title: MANAGEMENT OF ENDOCRINE DISEASE: Imaging for the diagnosis of malignancy in incidentally discovered adrenal masses: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Adrenal masses are incidentally discovered in 5% of CT scans. In 2013/2014, 81 million CT examinations were undertaken in the USA and 5 million in the UK. However, uncertainty remains around the optimal imaging approach for diagnosing malignancy. We aimed to review the evidence on the accuracy of imaging tests for differentiating malignant from benign adrenal masses.
  
  
  METHODS
  A systematic review and meta-analysis was conducted.
  
  
  METHODS
  We searched MEDLINE, EMBASE, Cochrane CENTRAL Register of Controlled Trials, Science Citation Index, Conference Proceedings Citation Index, and ZETOC (January 1990 to August 2015). We included studies evaluating the accuracy of CT, MRI, or (18)F-fluoro-deoxyglucose (FDG)-PET compared with an adequate histological or imaging-based follow-up reference standard.
  
  
  RESULTS
  We identified 37 studies suitable for inclusion, after screening 5469 references and 525 full-text articles. Studies evaluated the accuracy of CT (n=16), MRI (n=15), and FDG-PET (n=9) and were generally small and at high or unclear risk of bias. Only 19 studies were eligible for meta-analysis. Limited data suggest that CT density >10HU has high sensitivity for detection of adrenal malignancy in participants with no prior indication for adrenal imaging, that is, masses with ≤10HU are unlikely to be malignant. All other estimates of test performance are based on too small numbers.
  
  
  CONCLUSIONS
  Despite their widespread use in routine assessment, there is insufficient evidence for the diagnostic value of individual imaging tests in distinguishing benign from malignant adrenal masses. Future research is urgently needed and should include prospective test validation studies for imaging and novel diagnostic approaches alongside detailed health economics analysis.
authors.affiliation: Institute of Applied Health Research.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Dinnes
authors.affiliation: Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Irina
authors.initials: I
authors.lastname: Bancos
authors.affiliation: Institute of Applied Health Research.
authors.forename: Lavinia
authors.initials: L
authors.lastname: Ferrante di Ruffano
authors.affiliation: Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK.
authors.forename: Vasileios
authors.initials: V
authors.lastname: Chortis
authors.affiliation: Institute of Applied Health Research.
authors.forename: Clare
authors.initials: C
authors.lastname: Davenport
authors.affiliation: Institute of Applied Health Research.
authors.forename: Susan
authors.initials: S
authors.lastname: Bayliss
authors.affiliation: Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK.
authors.forename: Anju
authors.initials: A
authors.lastname: Sahdev
authors.affiliation: Department of RadiologyQueen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Guest
authors.affiliation: Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Fassnacht
authors.affiliation: Institute of Applied Health Research.
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Deeks
authors.affiliation: Institute of Metabolism and Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK w.arlt@bham.ac.uk.
authors.forename: Wiebke
authors.initials: W
authors.lastname: Arlt
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000000981:diagnostic imaging*; D006801:Humans; D033162:Incidental Findings; D008279:Magnetic Resonance Imaging; D049268:Positron-Emission Tomography; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed