Management of patients with adrenal cancer: recommendations of an international consensus conference.

Adrenocortical carcinomas are rare, highly malignant tumors that account for only 0.2% of deaths due to cancer. Given the limited number of patients seen in most medical centers with this diagnosis, series usually reported are small and clinical trials not randomized or blinded. In an attempt to answer important questions concerning the management of patients with adrenal cancer, a consensus conference was organized and held at the University of Michigan in Ann Arbor, MI, 11-13 September 2003, with the participation of an international group of physicians who had reported on the largest series of patients with this disease and who had recognized basic and clinical research expertise in adrenal cortical cancer. Totally 43 questions were addressed by the presenters and recommendations discussed in plenary and breakout sessions. Evidence for the recommendations of this conference was at the 2-4+ level and based on available literature and participants' experience. In addition to setting up guidelines in specific areas of the diagnosis and treatment of adrenal cancer, the conference recommended and initiated the planning of an international prospective trial for treatment of patients with adrenal cancer in stages III and IV. In terms of new therapies, first trials of dendritic cell therapy in human subjects with adrenal cancer have been started, but it is too early to comment on efficacy. Different strategies of immunotherapy, including DNA vaccination are currently being tried in animal models. There are no clinical gene therapy trials for human adrenal cortical cancer. The adrenals are a preferred target for adenovirus and the results of gene therapy in preclinical studies are promising. In addition, there is evidence that histone deacetylase inhibitors can further enhance the rate of adenoviral infectivity in human adrenal cancer cells. Testing of retroviral vectors, non-viral vectors, small interfering RNA technology, and combined approaches could be performed in various laboratories. Anti-angiogenic substances have only been applied in preclinical studies. The use of these and other agents in the treatment of adrenal cancer should be hypothesis-driven and based on a thorough analysis of tumor biology.

Effectiveness of abdominal compression during helical renal CT.

RATIONALE AND OBJECTIVES: The authors performed this study to assess the effect of abdominal compression on opacification and distention of the proximal renal collecting system during helical computed tomography (CT). MATERIALS AND METHODS: Abdominal compression was applied during helical CT in 31 patients who were scanned 150 and 300 seconds after initiating a dynamic bolus injection of contrast material. Two reviewers assessed renal collecting system opacification and measured the maximal short-axis diameter of the collecting system at three locations: the upper pole, the lower pole, and the proximal ureter. A similar evaluation was performed in a control group of 29 patients who underwent CT without compression at 300 seconds after initiating the injection of contrast material. RESULTS: Both reviewers noted collecting system opacification at all locations in 52 of 56 noncompressed collecting systems scanned at 300 seconds, 57 of 59 compressed collecting systems scanned at 300 seconds, but only 26 of 59 compressed collecting systems scanned at 150 seconds. Measured collecting system distention was statistically significantly greater at 300 seconds in patents who received compression than in patients who did not (P = .0013). For patients who received compression, measured collecting system distention was statistically significantly greater on scans obtained at 300 seconds than on scans obtained at 150 seconds (P = .0001). CONCLUSION: Abdominal compression during renal helical CT produces a detectable increase in renal collecting system distention. In patients who receive compression, scanning at 300 seconds rather than at 150 seconds results in greater collecting system distention and more consistent opacification.

Assessment of the clinical utility of the rim and comet-tail signs in differentiating ureteral stones from phleboliths.

OBJECTIVE: This study was designed to assess interobserver variability in identifying the rim and comet-tail signs and to determine the clinical utility of these signs in determining whether or not the calcifications with which they are associated represent ureteral calculi. MATERIALS AND METHODS: Two radiologists and a radiology resident, unaware of the final diagnosis, reviewed preselected helical CT images from renal stone examinations in patients with 65 indeterminate pelvic calcifications. Assessment of calcifications for rim or comet-tail signs was performed independently of an assessment for the following five secondary signs of urinary tract obstruction: caliectasis, pelviectasis, ureterectasis, perinephric stranding, and renal enlargement. Agreement in identifying rim and comet-tail signs was assessed by obtaining kappa statistics. The utility the of rim or comet-tail signs in determining whether ureterolithiasis was present in patients in whom perinephric stranding and ureterectasis were present or absent was determined. The frequency with which one or more of each of the five assessed secondary signs was identified ipsilateral to a calcification having rim or comet-tail signs was also tabulated. RESULTS: Kappa values for interobserver agreement ranged from 0.49 to 0.73. In only one patient was a rim sign detected in the absence of ureterectasis and perinephric stranding. Reviewers identified at least three of the five assessed secondary signs ipsilateral to calcifications showing a rim sign in all but one patient (by each radiologist) and four patients (by the resident). When three or more secondary signs of obstruction were seen ipsilateral to a calcification having a comet-tail sign, in all but one instance, this was because the calcification was a ureteral calculus or because there was a separate ipsilateral ureteral calculus. CONCLUSION: In many instances, observers did not agree about whether the rim and comet-tail signs were present. The rim sign was observed in the absence of any secondary signs of urinary tract obstruction in only one (1.5%) of the 65 patients in our series (95% confidence interval, 0-5.3%). The comet-tail sign, when accompanied by secondary signs of obstruction, should indicate that an ipsilateral ureteral stone is present and not the reverse.

Multi--detector row helical CT of the pancreas: effect of contrast-enhanced multiphasic imaging on enhancement of the pancreas, peripancreatic vasculature, and pancreatic adenocarcinoma.

PURPOSE: To determine the optimal phase for enhancement of the normal pancreas and peripancreatic vasculature and the maximal tumor-to-pancreatic parenchymal enhancement difference by using multiphase, contrast material-enhanced, multi-detector row helical computed tomography (CT). MATERIALS AND METHODS: Forty-nine patients with a normal-appearing pancreas but suspected of having pancreatic abnormality and 28 patients with proved pancreatic adenocarcinoma underwent multiphase, contrast-enhanced, multi-detector row CT during the arterial phase (AP), pancreatic parenchymal phase (PPP), and portal venous phase (PVP). Attenuation values of the normal pancreas, pancreatic adenocarcinoma, celiac and superior mesenteric arteries, and superior mesenteric and portal veins were measured during all three imaging phases. Quantitative analysis of these measurements and subjective qualitative analysis of tumor conspicuity were performed. RESULTS: Maximal enhancement of the normal pancreatic parenchyma occurred during the PPP. Maximal tumor-to-parenchyma attenuation differences during the PPP and PVP were equivalent but greater than that during the AP. Subjective analysis revealed that tumor conspicuity during the PPP and PVP was equivalent but superior to that during the AP. Maximal arterial enhancement was seen during the PPP, and maximal venous enhancement was seen during the PVP. CONCLUSION: A combination of PPP and PVP imaging is sufficient for detection of pancreatic adenocarcinoma, because it provides maximal pancreatic parenchymal and peripancreatic vascular enhancement. AP imaging can be reserved for patients in whom CT angiography is required.

Bladder tumor detection at virtual cystoscopy.

PURPOSE: To investigate the utility of computed tomographic (CT) virtual cystoscopy in the detection of bladder tumors. MATERIALS AND METHODS: Twenty-six patients suspected or known to have bladder neoplasms underwent CT virtual and conventional cystoscopy. The bladder was insufflated with carbon dioxide through a Foley catheter. Helical CT of the bladder was then performed. The data were downloaded to a workstation for interactive intraluminal navigation. Two radiologists blinded to the results of conventional cystoscopy independently reviewed the transverse and virtual images, with consensus readings for cases with discrepant results. RESULTS: Thirty-six (90%) of 40 bladder lesions proved at conventional cystoscopy were detected with a combination of transverse and virtual images. Four (10%) of 40 bladder lesions, all smaller than 5 mm, were undetected. Transverse and virtual images were complementary, since six polypoid lesions smaller than 5 mm depicted on the virtual images were not seen on the transverse images. In contrast, areas of wall thickening were more readily appreciated on transverse images. CT with patients in both supine and prone positions was necessary, since seven (19%) and five (14%) of 36 lesions were seen only on supine and prone images, respectively. CONCLUSION: CT virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than 5 mm. Optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images.

Correlation between radiology resident rotation performance and examination scores.

RATIONALE AND OBJECTIVES: The authors' purpose was to determine whether there is a relationship between subjective assessment of radiology resident performance on individual rotations and objective assessment of radiology resident performance on the American College of Radiology (ACR) in-training and American Board of Radiology (ABR) written examinations. MATERIALS AND METHODS: Records of 81 radiology residents completing their residency between 1991 and 2000 were reviewed. Mean scores from all rotation evaluation forms obtained during the study period were calculated for each residency year. The means of the overall raw scores and percentiles obtained on the annual ACR in-training examinations during the first 3 years of residency and of the written portion of the ABR examination taken during the 4th year of residency were also determined. Rotation evaluation scores were then compared to examination scores obtained during the same year of residency, and correlation coefficients were obtained. RESULTS: In the 2nd, 3rd, and 4th years of radiology residency, there is positive correlation between rotation evaluation scores and overall scores from the corresponding ACR in-training examination and written portion of the ABR examination taken during the same year. In contrast, in the 1st year of residency, resident rotation evaluation scores do not correlate with ACR in-training examination scores. CONCLUSION: Residents who are perceived as doing well on their rotations after the 1st year of residency are more likely to do well on standardized written examinations.

Delayed enhanced CT of lipid-poor adrenal adenomas.

OBJECTIVE: Although representing a minority of adrenal adenomas, the lipid-poor variety cannot be accurately identified on unenhanced CT or chemical shift MR imaging. We compared the delayed contrast-enhanced CT features of lipid-poor adenomas with those of lipid-rich adenomas and of adrenal nonadenomas to determine whether there were differences in the washout features between these groups of lesions. SUBJECTS AND METHODS: Eighteen proven lipid-poor adenomas, 56 lipid-rich adenomas, and 40 adrenal nonadenomas underwent CT before, immediately after, and 15 min delay after IV contrast injection. Region-of-interest measurements were made of all adrenal lesions at the three time points. The degree of enhancement, enhancement washout, percentage enhancement washout, and relative percentage enhancement washout were calculated for each adrenal mass. Pooled data were analyzed statistically. Optimal threshold values for diagnosing adrenal adenomas were also determined. RESULTS: The mean CT attenuation of lipid-poor adenomas was significantly higher than that of lipid-rich adenomas at all three phases but not significantly different from that of nonadenomas. The mean percentage enhancement washout on images obtained 15 min after administration of contrast material was similar for lipid-rich and lipid-poor adenomas but was significantly higher than that of nonadenomas. The mean relative percentage enhancement washout was significantly different among all three groups. CONCLUSION: Lipid-poor adenomas cannot be differentiated from adrenal nonadenomas on the basis of a single mean attenuation value. However, lipid-poor adrenal adenomas show enhancement and enhancement washout features nearly identical to lipid-rich adenomas and can be distinguished from nonadenomas on the basis of a percentage washout threshold value of 60% and a relative percentage washout of 40%.

Sensitivity of CT scout radiography and abdominal radiography for revealing ureteral calculi on helical CT: implications for radiologic follow-up.

OBJECTIVE: We compared the sensitivity of CT scout radiography with that of abdominal radiography in revealing ureteral calculi on unenhanced helical CT. MATERIALS AND METHODS: Over a 6-month period, patients presenting to the emergency department with acute flank pain were examined with standard abdominal radiography and unenhanced helical CT, which included CT scout radiography. In 60 patients in whom a diagnosis of ureteral calculus was made, CT scout radiographs and abdominal radiographs were examined by two interpreters who assessed whether stones could be visualized. All CT scout radiographs were viewed on a workstation using optimized window settings. RESULTS: CT scout radiography and abdominal radiography revealed 28 (47%) and 36 (60%) of 60 ureteral calculi, respectively. All ureteral calculi that appeared on CT scout radiography also appeared on abdominal radiography. However, eight calculi that were visible on abdominal radiography were not visible on CT scout radiography. CT scout radiography and abdominal radiography revealed 28% and 46% of 39 calculi less than or equal to 3 mm in diameter, respectively. For 21 calculi larger than 3 mm, the sensitivity of CT scout radiography and abdominal radiography was 81% and 86%, respectively. CONCLUSION: Abdominal radiography is more sensitive than CT scout radiography in revealing ureteral calculi; however, some calculi revealed on unenhanced helical CT cannot be seen on either abdominal radiography or CT scout radiography. Ureteral calculi not visible on either study can only be followed, when necessary, with unenhanced helical CT.

Comparison of nephrographic with excretory phase helical computed tomography for detecting and characterizing renal masses.

OBJECTIVE: A retrospective study was performed to compare nephrographic phase (NP) with excretory phase (EP) renal helical computed tomographic (CT) images with respect to detection of renal masses 10 mm or more in diameter, and reviewer confidence in mass characterization. METHODS: Two reviewers evaluated 39 renal helical CT examinations. All masses measuring 10 mm or more in maximal diameter were classified as simple cysts, complex cysts, solid lesions, or indeterminate lesions. Reviewers graded their confidence in the characterization of the masses and decided whether the NP or EP contrast-enhanced images were superior. RESULTS: The 2 reviewers confidently characterized 71 (reviewer 1) and 65 (reviewer 2) of 72 detected masses 10 mm or more in diameter on NP images and 70 (reviewer 1) and 67 (reviewer 2) of 71 detected masses on EP images. There was strong agreement between the 2 sets of images in respect to the characterization of renal masses (kappa = 1.00 and 0.86). Only one mass (a focus of acute pyelonephritis) was not detected by either reviewer on EP images. Collecting system artifact degraded the quality of the EP image in images from only 1 patient. CONCLUSION: Although EP images are often aesthetically inferior to NP images, use of EP images results in a similar rate of detection and confidence in characterization of renal masses measuring 10 mm or more in diameter.

Utility of routine trauma CT in the detection of bladder rupture.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the frequency with which routine computed tomography (CT) fails to depict bladder rupture, the potential utility of delayed CT scans, and whether these findings might be useful in determining which patients may require subsequent cystography. MATERIALS AND METHODS: Cystograms and abdominal and pelvic CT scans of 54 patients with blunt trauma and in whom bladder rupture was clinically suspected were retrospectively reviewed. Blind readings of CT scans were performed by two genitourinary radiologists. Cystograms were used as the standard. RESULTS: Cystograms depicted bladder rupture in 10 patients. On CT scans, extravesical fluid was depicted in all three patients with intraperitoneal bladder rupture (although only a small amount of pelvic intraperitoneal fluid was present in two of these patients), in all seven patients with extraperitoneal bladder rupture, and in 32 of the 44 patients without bladder injury. Contrast material had been excreted into the bladder at the time of the initial or delayed CT in eight patients with bladder rupture; however, extravasation was identified in only four of the eight. In two of the four patients without extravasation, the bladder was distended at the time of CT. No bladder injuries were found in the 12 patients in whom pelvic fluid was not identified on CT scans. CONCLUSION: The absence of pelvic fluid on a trauma CT scan indicates that bladder rupture is unlikely. Even when a partially opacified bladder is passively distended, bladder injury may be present despite the absence of contrast material extravasation.

CT of recurrent retroperitoneal sarcomas.

OBJECTIVE: We reviewed the medical records and CT scans of 33 patients with recurrent retroperitoneal sarcomas to determine the patterns of recurrent disease. MATERIALS AND METHODS: We reviewed the medical records and CT examinations obtained at the time the recurrence was diagnosed and tabulated data for all patients. Data for patients with high-grade malignancies were compared with those of patients with low-grade malignancies to determine whether there were differences in the interval between initial tumor resection and recurrence. We also compared CT appearances to determine patterns of recurrent disease. RESULTS: Twenty-five of 33 recurrences were detected within 2 years of initial surgery. Only 16 patients had symptoms, and when present, most symptoms were nonspecific. In 28 (85%) patients, recurrent tumor was in the abdomen at the time of diagnosis. In nine patients, the largest detectable abdominal tumor was less than 5 cm in diameter. Interval to recurrence was similar for patients with low- and high-grade tumors. Although the CT appearance was similar for both grades, distant metastases were identified only in patients with high-grade malignancies. CONCLUSION: Primary retroperitoneal malignancies frequently recur within 2 years of initial surgical resection. For asymptomatic patients, diagnosis is typically made during routine follow-up CT. Most patients have abdominal recurrences that may be small when first detected.

Orthotopic neobladder reconstruction: findings on excretory urography and CT.

OBJECTIVE: The excretory urographic and CT appearance of orthotopic ileal neobladder reconstruction after cystectomy and its complications are described. MATERIALS AND METHODS: We retrospectively reviewed the excretory urograms and CT scans of 32 patients (29 men and three women, 35-76 years old) with transitional cell carcinoma of the bladder who underwent orthotopic neobladder reconstruction with anastomosis to the native urethra after cystectomy. The radiologic review consisted of 25 excretory urograms in 20 patients and 37 CT scans in 21 patients. RESULTS: On excretory urography, the afferent segment of the neobladder was identified as a contrast-filled structure in all 20 patients, and was located in the right lower quadrant in 18 (90%). On CT, the afferent segment and the neobladder were identified in all 21 patients. Delayed imaging performed after initial scanning in 12 (57%) of 21 patients was helpful for revealing detailed anatomy such as the ureteral-afferent limb anastomoses. Complications occurred in two patients and were caused by a lymphocele in one and a urine leak from the neobladder in the other. In six other patients we found evidence of recurrent or metastatic tumor or both: two had local pelvic recurrence and pelvic nodal metastases, two other patients had metastatic nodal disease, one patient had a malignant distal ureteral stricture, and the sixth patient had distant osseous metastases. CONCLUSION: Orthotopic neobladder reconstruction after cystectomy has a characteristic appearance on both excretory urography and CT. Knowledge of this appearance and the altered anatomy is useful to recognize complications and tumor recurrence. Delayed images during excretory urography and CT are useful to define the ureteral-afferent limb anastomosis with the neobladder and also to differentiate between postoperative collections.

CT appearance of primary papillary serous carcinoma of the peritoneum.

OBJECTIVE: Our objective was to describe the CT characteristics of primary papillary serous carcinoma of the peritoneum. CONCLUSION: The presence of peritoneal masses, extensive omental calcification, and the absence of an ovarian mass on CT--particularly in postmenopausal women--is highly suggestive of primary papillary serous carcinoma of the peritoneum and should alert the radiologist to the possibility of this diagnosis.

Diagnostic evaluation of the adrenal incidentaloma: decision and cost-effectiveness analyses.

UNLABELLED: The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses. METHODS: We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data. RESULTS: At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities. CONCLUSION: Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.

Variability in the detection of enlarged mediastinal lymph nodes in staging lung cancer: a comparison of contrast-enhanced and unenhanced CT.

OBJECTIVE: Because CT protocols for staging lung cancer vary and little information exists regarding the diagnostic importance of using i.v. contrast material, our intent was to evaluate intra- and interobserver agreement in the detection of enlarged mediastinal lymph nodes, comparing i.v. contrast-enhanced and unenhanced CT. SUBJECTS AND METHODS: Fifty patients with known or suspected bronchogenic carcinoma underwent unenhanced thoracic CT followed by contrast-enhanced CT. Three observers noted enlarged lymph nodes (> 10 mm in the short axis) and assigned the enlarged nodes to American Thoracic Society nodal station designations. Enlarged lymph nodes were grouped two ways: by assigning the exact number of enlarged lymph nodes found (zero, one, two, three, four or more), and by assigning whether at least one, or no, enlarged mediastinal lymph nodes were found at a station ("one or none"). Agreement levels were determined for inter- and intraobserver interpretations using weighted kappa statistics and the McNemar test. RESULTS: The number of enlarged lymph nodes with enhanced CT was 11% higher than on unenhanced studies (418 versus 377; p = .044). Numbers of enlarged lymph nodes were different for five stations; however, the numbers were small except for the right upper paratracheal station (2R) (contrast-enhanced, 68 enlarged lymph nodes; unenhanced, 44 enlarged lymph nodes; p = .014). With regard to all stations together, intraobserver agreement between contrast-enhanced and unenhanced studies was almost perfect (kappa range, .85-.94), and no difference was found for any observer in the proportion of patients with at least one enlarged lymph node. Interobserver agreement was substantial or almost perfect for the total number of enlarged lymph nodes. For specific stations, the lowest kappa value was .48 at 2R. One observer reported more patients with at least one enlarged lymph node with contrast enhancement at station 2R (p = .031). Greater agreement existed between two observers at station 2R with contrast enhancement versus no enhancement (kappa = .85 versus .48; p = .02). Conclusions matched, and calculations of estimated kappa values gave similar results for determination of the specific number of enlarged lymph nodes at a station and the "one or none" category. CONCLUSION: We found high agreement for intra- and interobserver interpretations for contrast-enhanced and unenhanced CT, although contrast-enhanced CT revealed more enlarged lymph nodes, especially at station 2R.

CT time-attenuation washout curves of adrenal adenomas and nonadenomas.

OBJECTIVE: The purpose of this study was to analyze the CT contrast enhancement washout curves of adrenal masses and to determine the earliest time after initial enhancement that differentiation of adenomas from nonadenomas is possible. MATERIALS AND METHODS: Contrast enhancement washout curves were generated after delayed contrast-enhanced CT scans of 52 adrenal adenomas and 24 nonadenomas. The optimal threshold value and corresponding sensitivity and specificity for the diagnosis of adenoma were determined according to attenuation values. Also, we calculated the percentage and relative percentage of enhancement washout at time delays from 5 to 45 min after initial enhancement. RESULTS: The mean percentage of enhancement washout for adrenal adenomas was 51% at 5 min and 70% at 15 min, compared with 8% and 20%, respectively, for nonadenomas. The sensitivity and specificity for the diagnosis of adenoma were both 96% at a threshold attenuation value of 37 H on the 15-min delayed enhanced scan. CONCLUSION: On CT, adrenal adenomas show a much earlier and more rapid washout of contrast enhancement than do nonadenomas. Adenomas and nonadenomas can be differentiated by attenuation values or the percentage or relative percentage of washout as early as 5-15 min after enhancement.

Helical CT evaluation of potential kidney donors: findings in 154 subjects.

OBJECTIVE: The purpose of our study was to assess renal helical CT (RHCT) as the primary imaging technique in the evaluation of potential kidney donors. SUBJECTS AND METHODS: Unenhanced and enhanced (3-mm collimation) RHCT was performed in 154 kidney donors using 125-150 ml of i.v. contrast material at an injection rate of 3 or 4 ml/sec and a pitch of 1.3-2. Scans were reconstructed at 1.5-mm intervals for a three-dimensional image. RHCT images were compared with the results of renal arteriography (RA) (50 subjects) and surgery (117 subjects). RESULTS: CT and surgical findings agreed in 95% of patients (111/117), with five cases of missed accessory arteries (all < 2 mm in diameter) and one case of a missed early division of the main artery. In the 50 subjects who underwent CT and RA, imaging revealed concordance in 96% of 100 kidneys. One small accessory artery was not detected by CT (origin from the common iliac artery). RA did not detect accessory arteries in three subjects. All 22 kidneys with early dividing main arteries (< 1.5 cm from the aortic origin) were identified by both RHCT and RA. Axial and three-dimensional CT images were complementary: five small accessory arteries were seen well only on the axial sections, whereas four early dividing arteries and two cases of renal artery stenosis were prospectively identified only on the three-dimensional images. Twenty-five renal vein anomalies were detected only by CT. In the full series of 154 subjects, nonvascular renal findings included renal calculi (n = 11), cysts (n = 12), duplicated ureters (n = 6), horseshoe kidney (n = 1), and pelvic kidney (n = 1). CONCLUSION: RHCT can be the primary imaging technique in the assessment of potential kidney donors, reducing the number of examinations as well as the risk and cost of imaging in these subjects.

Imaging of adrenal masses.

Most adrenal masses are detected on CT scans, but only a minority has morphologic features that are characteristic of a specific histologic diagnosis. In patients with clinical or biochemical features of a hyperfunctioning adrenal syndrome, CT detection of a unilateral adrenal mass typically leads to surgical resection, although functional assessment of the mass with iodomethylnorcholesterol or MIBG scintigraphy sometimes is used to augment the CT findings. In patients with a nonhyperfunctioning adrenal mass, chemical shift MR and CT densitometry have begun to replace percutaneous adrenal biopsy or serial follow-up CT as methods to establish a specific diagnosis. In this article the authors review the clinical features and imaging findings of patients with known or suspected adrenal masses.