Differentiation of adrenal adenomas from nonadenomas using CT histogram analysis method: a prospective study

The objective of our study was to prospectively evaluate the effectiveness of computed tomography (CT) histogram analysis method in the differentiation of benign and malignant adrenal masses.

Between March 2007 and June 2008, 94 patients (46 males, 48 females, age range: 30-79 years, mean age: 57.7 years) with 113 adrenal masses (mean diameter: 3.03 cm, range: 1.07-8.02 cm) were prospectively evaluated. These included 66 adenomas, 45 metastases and 2 pheochromocytomas. Histogram analysis method was performed using a circular region of interest (ROI) and mean attenuation, total number of pixels, number of negative pixels and subsequent percentage of negative pixels were detected on both unenhanced and delayed contrast-enhanced CT images for each adrenal mass. A mean attenuation threshold of 10Hounsfield unit (HU) for unenhanced CT and 5% and 10% negative pixel thresholds for both unenhanced and delayed contrast-enhanced CT were calculated by a consensus of at least two reviewers and the correlation between mean attenuation and percentage of negative pixels was determined. Final diagnoses were based on imaging follow-up of minimum 6 months, biopsy, surgery and adrenal washout study.

51 of 66 adenomas (77.3%) showed attenuation values of < or =10HU and 15 (22.7%) adenomas showed more than 10HU on unenhanced CT. All of these adenomas contained negative pixels on unenhanced CT. Eight of 66 (12.1%) adenomas showed a mean attenuation value of < or =10HU on delayed contrast-enhanced scans and 45 adenomas (68.2%) persisted on containing negative pixels. All metastases had an attenuation value of greater than 10HU on unenhanced CT images. 21 of 45 (46.6%) metastases contained negative pixels on unenhanced images but only seven metastases (15.5%) had negative pixels on delayed contrast-enhanced images. Two pheochromocytomas had negative pixels on both unenhanced and delayed contrast-enhanced CT images. Increase in the percentage of negative pixels yielded high correlation with mean attenuation decreases, both on unenhanced and delayed contrast-enhanced CT. Our sensitivity was 90.9% for the 10% negative pixel percentage threshold compared to 77.2% sensitivity for < or =10HU mean attenuation threshold for unenhanced CT. Both methods gave a 100% specificity for the diagnosis of adenoma. We also obtained a 37.9% sensitivity for 5% negative pixel threshold and a slightly lower sensitivity of 28.8% for 10% negative pixel threshold compared to the 12.1% sensitivity of < or =10HU mean attenuation threshold while maintaining 100% specificity for contrast-enhanced CT.

The CT histogram analysis is a simple and easily applicable method which provides higher sensitivity than the commonly used 10HU threshold mean attenuation method of unenhanced CT and can replace it for the diagnosis of an adenoma. But with contrast-enhanced CT, although 100% specificity is being maintained, the sensitivities obtained are very poor for each method and is therefore likely to limit CT histogram analysis to be used as a clinically useful adjunct in the diagnosis of adenoma.