FDG-PET and CT characterization of adrenal lesions in cancer patients

  • Suman Jana
  • Tong Zhang
  • David M. Milstein
  • Carmen R. Isasi
  • M. Donald Blaufox
Original Article

Abstract

Purpose

Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) may differentiate benign from malignant adrenal lesions. In this study, standardized uptake values (SUVs), visual interpretation, and computed tomography (CT) data were correlated with the final diagnosis to determine the contribution of adrenal FDG-PET in patients with known non-adrenal cancer.

Methods

Ninety-two patients with adrenal lesions on CT underwent FDG-PET. Eighty adrenals in 74 patients met the inclusion criteria (PET scan within 4 weeks of CT plus >1 year of follow-up after PET scan with repeat CT or biopsy for final diagnosis). CT was considered positive for metastases (CT+) based on two of the following three criteria: >4 cm, Hounsfield units (HU) >30, and delayed contrast enhancement. Lesions with <2 cm, with HU <20, and showing no enhancement were considered benign (CT−). Remaining lesions were considered indeterminate (CT-Ind). Visually, adrenal uptake exceeding liver uptake was considered PET positive (PET+). Diagnosis of metastases was based on biopsy or interval CT growth (unchanged >1 year=benign). SUVmax and SUVavg were calculated from a 4×4 pixel region of interest drawn from CT, PET, and fused images. A receiver operator curve (ROC) determined the SUV with the best sensitivity and specificity.

Results

Overall, PET was 93% sensitive and 96% specific for metastases. A SUVmax of 3.4 was 95% sensitive and 86% specific. A SUVavg of 3.1 was 95% sensitive and 90% specific. There was no significant difference between visual interpretation and SUV (SUVmax or SUVavg). Among CT+ and CT− lesions, PET was 100% sensitive and 96% specific; CT was 86% sensitive and 100% specific. In the CT-Ind group, PET was 88% sensitive and 96% specific.

Conclusion

PET accurately characterized adrenal lesions. Visual interpretation was as accurate as SUV. FDG-PET was most useful in the 52.5% of cancer patients with inconclusive adrenal lesions on CT.

Keywords

Adrenal lesions FDG-PET PET/CT Adrenal metastases Image fusion 

References

  1. 1.
    Dunnick NR, Korobkin M. Imaging of Adrenal Incidentalomas: current status. AJR Am J Roentgenol 2002;179:559–68PubMedGoogle Scholar
  2. 2.
    Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: analysis of 1000 autopsied cases. Cancer 1950;3:74–85PubMedGoogle Scholar
  3. 3.
    Zornoza J, Bracken R, Wallace S. Radiologic features of adrenal metastases. Urology 1976;8:295–9CrossRefPubMedGoogle Scholar
  4. 4.
    Falk THM, Sandler MP. Classification of silent adrenal masses: time to get practical. J Nucl Med 1994;35:1152–4PubMedGoogle Scholar
  5. 5.
    Gross MD, Shapiro B. Clinical review 50: clinically silent adenal masses. J Clin Endocrinol Metab 1993;77:885–8Google Scholar
  6. 6.
    Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally discovered adrenal masses. Endocr Rev 1995;16:460–84CrossRefPubMedGoogle Scholar
  7. 7.
    Higgins JC. Diagnosis of renal and adrenal incidentalomas. Clinics in Family Practice 2002;4(3):505CrossRefGoogle Scholar
  8. 8.
    Barzon L, Boscara M. Diagnosis and management of adrenal incidentalomas. J Urol 2000;163(2):398–422Google Scholar
  9. 9.
    Cook DM, Loriaux LD. The incidental adrenal mass. Am J Med 1996;101(1) 88–94CrossRefPubMedGoogle Scholar
  10. 10.
    Ooi TC. Adrenal incidentalomas: in detection, not significance. CMAJ 1997;157(7):903–4PubMedGoogle Scholar
  11. 11.
    Herrera MF, Grant CS, van Heerden JA, Sheedy PF, Ilstrup DM. Incidentally discovered adrenal tumors: an institutional perspective. Surgery 1991;110(6):1014–21PubMedGoogle Scholar
  12. 12.
    Yun M, Kim W, Alnafisi N, Lacorte L, Jang S, Alavi A. 18F-FDG PET in characterizing adrenal lesions detected on CT or MRI. J Nucl Med 2001;42:1795–99PubMedGoogle Scholar
  13. 13.
    Boland GW, Goldberg MA, Lee MJ, Mayo-Smith WW, Dixon J, McNicholas MM, et al. Indeterminate adrenal mass in patients with cancer: evaluation at PET with 2-[F-18]-fluoro-2-deoxyglucose. Radiology 1995;194:131–4PubMedGoogle Scholar
  14. 14.
    Erasmus JJ, Patz EF Jr, McAdams HP, Murray JG, Herndon J, Coleman RE, et al. Evaluation of adrenal masses in patients with bronchogenic carcinoma using 18F- fluorodeoxyglucose positron emission tomography. AJR Am J Roentgenol 1997;168:1357–60PubMedGoogle Scholar
  15. 15.
    Maurea S, Mainolfi C, Bazzicalupo L, Panico MR, Imparato C, Alfano B, et al. Imaging of adrenal tumors using FDG PET: comparison of benign and malignant lesions. AJR Am J Roentgenol 1999;173:25–9PubMedGoogle Scholar
  16. 16.
    Lee MJ, Hahn PF, Papanicolaou N, Egglin TK, Saini S, Mueller PR, et al. Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size, and observer analysis. Radiology 1991;179:415–8PubMedGoogle Scholar
  17. 17.
    Korobkin M, Brodeur FJ, Yutzy GG, Francis IR, Quint LE, Dunnick NR, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol 1996;166:531–6PubMedGoogle Scholar
  18. 18.
    Boland GW, Lee MJ, Gazelle GS, Halpern EF, McNicholas MM, Mueller PR. Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature. AJR Am J Roentgenol 1998;171:201–4PubMedGoogle Scholar
  19. 19.
    Bagheri B, Maurer AH, Cone L, Doss M, Adler L. Characterization of the normal adrenal gland with 18F-FDG PET/CT. J Nucl Med 2004;45:1340–3PubMedGoogle Scholar
  20. 20.
    Prinz R, Brooks M, Churchill R, Graner JL, Lawrence AM, Paloyan E, et al. Incidental asymptomatic adrenal masses detected by computed tomographic scanning. JAMA 1982;248:701CrossRefPubMedGoogle Scholar
  21. 21.
    Paulsen SD, Nghiem HV, Korobkin M, Caoili EM, Higgins EJ. Changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies. AJR Am J Roentgenol 2004;182:1033–7PubMedGoogle Scholar
  22. 22.
    Bernardino ME, Walther MM, Phillips VM, Graham SD Jr, Sewell CW, Gedgaudas-McClees K, et al. CT-guided adrenal biopsy: accuracy, safety and indications. AJR Am J Roentgenol 1985;144(1):67–9PubMedGoogle Scholar
  23. 23.
    Silverman SG, Mueller PR, Pinkney LP, Koenker RM, Seltzer SE. Predictive value of image-guided adrenal biopsy: analysis of results of 101 biopsies. Radiology 1993;187(3):715–8PubMedGoogle Scholar
  24. 24.
    Welch TJ, Sheedy PF, Stephens DH, Johnson CM, Swensen SJ. Percutaneous adrenal biopsy: review of a 10-year experience. Radiology 1994;193:341–4PubMedGoogle Scholar
  25. 25.
    Ettinghausen SE, Burt ME. Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. J Clin Oncol 1991;9:1462–6PubMedGoogle Scholar
  26. 26.
    Mody MK, Kazerooni EA, Korobkin M. Percutaneous CT-guided biopsy of adrenal masses: immediate and delayed complications. J Comput Assist Tomogr 1995;19(3):434–9PubMedGoogle Scholar
  27. 27.
    Xarli VP, Steele AA, Davis PJ, Buescher ES, Rios CN, Garcia-Bunnel R. Adrenal hemorrhage in the adult. Medicine (Baltimore) 1978;47:211–21Google Scholar
  28. 28.
    Szolar DH, Kammerhuber F. Quantitative CT evaluation of adrenal gland masses: a step forward in the differentiation between adenomas and nonadenomas? Radiology 1997;202:517–21PubMedGoogle Scholar
  29. 29.
    Mitchell DG, Crovello M, Matteucci T, Petersen RO, Miettinen MM. Benign adrenocortical masses: diagnosis with chemical shift MR imaging. Radiology 1992;185:345–51PubMedGoogle Scholar
  30. 30.
    Mayo-Smith WW, Lee MJ, McNicholas MMJ, Hahn PF, Boland GW, Saini S. Characterization of adrenal masses (<5 cm) by use of chemical shift MR imaging: observer performance versus quantitative measures. AJR Am J Roentgenol 1995;165:91–5PubMedGoogle Scholar
  31. 31.
    Kreft BP, Muller-Miny H, Sommer T, Steudel A, Vahlensieck M, Novak D, et al. Diagnostic value of MR imaging in comparison to CT in the detection and differential diagnosis of renal masses. ROC analysis. Eur Radiol 1997;7:542–7CrossRefPubMedGoogle Scholar
  32. 32.
    Outwater EK, Siegelman ES, Huang AB, Birnbaum R. Adrenal masses: correlation between CT attenuation value and chemical shift ratio at MR imaging with in-phase and opposed-phase sequences. Radiology 1996;200:749–52PubMedGoogle Scholar
  33. 33.
    Korobkin M, Lombardi TJ, Aisen AM, Francis IR, Quint LE, Dunnick NR, et al. Characterization of adrenal masses with chemical shift and gadolinium-enhanced MR imaging. Radiology 1995;197:411–8PubMedGoogle Scholar
  34. 34.
    Jana S, Abdel-Dayem HM. Role of nuclear medicine in evaluating treatment response in oncology. Nuclear Medicine Annual 2004;1–59Google Scholar
  35. 35.
    Erasmus JJ, McAdams HP, Patz EF Jr, Coleman RE, Ahuja V, Goodman PC. Evaluation of primary pulmonary carcinoid tumors using FDG PET. AJR Am J Roentgenol 1998;170:1369–73PubMedGoogle Scholar
  36. 36.
    Hedeland H, Ostberg G, Hokfelt B. On the prevalence of adrenocortical adenomas in an autopsy material in relation to hypertension and diabetes. Acta Med Scand 1968;184(3):211–4PubMedGoogle Scholar
  37. 37.
    Pauling M, Williamson B. Adrenal involvement in non-Hodgkin lymphoma. AJR Am J Roentgenol 1983;141: 303–5PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Suman Jana
    • 1
  • Tong Zhang
    • 1
  • David M. Milstein
    • 1
  • Carmen R. Isasi
    • 1
  • M. Donald Blaufox
    • 1
  1. 1.Department of Nuclear MedicineMontefiore Medical Center and Albert Einstein College of MedicineBronxUSA

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