Abstract
Aims: The rate of adrenal mass detection has increased due to the development of imaging modalities. It is vital to differentiate benign adrenal adenomas from other adrenal masses in order to establish whether an active management strategy is essential. Volumetric CT histogram analysis calculates the percentage of covered pixels in the negative attenuation region. The goal of this research was to evaluate the diagnostic utility of volume histogram analysis for adrenal tumors confirmed histopathologically as well as the ideal slice thickness for CT histogram analysis to differentiate between benign and malignant lesions with a density greater than 10 Hounsfield units (HU).
Methods: The research analyzed the CT images of 127 individuals with 136 adrenal masses that were verified histopathologically after resection (57 lipid-poor adenomas, 21 pheochromocytomas, 47 metastases, and 11 adrenocortical carcinomas). For imaging, a 40-row MDCT device (Siemens Medical Solution, Erlanger, Germany) was utilized. 1 mm and 5 mm unenhanced CT images were obtained. Two separate radiologists manually assessed the Hounsfield units (HU) of the masses. The 5th to 95th percentiles of HU values, as well as the minimum, mean, and maximum values, skewness, kurtosis, and variance, were calculated. Interobserver agreement was determined by means of the interclass correlation coefficient (ICC).
Results: The HU parameters for the malignant group were all higher than those of the benign group, and the difference in the 5 mm slice thickness was more significant than the 1 mm slice thickness. The difference between HUmin (P=0.007), HUmean and HUmedian (P <0.001), 5th to 50th (P <0.001), 75th (P=0.004), 90th (P=0.016), and 95th (P=0.049) percentiles was statistically significant. The malignant group had higher skewness and kurtosis than the benign group, while the benign group had higher variance. Statistically, the disparity between the variances was significant (P=0.046). The area under the curve (AUC) of the 25th percentile of the HU value was the highest (AUC=0.932; cut-off value=15; sensitivity=90.0%; specificity=85.7%).
Conclusion: Noninvasive volumetric CT histogram analysis can detect malignant adrenal masses from benign tumors before an operation. Histogram analysis benefits from thicker slices. HUmin, HUmean, HUmedian, percentile values, and variance can identify adrenal masses.
Supporting Institution
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors
Thanks
Dear Editor-in-Chief, Please find enclosed our manuscript entitled, “The Efficacy of Volumetric Computed Tomography Histogram Analysis in Adrenal Masses” by Mustafa Orhan Nalbant and Ercan Inci, which we would like to submit for publication as a scientific article. Thank you for your time and assistance. Sincerely, Mustafa Orhan Nalbant
References
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- Čtvrtlík F, Koranda P, Schovánek J, Škarda J, Hartmann I, Tüdös Z. Current diagnostic imaging of pheochromocytomas and implications for therapeutic strategy. Exp Ther Med. 2018;15(4):3151-3160.
- Ctvrtlík F, Herman M, Student V, Tichá V, Minarík J. Differential diagnosis of incidentally detected adrenal masses revealed on routine abdominal CT. Eur J Radiol. 2009;69(2):243-252.
- 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(1):201-204.
- Korobkin M, Brodeur FJ, Yutzy GG, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol. 1996;166(3):531-536.
- Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions:principles, techniques, and algorithms for imaging characterization. Radiology. 2008;249(3):756-775.
- Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR. Characterization of indeterminate (lipid-poor) adrenal masses:use of washout characteristics at contrast-enhanced CT. Radiology. 2000;217(3):798-802.
- Park BK, Kim CK, Kim B, Lee JH. Comparison of delayed enhanced CT and chemical shift MR for evaluating hyperattenuating incidental adrenal masses. Radiology. 2007;243(3):760-765.
- Bae KT, Fuangtharnthip P, Prasad SR, Joe BN, Heiken JP. Adrenal masses: CT characterization with histogram analysis method. Radiology. 2003;228(3):735-742.
- Fassnacht M, Arlt W, Bancos I, et al. 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. 2016;175(2):1-34.
- Zhu Q, Zou J, Ye J, Zhu W, Wu J, Chen W. Comparative study of conventional ROI-based and volumetric histogram analysis derived from CT enhancement in differentiating malignant and benign renal tumors. Br J Radiol. 2022;95(1135):20210801.
- Flechsig P, Kratochwil C, Schwartz LH, et al. Quantitative volumetric CT-histogram analysis in N-staging of 18F-FDG-equivocal patients with lung cancer. J Nucl Med. 2014;55(4):559-564.
- Lu J, Hu D, Tang H, et al. Assessment of tumor heterogeneity: differentiation of periampullary neoplasms based on CT whole-lesion histogram analysis. Eur J Radiol. 2019;115:1-9.
- Tanabe M, Kunihiro Y, Higashi M, et al. Pancreatic Steatosis Evaluated by Automated Volumetric CT Fat Fraction of the Pancreas:Association with Severity in COVID-19 Pneumonia. Tomography. 2022;8(6):2806-2814.
- Lee JW, Kim EY, Kim DJ, et al. The diagnostic ability of 18F-FDG PET/CT for mediastinal lymph node staging using 18F-FDG uptake and volumetric CT histogram analysis in non-small cell lung cancer. Eur Radiol. 2016;26(12):4515-4523.
- Ho LM, Paulson EK, Brady MJ, Wong TZ, Schindera ST. Lipid-poor adenomas on unenhanced CT:does histogram analysis increase sensitivity compared with a mean attenuation threshold? AJR Am J Roentgenol. 2008;191(1):234-238.
- Jhaveri KS, Wong F, Ghai S, Haider MA. Comparison of CT histogram analysis and chemical shift MRI in the characterization of indeterminate adrenal nodules. AJR Am J Roentgenol. 2006;187(5):1303-1308.
- Halefoglu AM, Yasar A, Bas N, Ozel A, Erturk SM, Basak M. Comparison of computed tomography histogram analysis and chemical-shift magnetic resonance imaging for adrenal mass characterization. Acta Radiol. 2009;50(9):1071-1079.
- Lin MF, Chang-Sen LQ, Heiken JP, Pilgram TK, Bae KT. Histogram analysis for characterization of indeterminate adrenal nodules on noncontrast CT. Abdom Imaging. 2015;40(6):1666-1674.
- Szász P, Kučera P, Čtvrtlík F, Langová K, Hartmann I, Tüdös Z. Diagnostic value of unenhanced CT attenuation and CT histogram analysis in differential diagnosis of adrenal tumors. Medicina (Kaunas). 2020;56(11):597.
- Sprawls P. AAPM tutorial. CT image detail and noise. Radiographics. 1992;12(5):1041-1046.
- Tongdee R, Tongdee T, Goo J, Bae K, Comparison of CT histogram analysis and mean attenuation methods in characterization of adrenal masses: a phantom study. Radiological Society of North America. 2004 Scientific Assembly and Annual Meeting, November 28 - December 3,. 2004 ,Chicago IL. http://archive.rsna.org/2004/4412135.html Accessed April 2,. 2023.
- Halefoglu AM, Bas N, Yasar A, Basak M. Differentiation of adrenal adenomas from nonadenomas using CT histogram analysis method:a prospective study. Eur J Radiol. 2010;73(3):643-651.
- Remer EM, Motta-Ramirez GA, Shepardson LB, Hamrahian AH, Herts BR. CT histogram analysis in pathologically proven adrenal masses. AJR Am J Roentgenol. 2006;187(1):191-196.
- Tüdös Z, Kučera P, Szász P, et al. Influence of slice thickness on result of CT histogram analysis in indeterminate adrenal masses. Abdom Radiol (NY). 2019;44(4):1461-1469.
- Clark TJ, Hsu LD, Hippe D, Cowan S, Carnell J, Wang CL. Evaluation of diagnostic accuracy: multidetector CT image noise correction improves specificity of a Gaussian model-based algorithm used for characterization of incidental adrenal nodules. Abdom Radiol (NY). 2019;44(3):1033-1043.
- Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Pheochromocytoma as a frequent false-positive in adrenal washout CT: a systematic review and meta-analysis. Eur Radiol. 2018;28(3):1027-1036.
- Choi YA, Kim CK, Park BK, Kim B. Evaluation of adrenal metastases from renal cell carcinoma and hepatocellular carcinoma:use of delayed contrast-enhanced CT. Radiology. 2013;266(2):514-520.
- Canu L, Van Hemert JAW, Kerstens MN, et al. CT characteristics of pheochromocytoma: relevance for the evaluation of adrenal incidentaloma. J Clin Endocrinol Metab. 2019;104(2):312-318.
Abstract
References
- Bovio S, Cataldi A, Reimondo G, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest. 2006;29(4):298-302.
- Čtvrtlík F, Koranda P, Schovánek J, Škarda J, Hartmann I, Tüdös Z. Current diagnostic imaging of pheochromocytomas and implications for therapeutic strategy. Exp Ther Med. 2018;15(4):3151-3160.
- Ctvrtlík F, Herman M, Student V, Tichá V, Minarík J. Differential diagnosis of incidentally detected adrenal masses revealed on routine abdominal CT. Eur J Radiol. 2009;69(2):243-252.
- 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(1):201-204.
- Korobkin M, Brodeur FJ, Yutzy GG, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenuation values. AJR Am J Roentgenol. 1996;166(3):531-536.
- Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions:principles, techniques, and algorithms for imaging characterization. Radiology. 2008;249(3):756-775.
- Peña CS, Boland GW, Hahn PF, Lee MJ, Mueller PR. Characterization of indeterminate (lipid-poor) adrenal masses:use of washout characteristics at contrast-enhanced CT. Radiology. 2000;217(3):798-802.
- Park BK, Kim CK, Kim B, Lee JH. Comparison of delayed enhanced CT and chemical shift MR for evaluating hyperattenuating incidental adrenal masses. Radiology. 2007;243(3):760-765.
- Bae KT, Fuangtharnthip P, Prasad SR, Joe BN, Heiken JP. Adrenal masses: CT characterization with histogram analysis method. Radiology. 2003;228(3):735-742.
- Fassnacht M, Arlt W, Bancos I, et al. 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. 2016;175(2):1-34.
- Zhu Q, Zou J, Ye J, Zhu W, Wu J, Chen W. Comparative study of conventional ROI-based and volumetric histogram analysis derived from CT enhancement in differentiating malignant and benign renal tumors. Br J Radiol. 2022;95(1135):20210801.
- Flechsig P, Kratochwil C, Schwartz LH, et al. Quantitative volumetric CT-histogram analysis in N-staging of 18F-FDG-equivocal patients with lung cancer. J Nucl Med. 2014;55(4):559-564.
- Lu J, Hu D, Tang H, et al. Assessment of tumor heterogeneity: differentiation of periampullary neoplasms based on CT whole-lesion histogram analysis. Eur J Radiol. 2019;115:1-9.
- Tanabe M, Kunihiro Y, Higashi M, et al. Pancreatic Steatosis Evaluated by Automated Volumetric CT Fat Fraction of the Pancreas:Association with Severity in COVID-19 Pneumonia. Tomography. 2022;8(6):2806-2814.
- Lee JW, Kim EY, Kim DJ, et al. The diagnostic ability of 18F-FDG PET/CT for mediastinal lymph node staging using 18F-FDG uptake and volumetric CT histogram analysis in non-small cell lung cancer. Eur Radiol. 2016;26(12):4515-4523.
- Ho LM, Paulson EK, Brady MJ, Wong TZ, Schindera ST. Lipid-poor adenomas on unenhanced CT:does histogram analysis increase sensitivity compared with a mean attenuation threshold? AJR Am J Roentgenol. 2008;191(1):234-238.
- Jhaveri KS, Wong F, Ghai S, Haider MA. Comparison of CT histogram analysis and chemical shift MRI in the characterization of indeterminate adrenal nodules. AJR Am J Roentgenol. 2006;187(5):1303-1308.
- Halefoglu AM, Yasar A, Bas N, Ozel A, Erturk SM, Basak M. Comparison of computed tomography histogram analysis and chemical-shift magnetic resonance imaging for adrenal mass characterization. Acta Radiol. 2009;50(9):1071-1079.
- Lin MF, Chang-Sen LQ, Heiken JP, Pilgram TK, Bae KT. Histogram analysis for characterization of indeterminate adrenal nodules on noncontrast CT. Abdom Imaging. 2015;40(6):1666-1674.
- Szász P, Kučera P, Čtvrtlík F, Langová K, Hartmann I, Tüdös Z. Diagnostic value of unenhanced CT attenuation and CT histogram analysis in differential diagnosis of adrenal tumors. Medicina (Kaunas). 2020;56(11):597.
- Sprawls P. AAPM tutorial. CT image detail and noise. Radiographics. 1992;12(5):1041-1046.
- Tongdee R, Tongdee T, Goo J, Bae K, Comparison of CT histogram analysis and mean attenuation methods in characterization of adrenal masses: a phantom study. Radiological Society of North America. 2004 Scientific Assembly and Annual Meeting, November 28 - December 3,. 2004 ,Chicago IL. http://archive.rsna.org/2004/4412135.html Accessed April 2,. 2023.
- Halefoglu AM, Bas N, Yasar A, Basak M. Differentiation of adrenal adenomas from nonadenomas using CT histogram analysis method:a prospective study. Eur J Radiol. 2010;73(3):643-651.
- Remer EM, Motta-Ramirez GA, Shepardson LB, Hamrahian AH, Herts BR. CT histogram analysis in pathologically proven adrenal masses. AJR Am J Roentgenol. 2006;187(1):191-196.
- Tüdös Z, Kučera P, Szász P, et al. Influence of slice thickness on result of CT histogram analysis in indeterminate adrenal masses. Abdom Radiol (NY). 2019;44(4):1461-1469.
- Clark TJ, Hsu LD, Hippe D, Cowan S, Carnell J, Wang CL. Evaluation of diagnostic accuracy: multidetector CT image noise correction improves specificity of a Gaussian model-based algorithm used for characterization of incidental adrenal nodules. Abdom Radiol (NY). 2019;44(3):1033-1043.
- Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Pheochromocytoma as a frequent false-positive in adrenal washout CT: a systematic review and meta-analysis. Eur Radiol. 2018;28(3):1027-1036.
- Choi YA, Kim CK, Park BK, Kim B. Evaluation of adrenal metastases from renal cell carcinoma and hepatocellular carcinoma:use of delayed contrast-enhanced CT. Radiology. 2013;266(2):514-520.
- Canu L, Van Hemert JAW, Kerstens MN, et al. CT characteristics of pheochromocytoma: relevance for the evaluation of adrenal incidentaloma. J Clin Endocrinol Metab. 2019;104(2):312-318.
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| Primary Language | English |
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| Subjects | Radiology and Organ Imaging, Health Care Administration |
| Journal Section | Original Article |
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| Early Pub Date | July 28, 2023 |
| Publication Date | July 30, 2023 |
| Published in Issue | Year 2023 Volume: 6 Issue: 4 |
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