title: Dynamic contrast enhanced MRI in the differential diagnosis of adrenal adenomas and malignant adrenal masses.
abstract: OBJECTIVE
  To evaluate the value of dynamic MR imaging in the differential diagnosis of adrenal adenomas and malignant tumors, especially in cases with atypical adenomas.
  
  
  METHODS
  Sixty-four masses (48 adenomas, 16 malignant tumors) were included in this prospective study. Signal loss of masses was evaluated using chemical shift MR imaging. Five dynamic series of T1-weighted spoiled gradient echo (FFE) images were obtained, with the acquisition starting simultaneously with i.v. contrast administration (0-100 s) followed by a T1-weighted FFE sequence in the late phase (5th minute). Contrast enhancement patterns in the early (25th second) and late (5th minute) phase images were evaluated. For the quantitative evaluation, signal intensity (SI)-time curves were obtained according to the SIs on the 0th, 25th, 50th 75th and 100th second. Also, the wash-in rate, maximum relative enhancement, time-to-peak, and wash-out of contrast at 100 s of masses in both groups were calculated. The statistical significance was determined by Mann-Whitney U test. To evaluate the diagnostic performance of the quantitative tests, receiver operating characteristic (ROC) analysis was performed.
  
  
  RESULTS
  Chemical shift MR imaging was able to differentiate 44 out of 48 adenomas (91.7%) from non-adenomas. The 4 adenomas (8.3%) which could not be differentiated from non-adenomas by this technique did not exhibit signal loss on out-of-phase images. With a cut-off value of 30, SI indices of adenomas had a sensitivity of 93.8%, specificity of 100% and a positive predictive value of 100%. On visual evaluation of dynamic MR imaging, early phase contrast enhancement patterns were homogeneous in 75% and punctate in 20,83% of the adenomas; while patchy in 56.25% and peripheral in 25% of the malignant tumors. On the late phase images 58.33% of the adenomas showed peripheral ring-shaped enhancement and 10.41% showed heterogeneous enhancement. All of the malignant masses showed heterogeneous enhancement. At the 25th second, the SIs and wash-in rates of the adenomas were significantly higher than those of the malignant masses (p=0.010). Time-to-peak enhancement of the malignant masses was significantly longer than that of the adenomas. With a cut-off value of 52.85 s, the time-to-peak enhancement had 87.5% sensitivity and 80% specificity.
  
  
  CONCLUSIONS
  Chemical shift MR has a high sensitivity and specificity in the differential diagnosis of adenomas and malignant adrenal masses. However, taking into consideration only the atypical adenomas, chemical shift MRI is of no diagnostic value. Although the diagnostic value of dynamic MRI is lower than chemical shift MRI, in the atypical cases contrast enhancement patterns and time-to-peak and wash-in rates derived from SI-time curve of dynamic MRI give are contributory to the results of chemical shift MRI.
authors.affiliation: Department of Radiology, School of Medicine, University of Kocaeli, 41380 Umuttepe, Kocaeli, Turkey. inannagihan@ekolay.net
authors.forename: Nagihan
authors.initials: N
authors.lastname: Inan
authors.forename: Arzu
authors.initials: A
authors.lastname: Arslan
authors.forename: Gur
authors.initials: G
authors.lastname: Akansel
authors.forename: Yonca
authors.initials: Y
authors.lastname: Anik
authors.forename: N Cem
authors.initials: NC
authors.lastname: Balci
authors.forename: Ali
authors.initials: A
authors.lastname: Demirci
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000175:diagnosis*; D018246:Adrenocortical Adenoma / Q000175:diagnosis*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003287:Contrast Media; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric
chemical_list: D003287:Contrast Media