Letizia Canu1,2, Janna A W Van Hemert1, Michiel N Kerstens3, Robert P Hartman4, Aakanksha Khanna5, Ivana Kraljevic6, Darko Kastelan6, Corin Badiu7, Urszula Ambroziak8, Antoine Tabarin9, Magalie Haissaguerre9, Edward Buitenwerf3, Anneke Visser10, Massimo Mannelli2, Wiebke Arlt11, Vasileios Chortis11, Isabelle Bourdeau12, Nadia Gagnon12, Marie Buchy13, Francoise Borson-Chazot13, Timo Deutschbein14, Martin Fassnacht14,15, Alicja Hubalewska-Dydejczyk16, Marcin Motyka16, Ewelina Rzepka16, Ruth T Casey17, Benjamin G Challis17, Marcus Quinkler18, Laurent Vroonen19, Ariadni Spyroglou20,21, Felix Beuschlein20,21, Cristina Lamas22, William F Young5, Irina Bancos5, Henri J L M Timmers1. 1. Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands. 2. Department of Experimental and Clinical Biomedical Sciences University of Florence, Florence, Italy. 3. Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands. 4. Department of Radiology, Mayo Clinic, Rochester, Minnesota. 5. Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota. 6. Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia. 7. National Institute of Endocrinology C. I. Parhon, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. 8. Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland. 9. Service d'Endocrinologie Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France. 10. Department of Applied Health Research, University of Groningen, University Medical Center Groningen, GZ Groningen, Netherlands. 11. Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom. 12. Division of Endocrinology, Center Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada. 13. Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France. 14. Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany. 15. Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany. 16. Department of Endocrinology, Jagiellonian University, Collegium Medicum, Krakow, Poland. 17. Addenbrooke's Hospital, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Biomedical Research Center, Cambridge, United Kingdom. 18. Endocrinology in Charlottenburg, Berlin, Germany. 19. Department of Endocrinology, Center Hospitalier Universitaire de Liège, Liège, Belgium. 20. Medizinische Klinik und Poliklinik IV Ludwig-Maximilians-Universität München, Munich, Germany. 21. Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland. 22. Endocrinology Department, Hospital General Universitario de Albacete, Albacete, Spain.
Abstract
Background: Up to 7% of all adrenal incidentalomas (AIs) are pheochromocytomas (PCCs). In the evaluation of AI, it is generally recommended that PCC be excluded by measurement of plasma-free or 24-hour urinary fractionated metanephrines. However, recent studies suggest that biochemical exclusion of PCC not be performed for lesions with CT characteristics of an adrenocortical adenoma (ACA). Aim: To determine the proportion of PCCs with ACA-like attenuation or contrast washout on CT. Methods: For this multicenter retrospective study, two central investigators independently analyzed the CT reports of 533 patients with 548 histologically confirmed PCCs. Data on tumor size, unenhanced Hounsfield units (HU), absolute percentage washout (APW), and relative percentage washout (RPW) were collected in addition to clinical parameters. Results: Among the 376 PCCs for which unenhanced attenuation data were available, 374 had an attenuation of >10 HU (99.5%). In the two exceptions (0.5%), unenhanced attenuation was exactly 10 HU, which lies just within the range of ≤10 HU that would suggest a diagnosis of ACA. Of 76 PCCs with unenhanced HU > 10 and available washout data, 22 (28.9%) had a high APW and/or RPW, suggestive of ACA. Conclusion: Based on the lack of PCCs with an unenhanced attenuation of <10 HU and the low proportion (0.5%) of PCCs with an attenuation of 10 HU, it seems reasonable to abstain from biochemical testing for PCC in AIs with an unenhanced attenuation of ≤10 HU. The assessment of contrast washout, however, is unreliable for ruling out PCC.
Background: Up to 7% of all adrenal incidentalomas (AIs) are pheochromocytomas (PCCs). In the evaluation of AI, it is generally recommended that PCC be excluded by measurement of plasma-free or 24-hour urinary fractionated metanephrines. However, recent studies suggest that biochemical exclusion of PCC not be performed for lesions with CT characteristics of an adrenocortical adenoma (ACA). Aim: To determine the proportion of PCCs with ACA-like attenuation or contrast washout on CT. Methods: For this multicenter retrospective study, two central investigators independently analyzed the CT reports of 533 patients with 548 histologically confirmed PCCs. Data on tumor size, unenhanced Hounsfield units (HU), absolute percentage washout (APW), and relative percentage washout (RPW) were collected in addition to clinical parameters. Results: Among the 376 PCCs for which unenhanced attenuation data were available, 374 had an attenuation of >10 HU (99.5%). In the two exceptions (0.5%), unenhanced attenuation was exactly 10 HU, which lies just within the range of ≤10 HU that would suggest a diagnosis of ACA. Of 76 PCCs with unenhanced HU > 10 and available washout data, 22 (28.9%) had a high APW and/or RPW, suggestive of ACA. Conclusion: Based on the lack of PCCs with an unenhanced attenuation of <10 HU and the low proportion (0.5%) of PCCs with an attenuation of 10 HU, it seems reasonable to abstain from biochemical testing for PCC in AIs with an unenhanced attenuation of ≤10 HU. The assessment of contrast washout, however, is unreliable for ruling out PCC.
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