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A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas

  • Endocrine Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Contrast-enhanced computed tomography (CT) with washout has emerged as an option to distinguish lipid-poor adenomas from non-adenomas.

Objective

The aim of this study was to assess the utility of CT washout in characterizing indeterminate lipid-poor adrenal incidentalomas.

Methods

From an Institutional Review Board-approved database, patients with adrenal incidentalomas who had adrenal protocol CT scans with a 15-min washout between 2003 and 2019 were identified. Non-contrast CT attenuation and washout patterns of different tumor types were compared.

Results

Overall, 156 patients with 175 adrenal lesions were included. Average tumor size was 3.0 cm, non-contrast CT density was 24.7 Hounsfield units (HU), and absolute washout was 52.6%. In 102 lesions (58.3%), CT washout was ≥ 60%; 94 (92.2%) of these were benign adrenocortical adenomas, 7 (6.9%) were pheochromocytomas, and 1 (0.9%) was an adrenal hematoma. Furthermore, in 73 tumors (41.7%), CT washout was < 60%; diagnosis was benign adrenocortical adenoma in 45 (61.6%) lesions, pheochromocytoma in 8 (11%) lesions, metastasis in 9 (12.3%) lesions, adrenocortical cancer in 6 (8.2%) lesions, and ‘others’ in 5 (6.9%) lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of  > 60% absolute CT washout for detecting an adrenal adenoma was 67.6%, 77.8%, 92.2%, 38.4%, and 69.7%, respectively.

Conclusion

CT washout should be incorporated into the management algorithm of indeterminate adrenal incidentalomas with a high non-contrast CT attenuation to ‘rule-in’ benign tumors. For small tumors with mild elevation of plasma metanephrines, it should be kept in mind that adenomas and pheochromocytomas may have similar imaging and washout characteristics.

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Funding

No financial support was received for this study.

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Authors and Affiliations

  1. Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA

    Serkan Akbulut MD, Ozgun Erten MD, Bora Kahramangil MD, Mehmet Gokceimam MD, Yoo Seok Kim MD, Pengpeng Li MD & Eren Berber MD

  2. Imaging Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

    Erick M. Remer MD

Authors
  1. Serkan Akbulut MD
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  2. Ozgun Erten MD
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  3. Bora Kahramangil MD
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  4. Mehmet Gokceimam MD
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Correspondence to Eren Berber MD.

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Disclosure

Serkan Akbulut, Ozgun Erten, Bora Kahramangil, Mehmet Gokceimam, Yoo Seok Kim, Pengpeng Li, Erick M. Remer, and Eren Berber have no conflicts of interest to declare.

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Akbulut, S., Erten, O., Kahramangil, B. et al. A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas. Ann Surg Oncol 28, 2756–2762 (2021). https://doi.org/10.1245/s10434-020-09329-1

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  • DOI: https://doi.org/10.1245/s10434-020-09329-1

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