ADRENAL INCIDENTALOMAS:ANALYSIS OF 126 CASES

Purpose.To evaluate the diagnosis and treatment of adrenal incidentalomas.Methods.One hundred and twenty-six patients with incidentalomas were analyzed,among them98underwent operation.Results.Eighty-eight of the adrenal incidentalomas were discovered by ultrasound.Of all the types of adrenal incidentalomas,52(41.3%)of them were adenomas;43(34.1%)were hypersecretory adrenal tumors,including29pheochromocytomas,9primary aldosteronisms ,1adrenogenitol syndrome combined with adrenal adenoma ,2Cushing’s syndrome combined with adenomas and2Cushing’s syndrome com-bined with nodular hyperplasias.All nonhypersecretory adrenal adenomas were under6cm,and all a-drenal carcinomas were above6cm.Conclusions.To search for hypersecretory adrenal tumors and to detect malignant adrenal tumors are quite essential in the process of diagnosing adrenal incidentalomas.For nonhypersecretory adrenal adeno-mas,the size of tumor is the most important index in determining whether the tumor is benign or malig-nant and whether the tumor needs to be treated with operation.

Unexpected focal fluorodeoxyglucose uptake in main organs;pass through or pass by?

Since the inception of fluorine-18 fluorodeoxyglucose(F-18 FDG),positron emission tomography/computed tomography(PET/CT)utilizing F-18 FDG has become widely accepted as a valuable imaging modality in the field of oncology,with global prevalence in clinical practice.Given that a single Torso PET/CT scan encompasses the anatomical region from the skull base to the upper thigh,the detection of incidental abnormal focal hypermetabolism in areas of limited clinical interest is both feasible and not uncommon.Numerous investigations have been undertaken to delineate the distinctive features of these findings,yet the outcomes have proven inconclusive.The incongruent results of these studies present a challenge for physicians,leaving them uncertain about the appropriate course of action.This article provides a succinct overview of the characteristics of fluorodeoxyglucose,followed by a comprehensive discussion of the imaging findings and clinical significance associated with incidental focal abnormal F-18 FDG activity in several representative organs.In conclusion,while the prevalence of unrecognized malignancy varies across organs,malignancies account for a substantial proportion,ranging from approximately one-third to over half,of incidental focal uptake.In light of these rates,physicians are urged to exercise vigilance in not disregarding unexpected uptake,facilitating more assured clinical decisions,and advocating for further active evaluation.

Clinical,Biochemical,and Radiological Retrospective Analysis in Patients with Adrenal Incidentaloma-A Secondary Publication

Objective:To evaluate the epidemiological,demographic,clinical features,treatment approaches,and survival of patients followed up for adrenal incidentaloma.Methods:Data from 46 patients who were treated and followed up due to adrenal incidentaloma in the Endocrinology Department of Mersin University Health Research and Application Hospital between 2010 and 2014 were retrospectively analyzed.Results:Of the cases included in the study,13 were male,33 were female,and the mean age was 54.09±10.7 years.The most common reason for admission was abdominal pain in 34.78%of the patients,the most commonly diagnosed radiological method was dynamic adrenal CT in 60.87%,and the most common location was the left adrenal gland.The mean lesion diameter was between 26.8±16.5 mm.The frequency of hypertension was 50%,obesity 47.8%,type 2 diabetes 21.7%,osteoporosis 42.8%,and metabolic syndrome 41.3%.According to hormonal evaluation results,non-functional adrenal adenoma(NFAA)was found in 82.61%,subclinical Cushing’s syndrome(SCS)in 15.21%,and aldosteronoma in 2.1%.Myelolipoma,pheochromocytoma,and adrenocortical adenoma were diagnosed in 8 cases undergoing adrenalectomy.One patient died due to liver failure.No hormonal activation or growth in lesion size was detected during the follow-up of the patients.Conclusion:Due to the very different pathological and radiological appearances of adrenal incidentaloma,it is important to evaluate demographic,etiological,clinical,laboratory,and radiological data as a whole in the treatment and follow-up.

Collateral findings during computed tomography scan for atrial fibrillation ablation:Let's take a look around

The growing number of atrial fibrillation catheter ablation procedures warranted the development of advanced cardiac mapping techniques, such as image integration between electroanatomical map and cardiac computed tomography. While scanning the chest before catheter ablation, it is frequent to detect cardiac and extracardiac collateral findings. Most collateral findings are promptly recognized as benign and do not require further attention. However, sometimes clinically relevant collateral findings are detected, which often warrant extra diagnostic examinations or even invasive procedure, and sometimes need to be followed-up over time. Even though reporting and further investigating collateral findings has not shown a clear survival benefit, almost all the working groups providing data on collateral findings reported some collateral findings eventually coming out to be malignancies, sometimes at an early stage. Therefore, there is currently no clear agreement about the right strategy to be followed.

Cystic Tumours of the Pancreas – a Rare and Diverse Type of Tumours

Objective: Increasing incidence of non-inflammatory cystic lesions of the pancreas challenges work-up algorithms, surgery and surveillance. We have reviewed our experience with these tumours in accordance with International Consensus Guidelines and evaluated the outcome. Patients and Methods: From 1999 to 2009, 34 cases referred to Haukeland University Hospital were operated upon;ten were serous (SCN), twenty-one IPMNs, one MCN, and two solid pseudopapillary neoplasms (SPPN). A thorough medical history was supplemented by CT, MRI, and US before each case were discussed in a MDT to decide on the best subsequent care. Results: All SCN and SPPN patients had benign histopathology, and no deaths were reported. Survival for malignant IPMN was, 2 years: 75%, and 5 years: 67%, where after no deaths were registered in the observation period. Presence of jaundice had the highest impact on survival (p = 0.0009), followed by weight loss (p = 0.005) and dilatation of the common bile duct (p = 0.04). In the IPMN group two had pancreatic juice leakage, and reoperation was performed in one. Conclusions: All SCN turned out benign which justify a high threshold for resection unless unacceptable symptoms dominate. For branch duct IPMNs resections of asymptomatic and smaller lesions (<3 cm) should be avoided but kept under surveillance, whereas symptomatic and lager lesions together with main duct IPMNs lodge a substantial malignant potential and should be resected. Symptomatic or large SPPNs can be, or turn, malignant which require resection.

Intraductal papillary mucinous neoplasm and the pancreatic incidentaloma

Asymptomatic pancreatic lesions(APL) are a commonly encountered problem in today's pancreatic surgical practices.Current literature regarding etiologies and incidence of APLs,particularly intraductal papillary mucinous neoplasm(IPMN),is presented.APLs constitute a wide spectrum of pathology(solid/cystic,benign/premalignant/malignant) but,overall,IPMN is now the most common diagnosis.The Sendai Guidelines and their function as a basis for risk stratification in branch duct IPMN are presented.The importance of traditionally analyzed cyst characteristics including size,presence of mucin or nodules and cyst fluid aspirate as indicators of malignancy is emphasized,noting also the potential correlation of main duct dilatation,thickened septae and elevated cyst fluid CEA with increased risk of malignancy.Current complication rates after resection of APLs are reviewed and found to be generally equivalent to those for symptomatic resections.A potential multidisciplinary treatment strategy is offered considering the costs of surgery versus repeated imaging or follow up endoscopy for these lesions.The decision for intervention is ultimately based on the Sendai Guidelines in the context of the individual patient.

Primary aldosteronism due to bilateral micronodular hyperplasia and concomitant subclinical Cushing’s syndrome:A case report

BACKGROUND Adrenal incidentaloma(AI)has been frequently encountered in the clinical setting.It has been shown that primary aldosteronism(PA)or subclinical Cushing’s syndrome(SCS)are the representative causative diseases of AI.However,the coexistence of PA and SCS has been reportedly observed.Recently,we encountered a case of AI,in which PA and SCS coexisted,confirmed by histopathological examinations after a laparoscopic adrenalectomy.We believe that there were some clinical implications in the diagnosis of the present case.CASE SUMMARY A 58-year-old man presented with lower right abdominal pain with a blood pressure of 170/100 mmHg.A subsequent computed tomography scan revealed right ureterolithiasis,which was the cause of right abdominal pain,and right AI measuring 22 mm×25 mm.After the disappearance of right abdominal pain,subsequent endocrinological examinations were performed.Aldosterone-related evaluations,including adrenal venous sampling,revealed the presence of bilateral PA.In addition,several cortisol-related evaluations showed the presence of SCS on the right adrenal adenoma.A laparoscopic right adrenalectomy was then performed.The histopathological examination of the resected right adrenal revealed the presence of a cortisol-producing adenoma,while CYP11B2 immunoreactivity was absent in this adenoma.However,in the adjacent nonneoplastic adrenal,multiple CYP11B2-positive adrenocortical micronodules were detected,showing the presence of aldosterone-producing adrenocortical micronodules.CONCLUSION Careful clinical and pathological examination should be performed when a patient harboring AI presents with concomitant SCS and PA.

Characterization of focal hypermetabolic thyroid incidentaloma: An analysis with F-18 fluorodeoxyglucose positron emission tomography/computed tomography parameters

BACKGROUND Incidentally found thyroid tumor(thyroid incidentaloma,TI)on F-18 fluorodeoxyglucose(FDG)positron emission tomography-computed tomography(PETCT)is reported in 2.5%-5%of patients being investigated for non-thyroid purposes.Up to 50%of these cases have been diagnosed to be malignant by cytological/histological results.Ultrasonography(US)and fine-needle aspiration cytology are recommended for thyroid nodules with high FDG uptake(hypermetabolism)that are 1 cm or greater in size.It is important to accurately determine whether a suspicious hypermetabolic TI is malignant or benign.AIM To distinguish malignant hypermetabolic TIs from benign disease by analyzing F-18 FDG PET-CT parameters and to identify a cut-off value.METHODS Totally,12761 images of patients who underwent F-18 FDG PET-CT for nonthyroid purposes at our hospital between January 2016 and December 2020 were retrospectively reviewed,and 339 patients[185 men(mean age:68±11.2)and 154 women(mean age:63±15.0)]were found to have abnormal,either focal or diffuse,thyroid FDG uptake.After a thorough review of their medical records,US,and cytological/histological reports,46 eligible patients with focal hypermetabolic TI were included in this study.The TIs were categorized as malignant and benign according to the cytological/histological reports,and four PET parameters[standardized uptake value(SUV)max,SUV_(peak),SUV_(mean),and metabolic tumor volume(MTV)]were measured on FDG PET-CT.Total lesion glycolysis(TLG)was calculated by multiplying the SUV_(mean) by MTV.Both parametric and non-parametric methods were used to compare the five parameters between malignant and benign lesions.Receiver operating characteristic(ROC)curve analysis was performed to identify a cut-off value.RESULTS Each of the 46 patients[12 men(26.1%;mean age:62±13.1 years)and 34 women(73.9%;mean age:60±12.0 years)]with focal hypermetabolic TIs had one focal hypermetabolic TI.Among them,26(56.5%)were malignant and 20(43.5%)were benign.SUV_(max),SUV_(peak),SUV_(mean),and TLG were all higher in malignant lesions than benign ones,but the difference was statistically significant(P=0.012)only for SUV_(max).There was a positive linear correlation(r=0.339)between SUV_(max) and the diagnosis of malignancy.ROC curve analysis for SUV_(max) revealed an area under the curve of 0.702(P<0.05,95%confidence interval:0.550-0.855)and SUV_(max) cut-off of 8.5 with a sensitivity of 0.615 and a specificity of 0.789.CONCLUSION More than half of focal hypermetabolic TIs on F-18 FDG PET-CT were revealed as malignant lesions,and SUV_(max) was the best parameter for discriminating between malignant and benign disease.Unexpected focal hypermetabolic TIs with the SUV_(max) above the cut-off value of 8.5 may have a greater than 70%chance of malignancy;therefore,further active assessment is required.

Unilateral adrenal tuberculosis whose computed tomography imaging characteristics mimic a malignant tumor:A case report

BACKGROUND Adrenal tuberculosis usually presents with bilateral involvement.It has special characteristics in computed tomography(CT)images,such as small size,low attenuation in the center,and peripheral rim enhancement,which differ from those of primary tumors.CASE SUMMARY A 42-year-old female presented to the hospital with low back pain.She had been diagnosed with hypertension as well as pulmonary and cerebral tuberculosis but denied having any fever,fatigue,anorexia,night sweats,cough,or weight loss.Abdominal CT revealed an irregular 6.0 cm×4.5 cm mass with uneven density in the right adrenal gland,while the left adrenal gland was normal.No abnormalities were observed in plasma total cortisol(8 am),adrenocorticotropic hormone,aldosterone/renin ratio,blood catecholamines,or urine catecholamines.A fineneedle aspiration biopsy of the right adrenal gland provided evidence of tuberculosis.After three years of anti-tuberculosis treatments,the large mass in the right adrenal gland was reduced to a slight enlargement.CONCLUSION This is a case of unilateral adrenal tuberculosis with CT imaging characteristics mimicking those of a malignant tumor.Extended anti-tuberculosis therapy is recommended in such cases.

Primary Adrenal Tumors-Five Years Single Centre Experience

Primary adrenal tumors are less commonly encountered in clinic. They may be functional/non-functional and noted incidentally when investigating for other problems. However there is no study available in Asian countries, and especially India regarding the incidence and natural history of these tumors. We carried out a study on adrenal tumors noted in our set-up for last five years to document the prevalence of adrenal tumors, their presentation along with the most common tumor followed by incidence of other tumors and their clinical and pathological presentation. This was a retrospective study in our hospital from June 2006 to 2011. 29 adrenalectomies performed over 5 years. Their clinical presentation and investigations were recorded and analyzed. Adrenal tumors accounted for 0.6% of total surgical specimens, 18 out of 29 belonged to males. Majority (85.2%) of the patients were adults with mean age, 39.8 years. Majority (79.3%) had presented with symptoms, incidentalomas were found in 20.7% patients out of which 2 belonged to potential kidney donors. Nonfunctioning tumors were noted in 58.6% patients. Pheochromocytoma was the commonest tumor noted in 68.9% followed by adrenal cortical adenoma in 13.7%, carcinoma in 6.9% and lipoma, myelolipoma and ganglioneuroma, 3.45% each. All the patients are doing well over a mean follow-up of 2.5 years. To our knowledge this is the first study on incidence and natural history of primary adrenal tumors which are less commonly encountered and usually have good prognosis.

Multi-Detector-Row CT Diagnosis of Adrenal Incidentaloma in Patients with Hepatocellular Carcinoma

We investigate the diagnostic reliability of differentiating between lipid-poor adrenal adenomas and metastatic adrenal tumors originating from hepatocellular carcinoma (HCC) using a routine dynamic CT protocol for liver imaging. Eighteen metastatic adrenal tumors originating from HCC and 13 lipid-poor adrenal adenomas were identified. Dynamic CT data were analyzed for CT attenuation of adrenal lesions before and after contrast administration. When a cutoff of 36 HU was set for adrenal lesions at pre-contrast attenuation, the sensitivity and specificity for the diagnosis of metastatic lesions were 94.4%and 92.3%, respectively. Attenuation criteria on pre-contrast CT may help optimize the differentiation between these lesions.

Focal Thyroid Uptake during ¹⁸F-Choline PET/CT: A Case Report

Here we report the case of a 60-year-old patient previously affected by prostate cancer treated with prostatectomy. After surgery, the patient was scheduled for routine follow up examinations including biochemical and imaging evaluations. PSA testing evidenced a light, continuous increase in the course of the last four sampling. This finding calls for a biochemical recurrence. Thus the patient underwent a 18F-Fluorocholine (FCH) PET/CT to detect the possible sites of the relapse. FCH PET/CT did not disclose any focal uptake suggesting a metastatic spread. However, one focal uptake was noticed in the lower pole of the right thyroid lobe, corresponding to a hypodense nodule. Therefore, the patient was studied with 99 mTc thyroid scan and neck ultrasound. Both examinations had findings suspicious of a neoplasm. The fine needle aspiration biopsy (FNAB) that was carried out to rule out a malignancy, gave a TIR2 result. FCH PET/CT may give thyroidal uptakes in benign lesions.

Rare cause of abdominal incidentaloma: Hepatoduodenal ligament teratoma

The occurrence of a hepatoduodenal ligament teratoma is extremely rare,with only a few cases reported in the literature.This case report describes the discovery of a hepatoduodenal ligament lesion revealed during abdominal ultrasonography for cholelithiasis-related abdominal pain in a 27-year-old female.Cross-sectional imaging identified a 5 cm×4 cm heterogeneous mass of fat tissue with irregular calcification located in the posterior-superior aspect of the head of the pancreas.An encapsulated lesion showing no invasion to the common bile duct or adjacent organs and vessels was exposed during laparotomy and resected.Intraop-erative cholangiography during the cholecystectomy showed no abnormalities.The postoperative course was uneventful.Pathological analysis of the resected mass indicated hepatoduodenal ligament teratoma.This case report demonstrates that cross-sectional im-aging,such as computed tomography,can reveal sus-pected incidences of this rare type of teratoma,which can then be confirmed after pathologic analysis of the specimen.The prognosis after complete surgical resec-tion of lesions presenting with benign pathological fea-tures is excellent.

Pituitary apoplexy complicated with subarachnoid hemorrhage caused by incidentaloma following a head injury:case report

Plituitary apoplexy is a rare clinical syndrome caused by acute enlargement of pituitary adenomas, which may be secreting or nonfunctioning, and symptomatic or asymptomatic, resulted from hemorrhage or infarction. Subarachnoid hemorrhage （SAH） is an unusual presentation in patients with pituitary apoplexy, and that following a head injury is more infrequently reported. Here, we report a case of pituitary apoplexy complicated with subarachnoid hemorrhage caused by an incidentaloma after head trauma in an aged man, who experienced a spontaneous regression of the tumor.

Incidental thyroid uptake on PET scanning: epidemiology, clinical significance, and management challenge

Incidental lesions of the thyroid are increasingly discovered as the prevalence of medical imaging escalates.The likelihood of malignancy must be assessed for each of these incidentalomas.The utility of the metabolic data derived from the identification of these lesions on PET/CT imaging is unclear.The overall rate of detection of thyroid incidentalomas on PET/CT is estimated at 1.5%-4.2%.However,this rate varies by the pattern of uptake.Several studies have evaluated predictive measures such as maximal standardized uptake value(SUVmax)and radiomics.However,no definitive conclusion has been reached.Given that the majority of PET/CT scans are performed in the context of malignancy,we recommend first assessing the general condition and life expectancy of patients when PET-detected thyroid incidentalomas are unveiled.We also recommend considering observation versus diagnostic workup with further imaging and/or fine-needle aspiration and cytology.

Posterior mediastinal ganglioneuroma: A case report and literature review

Objectives: Ganglioneuroma is a rare, benign neurogenic tumor arising from the sympathetic ganglia. In this report, we reviewed and summarized the clinical features,treatment, and prognosis of a posterior mediastinal ganglioneuroma. Case: Here, we report on a 29-year-old man referred to us with transient pain in the right side of the chest, lasting for three days. Physical examination revealed no abnormalities.The results of routine laboratory tests were within the normal ranges. Thoracic spinal magnetic resonance imaging showed a well-defined, solid mass in the right paravertebral region at the T5-T8 level, measuring 7.5 cm × 4.2 cm × 1.5 cm. To accurately locate the lesion during surgery, O-arm intraoperative imaging was used in conjunction with the Stealth Station navigation system. The tumor was completely excised and no related complications occurred. The tumor was an encapsulated mass with a solid, homogenous, grayish-tan cut surface. Histopathological examinations confirmed that the mass was a ganglioneuroma. Conclusions: Ganglioneuroma is a rare, benign tumor. Prior to treatment, a careful imaging evaluation is necessary in order to obtain an accurate diagnosis. A definitive diagnosis can be made by histological examination. En bloc resection is the preferred treatment for ganglioneuroma as it has an excellent prognosis.