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Pheochromocytoma as a frequent false-positive in adrenal washout CT: A systematic review and meta-analysis

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Abstract

Objective

To evaluate the proportion of pheochromocytomas meeting the criteria for adenoma on adrenal washout CT and the diagnostic performance of adrenal washout CT for differentiating adenoma from pheochromocytoma.

Methods

MEDLINE and EMBASE were searched to 28 March 2017. We included studies that used adrenal washout CT for characterisation of pheochromocytomas. Two independent reviewers assessed the methodological quality using Quality Assessment of Diagnostic Accuracy Studies-2. Proportions were pooled using an inverse variance method for calculating weights (random-effects). Sensitivity and specificity were pooled using hierarchical logistic regression modelling and plotted in a hierarchical summary receiver-operating-characteristics (HSROC) plot.

Results

Ten studies (114 pheochromocytomas) were included. The pooled proportion of pheochromocytomas meeting the criteria for adenomas was 35 % (95 % CI 20–51). For eight studies providing information on diagnostic performance, the pooled sensitivity and specificity for differentiating adenoma from pheochromocytoma were 0.97 (95 % CI 0.93–0.99) and 0.67 (95 % CI 0.44–0.84), respectively. The area under the HSROC curve was 0.97 (95 % CI 0.95–0.98).

Conclusions

There was a non-negligible proportion of pheochromocytomas meeting the criteria for adenoma on adrenal washout CT. Although overall diagnostic performance was excellent for differentiating adenoma from pheochromocytoma, specificity was relatively low.

Key Points

• Non-negligible proportion of pheochromocytomas can be mistaken for adenoma.

• Adrenal washout CT showed good sensitivity (97%) but relatively low specificity (67%).

• Findings other than washout percentage should be used when diagnosing pheochromocytomas

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Abbreviations

APW:

Absolute percentage washout

CT:

Computed tomography

HSROC:

Hierarchical summary receiver operating characteristic

HU:

Hounsfield units

PICO:

Patient Index test Comparator Outcome

QUADAS-2:

Quality Assessment of Diagnostic Accuracy Studies-2

RPW:

Relative percentage washout

References

  1. Young WF Jr (2007) Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 356:601–610

    Article  CAS  PubMed  Google Scholar 

  2. Boland GW, Blake MA, Hahn PF, Mayo-Smith WW (2008) Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 249:756–775

    Article  PubMed  Google Scholar 

  3. Boland GWL (2010) Adrenal imaging: Why, when, what, and how? Part 1. Why and when to image? AJR Am J Roentgenol 195:W377–W381

    Article  PubMed  Google Scholar 

  4. Guller U, Turek J, Eubanks S, Delong ER, Oertli D, Feldman JM (2006) Detecting pheochromocytoma: defining the most sensitive test. Ann Surg 243:102–107

    Article  PubMed  PubMed Central  Google Scholar 

  5. Motta-Ramirez GA, Remer EM, Herts BR, Gill IS, Hamrahian AH (2005) Comparison of CT findings in symptomatic and incidentally discovered pheochromocytomas. AJR Am J Roentgenol 185:684–688

    Article  PubMed  Google Scholar 

  6. Blake MA, Kalra MK, Maher MM et al (2004) Pheochromocytoma: an imaging chameleon. Radiographics 24:S87–S99

    Article  PubMed  Google Scholar 

  7. Yoon JK, Remer EM, Herts BR (2006) Incidental pheochromocytoma mimicking adrenal adenoma because of rapid contrast enhancement loss. AJR Am J Roentgenol 187:1309–1311

    Article  PubMed  Google Scholar 

  8. Whiting PF, Rutjes AW, Westwood ME et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536

    Article  PubMed  Google Scholar 

  9. Higgins J, Green S Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration. http://handbook.cochrane.org/chapter_9/9_4_3_1_random_effects_dersimonian_and_laird_method_for.htm. Updated March 2011. Accessed 3 April 2017.

  10. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629–634

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Schieda N, Siegelman ES (2017) Update on CT and MRI of Adrenal Nodules. AJR Am J Roentgenol. https://doi.org/10.2214/ajr.16.17758:1-12

  12. Suh CH, Park SH (2016) Successful Publication of Systematic Review and Meta-Analysis of Studies Evaluating Diagnostic Test Accuracy. Korean J Radiol 17:5–6

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kim KW, Lee J, Choi SH, Huh J, Park SH (2015) Systematic Review and Meta-Analysis of Studies Evaluating Diagnostic Test Accuracy: A Practical Review for Clinical Researchers-Part I. General Guidance and Tips. Korean J Radiol 16:1175–1187

    Article  PubMed  PubMed Central  Google Scholar 

  14. Lee J, Kim KW, Choi SH, Huh J, Park SH (2015) Systematic Review and Meta-Analysis of Studies Evaluating Diagnostic Test Accuracy: A Practical Review for Clinical Researchers-Part II. Statistical Methods of Meta-Analysis. Korean J Radiol 16:1188–1196

    Article  PubMed  PubMed Central  Google Scholar 

  15. Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58:882–893

    Article  PubMed  Google Scholar 

  16. Blake MA, Krishnamoorthy SK, Boland GW et al (2003) Low-density pheochromocytoma on CT: a mimicker of adrenal adenoma. AJR Am J Roentgenol 181:1663–1668

    Article  PubMed  Google Scholar 

  17. Jun JH, Ahn HJ, Lee SM et al (2015) Is Preoperative Biochemical Testing for Pheochromocytoma Necessary for All Adrenal Incidentalomas? Medicine (Baltimore) 94:e1948

    Article  CAS  Google Scholar 

  18. Kim YK, Park BK, Kim CK, Park SY (2013) Adenoma characterization: Adrenal protocol with dual-energy CT. Radiology 267:155–163

    Article  PubMed  Google Scholar 

  19. Northcutt BG, Raman SP, Long C et al (2013) MDCT of adrenal masses: Can dual-phase enhancement patterns be used to differentiate adenoma and pheochromocytoma? AJR Am J Roentgenol 201:834–839

    Article  PubMed  Google Scholar 

  20. Park BK, Kim B, Ko K, Jeong SY, Kwon GY (2006) Adrenal masses falsely diagnosed as adenomas on unenhanced and delayed contrast-enhanced computed tomography: pathological correlation. Eur Radiol 16:642–647

    Article  PubMed  Google Scholar 

  21. Patel J, Davenport MS, Cohan RH, Caoili EM (2013) Can established CT attenuation and washout criteria for adrenal adenoma accurately exclude pheochromocytoma? AJR Am J Roentgenol 201:122–127

    Article  PubMed  Google Scholar 

  22. Raja A, Leung K, Stamm M, Girgis S, Low G (2013) Multimodality imaging findings of pheochromocytoma with associated clinical and biochemical features in 53 patients with histologically confirmed tumors. AJR Am J Roentgenol 201:825–833

    Article  PubMed  Google Scholar 

  23. Schieda N, Alrashed A, Flood TA, Samji K, Shabana W, McInnes MD (2016) Comparison of Quantitative MRI and CT Washout Analysis for Differentiation of Adrenal Pheochromocytoma From Adrenal Adenoma. AJR Am J Roentgenol 206:1141–1148

    Article  PubMed  Google Scholar 

  24. Szolar DH, Kammerhuber FH (1998) Adrenal adenomas and nonadenomas: Assessment of washout at delayed contrast-enhanced CT. Radiology 207:369–375

    Article  CAS  PubMed  Google Scholar 

  25. 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 234:479–485

    Article  PubMed  Google Scholar 

  26. 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 15:1–20

    Article  PubMed  Google Scholar 

  27. Grumbach MM, Biller BM, Braunstein GD et al (2003) Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med 138:424–429

    Article  PubMed  Google Scholar 

  28. Blake MA, Kalra MK, Sweeney AT et al (2006) Distinguishing benign from malignant adrenal masses: multi-detector row CT protocol with 10-minute delay. Radiology 238:578–585

    Article  PubMed  Google Scholar 

  29. Boland GW (2011) Adrenal imaging: why, when, what, and how? Part 2. What technique? AJR Am J Roentgenol 196:W1–W5

    Article  PubMed  Google Scholar 

  30. Sangwaiya MJ, Boland GW, Cronin CG et al (2010) Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging protocol revisited in a large patient cohort. Radiology 256:504–510

    Article  PubMed  Google Scholar 

  31. Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–34

    Article  PubMed  Google Scholar 

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Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea

    Sungmin Woo, Sang Youn Kim, Jeong Yeon Cho & Seung Hyup Kim

  2. Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea

    Chong Hyun Suh

  3. Department of Radiology, Namwon Medical Center, 365, Chungjeong-ro, Namwon-si, Jeollabuk-do, 590-702, Republic of Korea

    Chong Hyun Suh

  4. Institute of Radiation Medicine and Kidney Research Institute, Seoul National University Medical Research Center, Seoul, 110-744, Korea

    Jeong Yeon Cho & Seung Hyup Kim

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  1. Sungmin Woo
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Correspondence to Seung Hyup Kim.

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Guarantor

The scientific guarantor of this publication is Seung Hyup Kim.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors (Chong Hyun Suh) has significant statistical expertise.

Informed consent

Written informed consent was not required for this study due to the nature of our study, which was a systemic review and meta-analysis.

Ethical approval

Institutional Review Board approval was not required for this study due to the nature of our study, which was a systemic review and meta-analysis.

Methodology

• Meta-analysis performed at two medical institutions

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Woo, S., Suh, C.H., Kim, S.Y. et al. Pheochromocytoma as a frequent false-positive in adrenal washout CT: A systematic review and meta-analysis. Eur Radiol 28, 1027–1036 (2018). https://doi.org/10.1007/s00330-017-5076-5

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  • DOI: https://doi.org/10.1007/s00330-017-5076-5

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