title: Distinguishing benign from malignant adrenal masses: multi-detector row CT protocol with 10-minute delay.
abstract: OBJECTIVE
  To retrospectively evaluate the accuracy of precontrast attenuation, relative percentage washout (RPW), and absolute percentage washout (APW) in distinguishing benign from malignant adrenal masses at multi-detector row computed tomography (CT).
  
  
  METHODS
  This HIPAA-compliant retrospective study had institutional review board approval; the need for informed consent was waived. One hundred twenty-two adrenal masses were evaluated in 99 patients (51 men, 48 women; age range, 37-86 years) who had undergone CT performed according to the study protocol and who either were given a pathologic diagnosis or underwent follow-up imaging. Unenhanced images were obtained before administration of 120 mL of an intravenous contrast agent with a 75-second scan delay. Delayed images were obtained after 10 minutes. RPW and APW were computed. Receiver operating characteristic (ROC) analysis was performed to compare mean attenuation and both RPW and APW. Analysis was first performed with the exclusion of pheochromocytomas, myelolipomas, and cysts. Precontrast attenuation criteria specific for benignity or malignancy were determined, and ROC analysis of results for the entire nonpheochromocytoma group was then performed.
  
  
  RESULTS
  By using an RPW of 37.5% and excluding cysts and myelolipomas, all malignant lesions were detected with a sensitivity of 100% (17 of 17 lesions) and a specificity of 95% (90 of 95 lesions). Area under the binomial ROC curve (A(z)) values were 0.912, 0.985, and 0.892 for precontrast attenuation, RPW, and APW, respectively. Precontrast attenuation of less than 0 or more than 43 HU indicated benign and malignant entities, respectively. Incorporation of these criteria into the APW analysis yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (93 of 95 lesions) for a threshold washout value of 52.0%. This attenuation-corrected APW generated the greatest A(z) value (ie, 0.988). Combining all the information available from the protocol yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (98 of 100 lesions) for differentiating benign from malignant masses.
  
  
  CONCLUSIONS
  Precontrast attenuation of less than 0 HU supercedes the washout profile in the evaluation of an individual adrenal mass. Noncalcified, nonhemorrhagic adrenal lesions with precontrast attenuation of more than 43 HU should be considered suspicious for malignancy.
authors.affiliation: Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, White 270, 55 Fruit St, Boston, MA 02114, USA. mlake2@partners.org
authors.forename: Michael A
authors.initials: MA
authors.lastname: Blake
authors.forename: Mannudeep K
authors.initials: MK
authors.lastname: Kalra
authors.forename: Ann T
authors.initials: AT
authors.lastname: Sweeney
authors.forename: Brian C
authors.initials: BC
authors.lastname: Lucey
authors.forename: Michael M
authors.initials: MM
authors.lastname: Maher
authors.forename: Dushyant V
authors.initials: DV
authors.lastname: Sahani
authors.forename: Elkan F
authors.initials: EF
authors.lastname: Halpern
authors.forename: Peter R
authors.initials: PR
authors.lastname: Mueller
authors.forename: Peter F
authors.initials: PF
authors.lastname: Hahn
authors.forename: Giles W
authors.initials: GW
authors.lastname: Boland
mesh_terms: D000307:Adrenal Gland Diseases / Q000000981:diagnostic imaging*; D000310:Adrenal Gland Neoplasms / Q000000981:diagnostic imaging*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods