Clinical indications, safety, and effectiveness of percutaneous image-guided adrenal mass biopsy: an 8-year retrospective analysis in 160 patients.

PURPOSE: To assess indications, safety, and effectiveness of percutaneous adrenal mass biopsy in contemporary practice. METHODS: This institutional review board-approved, retrospective study included all patients undergoing percutaneous image-guided adrenal mass biopsies at an academic health system from January 6, 2015, to January 6, 2023. Patient demographics, biopsy indications, mass size, laboratory data, pathology results, and complications were recorded. Final diagnoses were based on pathology or ≥ 1 year of imaging follow-up when biopsy specimens did not yield malignant tissue. Test performance calculations excluded repeat biopsies. Continuous variables were compared with Student's t test, dichotomous variables with chi-squared test. RESULTS: A total of 160 patients underwent 186 biopsies. Biopsies were indicated to diagnose metastatic disease (139/186; 74.7%), for oncologic research only (27/186; 14.5%), diagnose metastatic disease and oncologic research (15/186; 8%), and diagnose an incidental adrenal mass (5/186; 2.7%). Biopsy specimens were diagnostic in 154 patients (96.3%) and non-diagnostic in 6 (3.8%). Diagnostic biopsies yielded malignant tissue (n = 136), benign adrenal tissue (n = 12), and benign adrenal neoplasms (n = 6) with sensitivity = 98.6% (136/138), specificity = 100% (16/16), positive predictive value = 100% (136/136), and negative predictive value = 88.9% (16/18). Adverse events followed 11/186 procedures (5.9%) and most minor (7/11, 63.6%). The adverse event rate was similar whether tissue was obtained for clinical or research purposes (10/144; 6.9% vs. 1/42; 2.4%, p = 0.27), despite more specimens obtained for research (5.8 vs. 3.7, p < 0.001). CONCLUSION: Percutaneous adrenal mass biopsy is safe, accurate, and utilized almost exclusively to diagnose metastatic disease or for oncologic research. The negative predictive value is high when diagnostic tissue samples are obtained. Obtaining specimens for research does not increase adverse event risk.

Can 3-Phase Computed Tomography Urography Be Used to Characterize Adrenal Nodules? Results in 145 Patients.

OBJECTIVE: The aim of the study is to determine whether computed tomography (CT) urography (CTU) can characterize incidental adrenal nodules. METHODS: This retrospective cohort study was performed at an academic medical center. Patients were identified by free text search of CTU reports that contained the terms "adrenal mass" "adrenal nodule" and "adrenal lesion." Computed tomography urography technique consisted of unenhanced images and postcontrast images obtained at 100 seconds and 15 minutes. The final cohort included 145 patients with 151 adrenal nodules. Nodules were considered lipid-rich adenomas or myelolipomas based on unenhanced imaging characteristics. Absolute and relative washout values were calculated for the remaining nodules, using a cutoff of 60% and 40%, respectively, to diagnose adenomas. Reference standard for lipid-poor adenomas and malignant nodules was histopathology or imaging/clinical follow-up. Mann-Whitney U test was used for comparison of continuous variables, and Fisher exact test was used for categorical variables. RESULTS: One hundred nodules were lipid-rich adenomas and 3 were myelolipomas. Forty-eight nodules were indeterminate at unenhanced CT, corresponding to 39 lipid-poor adenomas and 9 malignant nodules based on reference standards. Both absolute and relative washout correctly characterized 71% of nodules (34/48), with a sensitivity of 67% and specificity of 89%. Overall, 91% of all adrenal nodules (137/151) were correctly characterized by CTU alone. Lipid-poor adenomas were smaller than malignant nodules ( P < 0.01) and were lower in attenuation on unenhanced and delayed images ( P < 0.01). CONCLUSIONS: Adrenal nodules detected at 3-phase CTU can be accurately characterized, potentially eliminating the need for subsequent adrenal protocol CT or magnetic resonance imaging.

Lexicon for adrenal terms at CT and MRI: a consensus of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel.

PURPOSE: Substantial variation in imaging terms used to describe the adrenal gland and adrenal findings leads to ambiguity and uncertainty in radiology reports and subsequently their understanding by referring clinicians. The purpose of this study was to develop a standardized lexicon to describe adrenal imaging findings at CT and MRI. METHODS: Fourteen members of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel (SAR-DFP) including one endocrine surgeon participated to develop an adrenal lexicon using a modified Delphi process to reach consensus. Five radiologists prepared a preliminary list of 35 imaging terms that was sent to the full group as an online survey (19 general imaging terms, 9 specific to CT, and 7 specific to MRI). In the first round, members voted on terms to be included and proposed definitions; subsequent two rounds were used to achieve consensus on definitions (defined as ≥ 80% agreement). RESULTS: Consensus for inclusion was reached on 33/35 terms with two terms excluded (anterior limb and normal adrenal size measurements). Greater than 80% consensus was reached on the definitions for 15 terms following the first round, with subsequent consensus achieved for the definitions of the remaining 18 terms following two additional rounds. No included term had remaining disagreement. CONCLUSION: Expert consensus produced a standardized lexicon for reporting adrenal findings at CT and MRI. The use of this consensus lexicon should improve radiology report clarity, standardize clinical and research terminology, and reduce uncertainty for referring providers when adrenal findings are present.

Machine Learning for Adrenal Gland Segmentation and Classification of Normal and Adrenal Masses at CT.

Background Adrenal masses are common, but radiology reporting and recommendations for management can be variable. Purpose To create a machine learning algorithm to segment adrenal glands on contrast-enhanced CT images and classify glands as normal or mass-containing and to assess algorithm performance. Materials and Methods This retrospective study included two groups of contrast-enhanced abdominal CT examinations (development data set and secondary test set). Adrenal glands in the development data set were manually segmented by radiologists. Images in both the development data set and the secondary test set were manually classified as normal or mass-containing. Deep learning segmentation and classification models were trained on the development data set and evaluated on both data sets. Segmentation performance was evaluated with use of the Dice similarity coefficient (DSC), and classification performance with use of sensitivity and specificity. Results The development data set contained 274 CT examinations (251 patients; median age, 61 years; 133 women), and the secondary test set contained 991 CT examinations (991 patients; median age, 62 years; 578 women). The median model DSC on the development test set was 0.80 (IQR, 0.78-0.89) for normal glands and 0.84 (IQR, 0.79-0.90) for adrenal masses. On the development reader set, the median interreader DSC was 0.89 (IQR, 0.78-0.93) for normal glands and 0.89 (IQR, 0.85-0.97) for adrenal masses. Interreader DSC for radiologist manual segmentation did not differ from automated machine segmentation (P = .35). On the development test set, the model had a classification sensitivity of 83% (95% CI: 55, 95) and specificity of 89% (95% CI: 75, 96). On the secondary test set, the model had a classification sensitivity of 69% (95% CI: 58, 79) and specificity of 91% (95% CI: 90, 92). Conclusion A two-stage machine learning pipeline was able to segment the adrenal glands and differentiate normal adrenal glands from those containing masses. © RSNA, 2022 Online supplemental material is available for this article.

ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update.

The appropriate evaluation of adrenal masses is strongly dependent on the clinical circumstances in which it is discovered. Adrenal incidentalomas are masses that are discovered on imaging studies that have been obtained for purposes other than adrenal disease. Although the vast majority of adrenal incidentalomas are benign, further radiological and biochemical evaluation of these lesions is important to arrive at a specific diagnosis. Patients with a history of malignancy or symptoms of excess hormone require different imaging evaluations than patients with incidentalomas. This document reviews imaging approaches to adrenal masses and the various modalities utilized in evaluation of adrenal lesions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Incidental Adrenal Nodules.

Incidentally detected adrenal nodules are common, and prevalence increases with patient age. Although most are benign, it is important for the radiologist to be able to accurately determine which nodules require further testing and which are safely left alone. The American College of Radiology incidental adrenal White Paper provides a structured algorithm based on expert consensus for management of incidental adrenal nodules. If further diagnostic testing is indicated, adrenal computed tomography is the most appropriate test in patients for nodules less than 4 cm. In addition to imaging, biochemical testing and endocrinology referral is warranted to exclude a functioning mass.

Radiology Workload Changes During the COVID-19 Pandemic: Implications for Staff Redeployment.

RATIONALE AND OBJECTIVES: Quantify changes in total and by-subspecialty radiology workload due to deferring nonurgent services during the initial COVID-19 pandemic, and describe operational strategies implemented due to shifts in priority. MATERIALS AND METHODS: This retrospective, Institutional Review Board-exempt, study was performed between February 3, 2020 and April 19, 2020 at a large academic medical center. During March 9-15 (intervention period), nonurgent outpatient service deferments began. Five-week periods pre- (baseline) and postintervention (COVID) were defined. Primary outcomes were radiology volume (reports per day) overall and in 11 subspecialty divisions. Linear regression assessed relationship between baseline vs. COVID volumes stratified by division. Secondary outcomes included changes in relative value units (RVUs), inpatient and outpatient volumes. RESULTS: There were 62,791 baseline reports vs. 23,369 during COVID; a 60% overall precipitous volume decrease (p < 0.001). Mean volume decrease pre- and during-COVID was significant (p < 0.001) amongst all individual divisions. Mean volume decrease differed amongst divisions: Interventional Radiology experienced least disruption (29% volume decrease), 7 divisions experienced 40%-60% decreases, and Musculoskeletal, Breast, and Cardiovascular imaging experienced >75% volume decrease. Total RVUs decreased 60% (71,186 baseline; 28,476 COVID). Both outpatient and inpatient report volumes decreased; 72% (41,115 baseline; 11,326 COVID) and 43% (12,626 baseline vs. 6,845 COVID), respectively. In labor pool tracking data, 21.8% (162/744) total radiology employees were reassigned to other hospital duties during the intervention period. CONCLUSION: Precipitous radiology workload reductions impacted subspecialty divisions with marked variation. Data-driven operational decisions during COVID-19 assisted workflow and staffing assignment changes. Ongoing adjustments will be needed as healthcare systems transition operations to a "new normal."

Trainee and Attending Perspectives on Remote Radiology Readouts in the Era of the COVID-19 Pandemic.

RATIONALE AND OBJECTIVES: Social distancing mandates due to COVID-19 have necessitated adaptations to radiology trainee workflow and educational practices, including the radiology "readout." We describe how a large academic radiology department achieved socially distant "remote readouts," provide trainee and attending perspectives on this early experience, and propose ways by which "remote readouts" can be used effectively by training programs beyond COVID-19. MATERIALS AND METHODS: Beginning March 2020, radiologists were relocated to workspaces outside of conventional reading rooms. Information technologies were employed to allow for "remote readouts" between trainees and attendings. An optional anonymous open-ended survey regarding remote readouts was administered to radiology trainees and attendings as a quality improvement initiative. From the responses, response themes were abstracted using thematic analysis. Descriptive statistics of the qualitative data were calculated. RESULTS: Radiologist workstations from 14 traditional reading rooms were relocated to 36 workspaces across the hospital system. Two models of remote readouts, synchronous and asynchronous, were developed, facilitated by commercially available information technologies. Thirty-nine of 105 (37%) trainees and 42 of 90 (47%) attendings responded to the survey. Main response themes included: social distancing, technology, autonomy/competency, efficiency, education/feedback and atmosphere/professional relationship. One hundred and forty-eight positive versus 97 negative comments were reported. Social distancing, technology, and autonomy/competency were most positively rated. Trainees and attending perspectives differed regarding the efficiency of remote readouts. CONCLUSION: "Remote readouts," compliant with social distancing measures, are feasible in academic radiology practice settings. Perspectives from our initial experience provide insight into how this can be accomplished, opportunities for improvement and future application, beyond the COVID-19 pandemic.

Management of incidental adrenal masses: an update.

OBJECTIVE: To review the current evidence and guidelines for diagnosis and management of incidental adrenal masses with a focus on the recent changes made by the American College of Radiology (ACR) Incidental Findings Committee. CONCLUSION: Incidentally detected adrenal nodules are a commonly encountered finding estimated to occur in 5-7% of the adult population. By following current recommendations, radiologists can improve patient care by efficiently determining which masses require further diagnostic testing and which masses can be considered benign and not require further follow-up.

Variability in the Use of Simulation for Procedural Training in Radiology Residency: Opportunities for Improvement.

OBJECTIVE: Increased attention to quality and safety has led to a re-evaluation of the classic apprenticeship model for procedural training. Many have proposed simulation as a supplementary teaching tool. The purpose of this study was to assess radiology resident exposure to procedural training and procedural simulation. MATERIALS AND METHODS: An IRB-exempt online survey was distributed to current radiology residents in the United States by e-mail. Survey results were summarized using frequency and percentages. Chi-square tests were used for statistical analysis where appropriate. RESULTS: A total of 353 current residents completed the survey. 37% (n = 129/353) of respondents had never used procedure simulation. Of the residents who had used simulation, most did not do so until after having already performed procedures on patients (59%, n = 132/223). The presence of a dedicated simulation center was reported by over half of residents (56%, n = 196/353) and was associated with prior simulation experience (P = 0.007). Residents who had not had procedural simulation were somewhat likely or highly likely (3 and 4 on a 4-point Likert-scale) to participate if it were available (81%, n = 104/129). Simulation training was associated with higher comfort levels in performing procedures (P < 0.001). CONCLUSIONS: Although procedural simulation training is associated with higher comfort levels when performing procedures, there is variable use in radiology resident training and its use is not currently optimized. Given the increased emphasis on patient safety, these results suggest the need to increase procedural simulation use during residency, including an earlier introduction to simulation before patient exposure.

Radiologist Preferences, Agreement, and Variability in Phrases Used to Convey Diagnostic Certainty in Radiology Reports.

PURPOSE: To understand radiologists' preference and variability in phrases for expressing diagnostic certainty in radiology reports. MATERIALS AND METHODS: This institutional review board-approved study was part of a quality improvement initiative to improve the quality of radiology reports at a tertiary academic hospital. Sixteen phrases commonly used in radiology reports to convey diagnostic certainty were extracted from prior publications. The degree of diagnostic certainty was divided into six arbitrary categories by an expert panel. We used an anonymous online survey to query 239 radiologists at our institution regarding their preferred phrase for each category. We evaluated the distribution of preferred phrases, performed cluster analysis to find groups of phrases used to describe specific diagnostic certainty categories, and calculated Krippendorff's α to evaluate how reliably radiologists use various phrases to express diagnostic certainty. FINDINGS: In all, 59.4% (142 of 239) of radiologists completed the survey. The most commonly preferred phrases were "consistent with" (45.1%; 64 of 142) for 100% confident, "highly suggestive of" (46.5%; 66 of 142) for very high likelihood, "most likely" (31.0%; 44 of 142) for high likelihood, "may represent" (50.7%; 72 of 142) for intermediate likelihood, "unlikely" (47.2%; 67 of 142) for low likelihood, and "very unlikely" (40.1%; 57 of 142) for very low likelihood. Cluster analysis identified six groups of phrases used to indicate a similar level of diagnostic certainty; however, Krippendorff's α was 0.217, indicating radiologists do not consistently use the same phrases for similar degrees of confidence. CONCLUSION: Wide variability persists among radiologists' preferences for phrases used to convey diagnostic certainty. Interventions to improve consistency of use of these phrases may help reduce ambiguity and improve quality of radiology reports.

Navigating Uncertainty in the Management of Incidental Findings.

The lack of prospective outcomes studies for many types of incidental findings limits our understanding of both their natural history and the potential efficacy of treatment. To support decision making for the management of incidental findings, major sources of uncertainty in management pathways can be mapped and analyzed using mathematical models. This process yields important insights into how uncertainty influences the best treatment decision. Here, we consider a classification scheme, grounded in decision science, which exposes various levels and types of uncertainty in the management of incidental findings and addresses (1) disease-related risks, which are considered in context of a patient's competing causes of mortality; (2) potential degrees of intervention; (3) strength of evidence; and (4) patients' treatment-related preferences. Herein we describe how categorizing uncertainty by the sources, issues, and locus can build a framework from which to improve the management of incidental findings. Accurate and comprehensive handling of uncertainty will improve the quality of related decision making and will help guide future research priorities.

Should Renal Mass Biopsy Be Performed prior to or Concomitantly with Thermal Ablation?

PURPOSE: To determine diagnostic yield of renal biopsies performed in patients referred for image-guided tumor ablation (IGTA) and the frequency with which biopsy results would have obviated the need for subsequent ablation. MATERIALS AND METHODS: Retrospective review of an internal ablation database of a single institution revealed 401 consecutive percutaneous renal mass IGTAs performed from April 2000 to April 2015. Of 401 ablations, 32 were excluded, yielding 369 ablation events in 342 patients, which represented the study cohort. Patients were subdivided into groups according to whether or not biopsy was performed. Lesions were categorized according to size, malignancy/benignity, and pathology. RESULTS: IGTA was performed with biopsy for 317/369 (85.9%) and without biopsy for 52/369 (14.1%) lesions. Overall diagnostic yield for percutaneous biopsy was 94.3% (299/317). Based on biopsy results, 82.6% (262/317) were classified as malignant or suspicious, 9.5% (30/317) were classified as likely benign, and 2.2% (7/317) were classified as definitively benign. Only definitively benign lesions were designated as obviating the need for IGTA. IGTA was supported by biopsy results in the remaining 97.8% (310/317), including renal cell carcinomas, oncocytic neoplasms, metastases, and nondiagnostic biopsy results. CONCLUSIONS: Biopsy of renal masses with suspicious imaging features rarely (2.2%) obviated the need for IGTA. For patients who have undergone counseling and have elected to forgo active surveillance and surgical options, biopsy can safely be performed concomitantly with ablation.

Automated Delivery of Clinical Follow-Up to the Radiologist via E-Mail: Feasibility Study of a New Information Technology Algorithm.

OBJECTIVE: The purposes of this study were to develop an automated process for radiologists to obtain clinical follow-up on radiology reports via HIPAA-compliant e-mail and to determine what follow-up data were collected and whether they were relevant to the radiology reports. CONCLUSION: The algorithm generated high-yield follow-up data for radiologists that may improve patient care by facilitating radiologist engagement and self-assessment.

Customized Residency Leadership Tracks: A Review of What Works, What We're Doing and Ideas for the Future.

Effective leaders are essential to ensure the future of radiology. Radiologists often find themselves in leadership positions despite a lack of formal leadership training. The fourth year of residency is the ideal time to expose young physicians to leadership and extraclinical specialization, as such leadership development prior to fellowship may still impact academic career choice. In this manuscript, we discuss prior successes of leadership tracks within medicine and review the evidence supporting the saying that "leaders are made, not born". Finally, we describe the evolution of our institution's residency leadership tracks highlighting key components, challenges, early successes and future endeavors.

Incidentally Detected Bilateral Adrenal Nodules in Patients Without Cancer: Is Further Workup Necessary?

OBJECTIVE: The purpose of this study was to determine the rate of malignancy in incidentally detected bilateral adrenal masses in patients with no known history of cancer. MATERIALS AND METHODS: A retrospective search of CT reports of patients with incidentally detected bilateral adrenal nodules was performed from January 1, 2002, to January 1, 2014. Patients were excluded if they had a known cancer or suspected functioning adrenal tumor; 161 patients were included. Nodules were characterized as benign or malignant on the basis of imaging features at the index CT examination, imaging features at subsequent adrenal protocol CT or MRI, imaging stability for a minimum of 1 year, or clinical follow-up of a minimum of 2 years. RESULTS: Mean nodule size was 1.8 cm (range, 0.7-4.9 cm). There were no cases of primary or secondary adrenal malignancy (95% CI, 0.00-0.023). The nodules diagnosed on index CT scans were 73 adrenal adenomas and two myelolipomas. Seventy-four nodules were subsequently characterized as adrenal adenomas on the basis of imaging findings. Of the 113 indeterminate nodules that had imaging follow-up, 111 were stable at the latest follow-up examination. One nodule grew 26% over 8.1 years, and the other grew 59% over 12.4 years. Clinical follow-up of patients with 60 indeterminate nodules revealed no evidence of adrenal malignancy. CONCLUSION: No case of malignancy was found in 322 incidentally detected bilateral adrenal nodules at CT of patients without known cancer. Imaging follow-up of such lesions may be unnecessary.

Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee.

The ACR Incidental Findings Committee presents recommendations for managing adrenal masses that are incidentally detected on CT or MRI. These recommendations represent an update to the adrenal component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Adrenal Subcommittee, constituted by abdominal radiologists and an endocrine surgeon, developed this algorithm. The algorithm draws from published evidence coupled with expert subspecialist opinion and was finalized by a process of iterative consensus. Algorithm branches categorize incidental adrenal masses on the basis of patient characteristics and imaging features. For each specified combination, the algorithm concludes with characterization of benignity or indolence (sufficient to discontinue follow-up) and/or a subsequent management recommendation. The algorithm addresses many, but not all, possible pathologies and clinical scenarios. Our goal is to improve the quality of patient care by providing guidance on how to manage incidentally detected adrenal masses.