Edward Buitenwerf1, Tijmen Korteweg2, Anneke Visser3, Charlotte M S C Haag2, Richard A Feelders4, Henri J L M Timmers5, Letizia Canu5,6, Harm R Haak7,8,9, Peter H L T Bisschop10, Elisabeth M W Eekhoff11, Eleonora P M Corssmit12, Nanda C Krak13, Elise Rasenberg14, Janneke van den Bergh15, Jaap Stoker16, Marcel J W Greuter2, Robin P F Dullaart3, Thera P Links3, Michiel N Kerstens3. 1. Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands e.buitenwerf@umcg.nl. 2. Departments of RadiologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 3. Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 4. Department of EndocrinologyErasmus Medical Center, Rotterdam, The Netherlands. 5. Section of EndocrinologyDepartment of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands. 6. Department of Experimental and Clinical Biomedical SciencesUniversity of Florence, Florence, Italy. 7. Department of Internal MedicineMáxima Medical Center, Eindhoven, The Netherlands. 8. Division of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands. 9. Maastricht UniversityCAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands. 10. Department of Endocrinology and MetabolismAcademic Medical Center, Amsterdam, The Netherlands. 11. Endocrinology SectionDepartment of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands. 12. Department of EndocrinologyLeiden University Medical Center, Leiden, The Netherlands. 13. Department of RadiologyErasmus Medical Center, Rotterdam, The Netherlands. 14. Department of RadiologyMáxima Medical Center, Eindhoven, The Netherlands. 15. Department of RadiologyVU University Medical Center, Amsterdam, The Netherlands. 16. Department of Radiology and Nuclear MedicineAcademic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Abstract
BACKGROUND: A substantial proportion of all pheochromocytomas is currently detected during the evaluation of an adrenal incidentaloma. Recently, it has been suggested that biochemical testing to rule out pheochromocytoma is unnecessary in case of an adrenal incidentaloma with an unenhanced attenuation value ≤10 Hounsfield Units (HU) at computed tomography (CT). OBJECTIVES: We aimed to determine the sensitivity of the 10 HU threshold value to exclude a pheochromocytoma. METHODS: Retrospective multicenter study with systematic reassessment of preoperative unenhanced CT scans performed in patients in whom a histopathologically proven pheochromocytoma had been diagnosed. Unenhanced attenuation values were determined independently by two experienced radiologists. Sensitivity of the 10 HU threshold was calculated, and interobserver consistency was assessed using the intraclass correlation coefficient (ICC). RESULTS: 214 patients were identified harboring a total number of 222 pheochromocytomas. Maximum tumor diameter was 51 (39-74) mm. The mean attenuation value within the region of interest was 36 ± 10 HU. Only one pheochromocytoma demonstrated an attenuation value ≤10 HU, resulting in a sensitivity of 99.6% (95% CI: 97.5-99.9). ICC was 0.81 (95% CI: 0.75-0.86) with a standard error of measurement of 7.3 HU between observers. CONCLUSION: The likelihood of a pheochromocytoma with an unenhanced attenuation value ≤10 HU on CT is very low. The interobserver consistency in attenuation measurement is excellent. Our study supports the recommendation that in patients with an adrenal incidentaloma biochemical testing for ruling out pheochromocytoma is only indicated in adrenal tumors with an unenhanced attenuation value >10 HU.
BACKGROUND: A substantial proportion of all pheochromocytomas is currently detected during the evaluation of an adrenal incidentaloma. Recently, it has been suggested that biochemical testing to rule out pheochromocytoma is unnecessary in case of an adrenal incidentaloma with an unenhanced attenuation value ≤10 Hounsfield Units (HU) at computed tomography (CT). OBJECTIVES: We aimed to determine the sensitivity of the 10 HU threshold value to exclude a pheochromocytoma. METHODS: Retrospective multicenter study with systematic reassessment of preoperative unenhanced CT scans performed in patients in whom a histopathologically proven pheochromocytoma had been diagnosed. Unenhanced attenuation values were determined independently by two experienced radiologists. Sensitivity of the 10 HU threshold was calculated, and interobserver consistency was assessed using the intraclass correlation coefficient (ICC). RESULTS: 214 patients were identified harboring a total number of 222 pheochromocytomas. Maximum tumor diameter was 51 (39-74) mm. The mean attenuation value within the region of interest was 36 ± 10 HU. Only one pheochromocytoma demonstrated an attenuation value ≤10 HU, resulting in a sensitivity of 99.6% (95% CI: 97.5-99.9). ICC was 0.81 (95% CI: 0.75-0.86) with a standard error of measurement of 7.3 HU between observers. CONCLUSION: The likelihood of a pheochromocytoma with an unenhanced attenuation value ≤10 HU on CT is very low. The interobserver consistency in attenuation measurement is excellent. Our study supports the recommendation that in patients with an adrenal incidentaloma biochemical testing for ruling out pheochromocytoma is only indicated in adrenal tumors with an unenhanced attenuation value >10 HU.
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