Abstract
Purpose
Large adrenal masses pose a diagnostic dilemma. The purpose of this study was twofold: first, to assess the degree of interobserver agreement in evaluating the morphology of pathologically proven adrenal adenomas and adrenocortical carcinomas larger than 4 cm in diameter; and second, to identify morphologic characteristics that correlated with the pathologic diagnosis.
Materials and methods
For this blinded, retrospective study, we collected cases of 25 adrenal adenomas and 33 adrenocortical carcinomas measuring larger than 4 cm. Two radiologists evaluated morphologic characteristics of the lesions on CT. Interobserver agreement was evaluated using kappa statistics, and the correlation of imaging characteristics with the diagnosis was evaluated using a logistic regression model.
Results
We found the highest interobserver agreement in the assessment of precontrast attenuation (Κ = 0.81) as well as substantial agreement in determining the shape and the presence of calcifications (Κ = 0.69 and 0.74, respectively). Readers agreed less often regarding the presence of fat (Κ = 0.48), as well as regarding the presence of necrosis, heterogeneity, and the overall impression (Κ = 0.15, 0.24, and 0.26, respectively). CT characteristics correlated with benignity included round shape (p = 0.02), an overall radiologic impression of a benign lesion (p < 0.0001), the presence of fat (p = 0.01), and a precontrast attenuation of less than 10 Hounsfield units (p < 0.0001). The latter two of these characteristics were highly specific for benign pathology (93% and 100%, respectively).
Conclusion
Our study suggests that CT has the ability to consistently identify characteristics significantly correlated with benign vs. malignant adrenal tumors.
Similar content being viewed by others
References
Bovio S, Cataldi A, Reimondo G, et al. (2006) Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest 29(4):298–302. https://doi.org/10.1007/BF03344099
Caoili EM, Korobkin M, Francis IR, Cohan RH, Dunnick NR (2000) Delayed enhanced CT of lipid-poor adrenal adenomas. AJR Am J Roentgenol 175(5):1411–1415. https://doi.org/10.2214/ajr.175.5.1751411
Blake MA, Holalkere NS, Boland GW (2008) Imaging techniques for adrenal lesion characterization. Radiol Clin North Am 46(1):65–78. https://doi.org/10.1016/j.rcl.2008.01.003
Bilimoria KY, Shen WT, Elaraj D, et al. (2008) Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer 113(11):3130–3136. https://doi.org/10.1002/cncr.23886
Wajchenberg BL, Albergaria Pereira MA, et al. (2000) Adrenocortical carcinoma: clinical and laboratory observations. Cancer 88(4):711–736
Wooten MD, King DK (1993) Adrenal cortical carcinoma. Epidemiology and treatment with mitotane and a review of the literature. Cancer 72(11):3145–3155
Ayala-Ramirez M, Jasim S, et al. (2013) Adrenocortical carcinoma: clinical outcomes and prognosis of 330 patients at a tertiary care center. Eur J Endocrinol 169(6):891–899. https://doi.org/10.1530/EJE-13-0519
Bharwani N, Rockall AG, Sahdev A, et al. (2011) Adrenocortical carcinoma: the range of appearances on CT and MRI. AJR Am J Roentgenol 196(6):W706–714. https://doi.org/10.2214/AJR.10.5540
Koschker AC, Fassnacht M, Hahner S, Weismann D, Allolio B (2006) Adrenocortical carcinoma – improving patient care by establishing new structures. Exp Clin Endocrinol Diabetes 114(2):45–51. https://doi.org/10.1055/s-2006-923808
Fishman EK, Deutch BM, Hartman DS, et al. (1987) Primary adrenocortical carcinoma: CT evaluation with clinical correlation. AJR Am J Roentgenol 148(3):531–535. https://doi.org/10.2214/ajr.148.3.531
Icard P, Goudet P, Charpenay C, et al. (2001) Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group. World J Surg 25(7):891–897
Angeli A, Osella G, Alì A, Terzolo M (1997) Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Horm Res 47(4–6):279–283
Mansmann G, Lau J, Balk E, et al. (2004) The clinically inapparent adrenal mass: update in diagnosis and management. Endocr Rev 25(2):309–340. https://doi.org/10.1210/er.2002-0031
Boland GW, Blake MA, Hahn PF, Mayo-Smith WW (2008) Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 249(3):756–775. https://doi.org/10.1148/radiol.2493070976
Dunnick NR, Heaston D, Halvorsen R, Moore AV, Korobkin M (1982) CT appearance of adrenal cortical carcinoma. J Comput Assisted Tomogr 6(5):978–982
Malayeri AA, Zaheer A, Fishman EK, Macura KJ (2013) Adrenal masses: contemporary imaging characterization. J Comput Assisted Tomogr 37(4):528–542. https://doi.org/10.1097/RCT.0b013e31828b690d
Elsayes KM, Emad-Eldin S, Morani AC, Jensen CT (2017) Practical Approach to Adrenal Imaging. Radiol Clin North Am 55(2):279–301. https://doi.org/10.1016/j.rcl.2016.10.005
Johnson PT, Horton KM, Fishman EK (2009) Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls. Radiographics 29(5):1333–1351. https://doi.org/10.1148/rg.295095027
Szolar DH, Korobkin M, Reittner P, et al. (2005) Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT. Radiology 234(2):479–485. https://doi.org/10.1148/radiol.2342031876
Song JH, Chaudhry FS, Mayo-Smith WW (2008) The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR Am J Roentgenol 190(5):1163–1168. https://doi.org/10.2214/AJR.07.2799
Dunnick NR, Korobkin M (2002) Imaging of adrenal incidentalomas: current status. AJR Am J Roentgenol 179(3):559–568. https://doi.org/10.2214/ajr.179.3.1790559
Korobkin M, Giordano TJ, Brodeur FJ, et al. (1996) Adrenal adenomas: relationship between histologic lipid and CT and MR findings. Radiology 200(3):743–747. https://doi.org/10.1148/radiology.200.3.8756925
Boland GW, Lee MJ, Gazelle GS, et al. (1998) Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature. AJR Am J Roentgenol 171(1):201–204. https://doi.org/10.2214/ajr.171.1.9648789
Johnson PT, Horton KM, Fishman EK (2009) Adrenal imaging with multidetector CT: evidence-based protocol optimization and interpretative practice. Radiographics 29(5):1319–1331. https://doi.org/10.1148/rg.295095026
Lattin GE, Sturgill ED, Tujo CA, et al. (2014) From the radiologic pathology archives: adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics 34(3):805–829. https://doi.org/10.1148/rg.343130127
Berland LL, Silverman SG, Gore RM, et al. (2010) Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 7(10):754–773. https://doi.org/10.1016/j.jacr.2010.06.013
Zeiger MA, Thompson GB, Duh QY, et al. (2009) The American association of clinical endocrinologists and American association of endocrine surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract 15(Suppl 1):1–20. https://doi.org/10.4158/EP.15.S1.1
Fassnacht M, Arlt W, Bancos I, et al. (2016) Management of adrenal incidentalomas: european society of endocrinology clinical practice guideline in collaboration with the European Network for the study of adrenal tumors. Eur J Endocrinol 175(2):G1–G34. https://doi.org/10.1530/EJE-16-0467
Mayo-Smith WW, Song JH, Boland GL, et al. (2017) Management of incidental adrenal masses: a white paper of the acr incidental findings committee. J Am Coll Radiol 14(8):1038–1044. https://doi.org/10.1016/j.jacr.2017.05.001
Gallagher SF, Wahi M, Haines KL, et al. (2007) Trends in adrenalectomy rates, indications, and physician volume: a statewide analysis of 1816 adrenalectomies. Surgery 142(6):1011–1021. https://doi.org/10.1016/j.surg.2007.09.024
Murphy MM, Witkowski ER, Ng SC, et al. (2010) Trends in adrenalectomy: a recent national review. Surgical endoscopy 24(10):2518–2526. https://doi.org/10.1007/s00464-010-0996-z
Monn MF, Calaway AC, Mellon MJ, et al. (2015) Changing USA national trends for adrenalectomy: the influence of surgeon and technique. BJU Int 115(2):288–294. https://doi.org/10.1111/bju.12747
Liang K-Y, Zeger SL (1986) Longitudinal data analysis using generalized linear models. Biometrika 73(1):13–22
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174
Korobkin M, Brodeur FJ, Yutzy GG, et al. (1996) Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol 166(3):531–536. https://doi.org/10.2214/ajr.166.3.8623622
Lee MJ, Hahn PF, Papanicolaou N, et al. (1991) Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size, and observer analysis. Radiology 179(2):415–418. https://doi.org/10.1148/radiology.179.2.2014283
Elsayes KM, Mukundan G, Narra VR, et al. (2004) Adrenal masses: mr imaging features with pathologic correlation. Radiographics 24(Suppl 1):S73–86. https://doi.org/10.1148/rg.24si045514
Adam SZ, Nikolaidis P, Horowitz JM, et al. (2016) Chemical shift MR imaging of the adrenal gland: principles, pitfalls, and applications. Radiographics 36(2):414–432. https://doi.org/10.1148/rg.2016150139
Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR (2000) Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology 217(3):798–802. https://doi.org/10.1148/radiology.217.3.r00dc29798
Taffel M, Haji-Momenian S, Nikolaidis P, Miller FH (2012) Adrenal imaging: a comprehensive review. Radiol Clin North Am 50(2):219–243. https://doi.org/10.1016/j.rcl.2012.02.009
Hussain S, Belldegrun A, Seltzer SE, et al. (1985) Differentiation of malignant from benign adrenal masses: predictive indices on computed tomography. AJR Am J Roentgenol 144(1):61–65. https://doi.org/10.2214/ajr.144.1.61
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Thomas, A.J., Habra, M.A., Bhosale, P.R. et al. Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography. Abdom Radiol 43, 3101–3108 (2018). https://doi.org/10.1007/s00261-018-1603-3
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00261-018-1603-3