatory agonists were adjusted accordingly. The blood pressure changes gradually stabilized with α-blockade. Surgery was performed on hospital day 26, and the pathological diagnosis was consistent with a pheochromocytoma. She was discharged on hospital day 37. Conclusion: Computed tomography may facilitate early diagnosis in the acute phase of PCC in case of limited patient medical information and insufficient time to wait for a definitive diagnosis using traditional hormone tests. The shock requires pharmacological therapy to maintain circulation, and paradoxically, the administration of α-blockade can be lifesaving.

Adrenal neuroblastoma in three year old boy, mistaken for pancreatic tumor: A case report.

Neuroblastoma is the most common extracranial solid tumor in children, often manifests in the retroperitoneal region. We present a case of a 3-year-old boy with no previous medical history, presented for abdominal distension. Physical examination revealed a distinct, mobile, solid mass situated in the left lumbar region. Abdominal magnetic resonance imaging displayed a well delimited, well-encapsulated mass attached to the tail of the pancreas. Urinary catecholamine metabolite levels were negative. Surgical exploration revealed that the tumor was primitively related to the left adrenal gland, and a complete resection was performed. The postoperative recovery was uncomplicated. NMYC oncogene was non-amplified.

Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement.

Objective: To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods: We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results: We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion: For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.

Objetivo: Avaliar a acurácia diagnóstica da análise por histograma na tomografia computadorizada (TC) sem contraste para a diferenciação entre adenomas adrenais e feocromocitomas (FCCs). Materiais e Métodos: Identificamos, retrospectivamente, pacientes com diagnóstico de FCC confirmado que foram submetidos a exames de TC entre janeiro de 2009 e julho de 2019 em duas instituições distintas. Para cada FCC, selecionamos um ou dois adenomas diagnosticados em até duas semanas da data do diagnóstico do FCC. Para cada lesão, dois leitores pontuaram o tamanho, determinaram a atenuação média e geraram um histograma com os voxels das imagens. O percentil 10 (P10) foi obtido a partir da análise convencional do histograma, além de ser calculado com a seguinte fórmula: P10 = atenuação média - (1,282 × desvio-padrão). O limiar de atenuação média, o P10 da análise por histograma (P10 observado) e o P10 calculado (P10calc) foram comparados em termos de acurácia diagnóstica. Resultados: Foram incluídos 52 adenomas e 29 FCCs. A sensibilidade, especificidade e acurácia do limiar de atenuação média foram de 75,0%, 100,0% e 82,5% para o leitor 1, respectivamente, e de 71,5%, 100,0% e 81,5% para o leitor 2, respectivamente. A sensibilidade, especificidade e acurácia do P10 observado e do P10calc foram idênticas para os dois leitores: 90,4%, 96,5% e 92,6%, respectivamente, para o leitor 1; e 92,3%, 93,1% e 92,6%, respectivamente, para o leitor 2. O aumento da sensibilidade foi significativo para ambos os leitores (p = 0,009 e p = 0,005, respectivamente). Conclusão: Para a diferenciação entre adenomas e FCCs, a análise por histograma (P10 observado ou P10calc) parece superar o limiar de atenuação média como critério diagnóstico.

Bilateral adrenal myelolipoma revealing an adrenal insufficiency: A case report.

INTRODUCTION: Once mostly discovered on autopsy, adrenal myelolipomas are now increasingly diagnosed due to the frequent use of modern imaging methods. However, bilaterality remains quite rare. We present the case of a 31 years old female patient treated in our department for a bilateral adrenal myelolipoma which revealed an unknown peripheral adrenal insufficiency. CASE PRESENTATION: We describe the case of a 31-year-old woman in apparent good health with no medical history who was explored for recurrent right lumbar pain by a computed tomography scanner which showed a large right adrenal mass and a smaller lesion in the left adrenal gland. Preoperative biology revealed an unknown peripheral adrenal insufficiency. Right open sub-costal adrenalectomy was performed, Histological examination confirmed the diagnosis of bilateral adrenal myelolipomas and radiological surveillance was planned for the left tumor. DISCUSSION: Adrenal myelolipoma (AML) is a rare, benign and typically non-functional tumor of the adrenal gland, usually unilateral and asymptomatic, incidentally detected on CT. Commonly diagnosed between the fifth and seventh decades of life. It can affect both sexes our patient is a 31-year-old female and presented with bilateral AML. Unlike previous reported cases, our patient has a previously unknown peripheral adrenal insufficiency, which could be incriminated in the development of his bilateral adrenal myelolipomas. The optimal management depends on both clinical presentation and tumor characteristics. CONCLUSION: Adrenal myelolipoma is a rare tumor. Endocrinological investigation should be performed to detect and treat endocrine disorders. The therapeutic attitude depends on tumor size complications and clinical complaints. METHODS: This is a case report from our urology department, and has been reported in line with the SCARE criteria.

Pathological Aspects and Immunohistochemical Evaluation of Troponin C in the Cardiovascular System of Dogs With Pheochromocytoma.

Functional pheochromocytomas secrete catecholamines and have been associated with cardiovascular lesions in dogs. This study aimed to describe the postmortem pathological findings in the cardiovascular system of dogs with pheochromocytoma and to evaluate the expression of cardiac troponin C in these dogs using immunohistochemical analysis. Twelve cases were identified, with a mean age of 10.6 years. The heart of all dogs was enlarged and with concentric hypertrophy of the left ventricular myocardium. Histological analysis showed cardiomyocyte necrosis and degeneration in the myocardium, with frequent bands of contraction, fibrosis, inflammation, and thickening of the medium-caliber arteries in the myocardium. There was a marked decrease or absence of immunolabeling in necrotic cardiomyocytes. We conclude that IHC for troponin C can be a useful tool for detecting myocardial necrosis in dogs with pheochromocytomas, including early cases of necrosis with only incipient cardiac changes where overt histologic abnormalities are not immediately apparent in the cardiomyocytes.

Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement / Análise por histograma para diferenciação entre adenomas da adrenal e feocromocitomas: o valor de uma medida única

Abstract Objective: To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods: We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results: We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion: For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.

Resumo Objetivo: Avaliar a acurácia diagnóstica da análise por histograma na tomografia computadorizada (TC) sem contraste para a diferenciação entre adenomas adrenais e feocromocitomas (FCCs). Materiais e Métodos: Identificamos, retrospectivamente, pacientes com diagnóstico de FCC confirmado que foram submetidos a exames de TC entre janeiro de 2009 e julho de 2019 em duas instituições distintas. Para cada FCC, selecionamos um ou dois adenomas diagnosticados em até duas semanas da data do diagnóstico do FCC. Para cada lesão, dois leitores pontuaram o tamanho, determinaram a atenuação média e geraram um histograma com os voxels das imagens. O percentil 10 (P10) foi obtido a partir da análise convencional do histograma, além de ser calculado com a seguinte fórmula: P10 = atenuação média - (1,282 × desvio-padrão). O limiar de atenuação média, o P10 da análise por histograma (P10 observado) e o P10 calculado (P10calc) foram comparados em termos de acurácia diagnóstica. Resultados: Foram incluídos 52 adenomas e 29 FCCs. A sensibilidade, especificidade e acurácia do limiar de atenuação média foram de 75,0%, 100,0% e 82,5% para o leitor 1, respectivamente, e de 71,5%, 100,0% e 81,5% para o leitor 2, respectivamente. A sensibilidade, especificidade e acurácia do P10 observado e do P10calc foram idênticas para os dois leitores: 90,4%, 96,5% e 92,6%, respectivamente, para o leitor 1; e 92,3%, 93,1% e 92,6%, respectivamente, para o leitor 2. O aumento da sensibilidade foi significativo para ambos os leitores (p = 0,009 e p = 0,005, respectivamente). Conclusão: Para a diferenciação entre adenomas e FCCs, a análise por histograma (P10 observado ou P10calc) parece superar o limiar de atenuação média como critério diagnóstico.

Prevalence of Malignancy in Adrenal Nodules With Heterogeneous Microscopic Fat on Chemical-Shift MRI: A Multiinstitutional Study.

BACKGROUND. Homogeneous microscopic fat within adrenal nodules on chemical-shift MRI (CS-MRI) is diagnostic of benign adrenal adenoma, but the clinical relevance of heterogeneous microscopic fat is not well established. OBJECTIVE. This study sought to determine the prevalence of malignancy in adrenal nodules with heterogeneous microscopic fat on dual-echo T1-weighted CS-MRI. METHODS. We performed a retrospective study of adult patients with adrenal nodules detected on MRI performed between August 2007 and November 2020 at seven institutions. Eligible nodules had a short-axis diameter of 10 mm or larger with heterogeneous microscopic fat (defined by an area of signal loss of < 80% on opposed-phase CS-MRI). Two radiologists from each center, blinded to reference standard results, determined the signal loss pattern (diffuse, two distinct parts, speckling pattern, central loss, or peripheral loss) within the nodules. The reference standard used was available for 283 nodules (pathology for 21 nodules, ≥ 1 year of imaging follow-up for 245, and ≥ 5 years of clinical follow-up for 17) in 282 patients (171 women and 111 men; mean age, 60 ± 12 [SD] years); 30% (86/282) patients had prior malignancy. RESULTS. The mean long-axis diameter was 18.7 ± 7.9 mm (range, 10-80 mm). No malignant nodules were found in patients without prior cancer (0/197; 95% CI, 0-1.5%). Four of the 86 patients with prior malignancy (hepatocellular carcinoma [HCC], renal cell carcinoma [RCC], lung cancer, or both colon cancer and RCC) (4.7%; 95% CI, 1.3-11.5%) had metastatic nodules. Detected patterns were diffuse heterogeneous signal loss (40% [114/283]), speckling (28% [80/283]), two distinct parts (18% [51/283]), central loss (9% [26/283]), and peripheral loss (4% [12/283]). Two metastases from HCC and RCC showed diffuse heterogeneous signal loss. Lung cancer metastasis manifested as two distinct parts, and the metastasis in the patient with both colon cancer and RCC showed peripheral signal loss. CONCLUSION. Presence of heterogeneous microscopic fat in adrenal nodules on CS-MRI indicates a high likelihood of benignancy, particularly in patients without prior cancer. This finding is also commonly benign in patients with cancer; however, caution is warranted when primary malignancies may contain fat or if the morphologic pattern of signal loss may indicate a collision tumor. CLINICAL IMPACT. In the absence of prior cancer, adrenal nodules with heterogeneous microscopic fat do not require additional imaging evaluation.

Preliminary study on the ability of 68Ga-Pentixafor PET/CT to differentiate between adrenal aldosterone-producing adenoma and nonfunctional adenoma / 中华内科杂志

Objective:To evaluate the ability of 68Ga-Pentixafor (nuclide ligand imaging agents for chemokine receptor 4) PET/CT to differentiate between aldosterone-producing adenoma (APA) and adrenal nonfunctional adenoma (NFA), and to assess how well this imaging method correlates with clinical features and postoperative outcomes. Methods:This was a cross-sectional study involving 73 APA and 12 NFA patients who received 68Ga-Pentixafor PET/CT imaging at Peking Union Medical College Hospital from August 2018 to October 2021. The receiver operating characteristic (ROC) curve was used to evaluate the differential value of visual analysis and the maximum standard uptake value (SUV max) of the focus on APA and NFA. The related factors of SUV max, and its predictive effect on postoperative outcomes were analyzed using Pearson or Spearman analysis and χ2 text. Results:68Ga-Pentixafor PET/CT imaging was positive in 64 APA patients (sensitivity=87.7%) and negative in all 12 NFA patients (specificity=100%). The area under the ROC curve with SUV max differentiating APA and NFA was 0.932 ( P<0.001). When the SUV max cut-off point was 6.23, the sensitivity was 80.8% and the specificity was 100%. The SUV max correlated positively with lesion size ( r=0.598) and aldosterone/renin activity ratio ( r=0.313) and correlated negatively with potassium level ( r=-0.286), renin activity ( r=-0.240) and age of diagnosis ( r=-0.273) (all P<0.05). Of the patients who underwent adrenalectomy and received more than 6 months of post-surgical follow-up, the clinical complete remission rate was higher for 68Ga-Pentixafor PET/CT imaging-positive patients than imaging-negative patients (24/39 vs. 0/4, P=0.031). Conclusions:68Ga-Pentixafor PET/CT is effective at differentiating between APA and NFA. The SUV max of 68Ga-Pentixafor PET/CT correlates with age at onset, lesion size, and the severity of clinical manifestations, and is able to predict postoperative outcomes.

Primary adrenal small cell neuroendocrine carcinoma complicated with renal venous carcinoma thrombus: a case report / 中华泌尿外科杂志

Primary adrenal small cell neuroendocrine carcinoma is clinically rare. This article reported a patient, who was diagnosed as primary adrenal small cell neuroendocrine carcinoma complicated with renal vein cancer thrombus, and underwent laparoscopic left adrenal + left kidney + left renal vein tumor embolectomy.The carcinoma relapsed after 19 months of follow-up after surgery. The patient and his family refused further treatment.

Primary adrenal epithelioid sarcoma: a case report / 中华泌尿外科杂志

Adrenal epithelioid sarcoma is very rare in clinic. A case of epithelioid sarcoma of the right adrenal gland was reported in this paper. After physical examination, the patient was found to have a mass in the right adrenal area and underwent right adrenalectomy. The postoperative pathological diagnosis was right adrenal epithelioid sarcoma. Two months after adrenalectomy, positron emission tomography computed tomography(PET/CT) noted recurrence at the tumor bed and multiple metastases.The patient underwent chemotherapy combined with immunotherapy. After 16 months of follow-up, the disease was stable.

The Spectrum of Postoperative Complications and Outcomes After Open Adrenalectomy: An Experience From a Developing Country.

Background Open adrenalectomy is an invasive surgical procedure that is commonly performed for adrenal gland neoplasms in developing countries. Due to its complexity, the patients are predisposed to a number of complications and dismal outcomes. The objective of our study is to assess different characteristics of patients undergoing open adrenalectomy, including their histology, postoperative complications, and outcomes. Methods This retrospective cross-sectional study included 107 patients undergoing open adrenalectomy for primary adrenal gland neoplasms. Patients with bilateral involvement, metastatic disease, or unresectable tumors were excluded. Patients were evaluated for different features that included demographic data, tumor properties, postoperative outcomes, and complications. Results Out of 107 patients, 45 (42.1%) were females. The mean age of the patients was 47.53 ± 8.45 years. Abdominal pain and severe headaches were the most common presenting complaints. A total of 96 (89.7%) tumors were benign, while 11 (10.3%) were malignant. Upon the histopathological examination of the resected specimen, adrenal adenoma was present in 49 (45.8%) cases, while adrenal pheochromocytoma was present in 41 (38.3%) cases. A total of 51 patients developed different postoperative complications including surgical site infections (22.4%), atelectasis (11.2%), deep venous thrombosis (7.5%), and retroperitoneal hematoma (5.6%). In-hospital mortality occurred in three (2.8%) patients. Conclusion Surgical site infections, atelectasis, deep venous thrombosis, and retroperitoneal hematoma were frequent postoperative complications after open adrenalectomy. These complications increase morbidity and mortality, especially in developing countries. Improved surgical techniques, intraoperative hemostasis, and multidisciplinary approach can yield favorable postoperative outcomes.

Metastatic neuroendocrine carcinoma of right adrenal gland successfully treated with laparoscopic adrenalectomy after multimodal therapy.

Introduction: We report a case of laparoscopic adrenalectomy in a salvage setting after multiple chemotherapies for neuroendocrine carcinoma. Case presentation: A 49-year-old man was diagnosed with unknown primary carcinoma with single brain metastasis, and right supraclavicular and mediastinal lymph node metastases. After stereotactic radiotherapy of the brain metastasis and systemic chemotherapy, lymphadanectomy was performed. The pathologic diagnosis was neuroendocrine carcinoma. At 11 months after surgery, computed tomography revealed right adrenal metastasis. Local radiotherapy initially resulted in complete remission. However, adrenal recurrence was noted 10 months later. Laparoscopic adrenalectomy was performed with curative intent. The patient is currently alive without recurrence at 20 months after the operation. Conclusion: Adrenalectomy can become a treatment option if other metastases are well-controlled with systemic therapy. Surgical elimination of oligometastases can offer long-term disease control in selected patients as part of a multimodal approach.