Upper airway mucosa temperature in obstructive sleep apnoea/hypopnoea syndrome, nonapnoeic snorers and nonsnorers

BACKGROUND: This study was performed to assess chemical shift magnetic resonance imaging (CSMRI) for characterizing adrenal masses in patients with lung cancer, and to compare charges associated with two algorithms for assessing adrenal masses in these patients. METHODS: Forty-two patients with lung cancer underwent both CSMRI (using in-phase and opposed-phase gradient echo images) and computed tomography-guided percutaneous biopsy of adrenal masses. Adrenal-to-spleen signal intensity ratios on the opposed-phase images were correlated with histopathologic results. The normalized charges for two algorithms were compared. In algorithm A, computed tomography-guided biopsy is used first to evaluate an adrenal mass; in algorithm B, CSMRI is used first, followed by computed tomography-guided biopsy only if CSMRI findings are not diagnostic of adenoma. RESULTS: Biopsy showed 24 (57%) adrenal adenomas and 18 (43%) metastases. Chemical shift magnetic resonance imaging was 96% sensitive for adenoma and 100% specific. The average normalized charges associated with algorithm A were $1,905 per patient versus $1,890 with algorithm B. CONCLUSIONS: Initial use of CSMRI in evaluating an adrenal mass in lung cancer patients can obviate biopsy in 55% of patients, and its charges are similar to those for performing computed tomography-guided biopsy in all patients.     

MR imaging of the adrenal gland: radiologic-pathologic correlation

Complex physiologic and neoplastic processes affect the adrenal glands. An appreciation of the gross pathologic and histologic correlates of disease aids in understanding the mechanisms by which diagnostic imaging helps characterize adrenal masses. Computed tomographic (CT) densitometry and chemical shift magnetic resonance (MR) imaging would seem to be the most reliable tools in determining whether a given adrenal mass is specifically an adenoma. Such a determination is made on the basis of the presence of substantial amounts of intracytoplasmic lipid. Thus, although a homogeneous mass with a CT attenuation of less than 10 HU or a decrease in signal intensity at opposed-phase MR imaging is diagnostic for adenoma, lesions that do not have these features are indeterminate and may necessitate biopsy. Adrenal myelolipoma also has a distinctive imaging appearance that reflects the presence of macroscopic fat deposits. Diagnosis of adenoma or adrenal myelolipoma is very helpful in the assessment and treatment of asymptomatic patients with adrenal masses and may make biopsy unnecessary. In patients with clinical or biochemical evidence of adrenal disease, MR imaging helps confirm the presence of a mass and allows localization and further characterization of the lesion.     

Collision tumors of the adrenal gland: demonstration and characterization at MR imaging

PURPOSE: To evaluate the magnetic resonance (MR) imaging findings in collision tumors of the adrenal gland. MATERIALS AND METHODS: MR images obtained in 104 patients with a known primary malignant tumor and an adrenal mass were reviewed to find adrenal glands that contained two contiguous but histologically distinct masses. The findings in such cases were correlated with histopathologic findings. RESULTS: In two (2%) cases, both MR and histopathologic findings showed a mass within the adrenal gland that consisted of contiguous adrenal adenoma and metastasis, which represented a collision tumor. The adenomatous component in each tumor showed a (quantitative) decrease in signal intensity relative to that of the liver (79% and 61%) on opposed-phase images, whereas the metastatic component showed an increase in signal intensity (50% and 15%). Similarly, the adrenal lesion-to-spleen signal intensity ratio on opposed-phase images was lower for the adenomatous component in each (0.39 and 0.43) than for the metastatic component (1.17 and 0.90). CONCLUSION: MR imaging can demonstrate and enable characterization of the separate components of collision tumors within the adrenal gland. These findings can be crucial in planning and guiding subsequent percutaneous needle biopsy and patient care.     

Adrenocortical SPECT using iodine-131 NP-59

Adrenal scintigraphy with 131I-labeled 6-beta-iodomethyl-19-norcholesterol (NP-59) is a technically demanding and complex procedure. However, it can provide crucial and unique information about the functional status of the adrenal glands and guide the appropriate therapeutic management of patients with biochemically proven disease. Since the introduction of this new investigational drug, scintigraphic imaging has been performed using conventional planar techniques. We present an interesting case of primary aldosteronism in which planar scintigraphy and SPECT were combined in an attempt to increase the sensitivity of the study. SPECT revealed scintigraphic evidence of bilateral adrenocortical hyperplasia. Interestingly, the CT scan of this patient showed only an equivocal abnormality in the left adrenal gland, suggestive of an adenoma.     

Complications of CT-guided biopsy of the spine and sacrum

This study reviews the results of 94 computed tomography (CT)-guided Craig needle biopsies of the spine and sacrum performed at one center. An indication for biopsy in this study was prompted by abnormal findings identified by one or more of the following diagnostic modalities: radiography, CT, magnetic resonance imaging (MRI), or bone scanning. These patients then underwent CT-guided Craig needle biopsy of the spine and sacrum for further evaluation. There were 1 biopsy of the cervical spine, 19 of the thoracic spine, 66 of the lumbar spine, and 8 of the sacrum. Biopsy sensitivity was 94.5% and specificity was 96.8%. This accuracy compared with other diagnostic modalities showed biopsy to be the gold standard for diagnosis of spine or sacral lesions. Of the 94 cases reviewed, 6 complications were noted. All complications were acute in nature and included 1 aortic puncture, 2 psoas punctures with associated psoas hematomas, 1 biopsy of an incorrect level, and 2 aborted procedures secondary to patient discomfort. No infections or neurological sequelae were seen. Although the benefits of CT-guided biopsy over open biopsy have been shown previously, this review demonstrates it is not without significant risk.     

Adrenal incidentaloma: proposal for a correct treatment

BACKGROUND: The incidence of unsuspected adrenal masses (incidentalomas) based on CT-scan results to be higher than in the past. The aim for our study was to establish some guidelines for an appropriate management. METHODS: From 1986 to 1995, 61 patients with no history or clinical findings suggestive of adrenal mass or adrenal hyperfunction were discovered by radiologic examination to have an incidentaloma larger than 1 cm. In each patient basal biochemical evaluations were obtained to exclude the presence of adrenal cortical or medullary dysfunction. There were 28 men and 33 (54.1%) women, with a mean age of 53 years (range 16-74). 19 patients underwent CT-guided fine-needle biopsy to exclude metastatic tumors. Furthermore in 29 patients 75-Se-selenomethyl-norcholesterol was performed and 17 were studied by MRI. RESULTS: At CT-scan mean lesion diameter was 5.48 +/- 3.76 cm (range 2-23); 32 adrenal masses were right sided and 3 (4.9%) were bilateral. 17 patients had concordant scintigraphic imaging pattern, 6 bilateral uptake and 6 had discordant imaging. CT-guided FNAB showed malignancy in 9. Adrenalectomy was performed in 45 patients according to a score calculated by 4 parameters: age of the patients, size of the mass, scintigraphic pattern, MR imaging. Twenty-four had a score greater than 9 and in the remaining 21 patients in spite of a score lower than 10 adrenalectomy was performed based on: 1) increased size at CT scan follow-up (15 pts); 2) either suspected primitive malignant neoplasm at CT-guided FNAB or history of malignancy (6 pts); 3) elevated 24-hour dopamine (4 pts). In 12 (26.7%) patients a malignant tumor was found. There were not any statistically significant differences (p > 0.05) between the age of the patients with malignant neoplasms and those with benign masses, and between the size of the masses, which were 7.58 +/- 5.93 cm (range 2-23) and 5.03 +/- 2.81 cm (range 3-17) respectively. The difference in scores between the patients with malignant masses (12.17 +/- 2.95) and those with benign ones (9.09 +/- 1.33) was statistically significant (p < 0.01). CONCLUSIONS: Since adrenal incidentaloma have a malignancy rate higher than the other adrenal tumors, it is crucial to outlinesome criteria to sort out the patients at risk for whom adrenalectomy is to be warranted. Based on our results we believe that patients with a score > 9 should undergo adrenalectomy.     

Cleveland Clinic experience with adrenal Cushing's syndrome

PURPOSE: Cushing's syndrome due to adrenal adenoma or adrenocortical carcinoma is rare. To understand better the clinical and biochemical presentation of this disorder, as well as therapy efficacy and patient survival, we conducted a retrospective review. MATERIALS AND METHODS: Between August 1971 and April 1994, 40 patients presented to our institution with adrenal Cushing's syndrome (27 adenomas and 13 carcinomas). These groups were analyzed with respect to clinical signs and symptoms preoperatively and postoperatively, biochemical analysis, length of postoperative steroid replacement therapy, disease recurrence and patient survival. Followup was obtained by chart review and telephone interviews and averaged 59.6 +/- 66.4 and 47.6 +/- 56.2 months for adenoma and carcinoma patients, respectively. RESULTS: Women predominated in both groups (26 of 27 adenomas, 11 of 13 carcinomas), and tumors affected the left adrenal gland more frequently (19 of 27 adenomas, 9 of 13 carcinomas). Adenoma patients were younger than carcinoma patients (39.6 +/- 14.4 versus 51.5 +/- 16.6 years, p = 0.026) and presented with smaller tumors (3.3 +/- 1.0 versus 8.6 +/- 4.5 cm., p = 0.001). There was a trend toward increased incidence of glucose intolerance among carcinoma patients but no significant differences in clinical signs or symptoms between adenoma and carcinoma patients could be made. Similarly, while there was no significant difference in biochemical evaluation of adenoma versus carcinoma patients, 24-hour urinary free cortisol and serum lactate dehydrogenase levels tended to be higher among carcinoma patients. In addition 17-ketosteroid and dehydroepiandrosterone sulfate levels were more elevated in carcinoma than in adenoma patients, and several adenoma patients actually had subnormal levels. Among adenoma patients mean length of steroid replacement therapy was 16.8 +/- 9.1 months. However, 7 adenoma patients (25.9%) required greater than 24 months of exogenous steroids, and only 1 of these patients was subsequently weaned off steroid replacement. There were no recurrences among adenoma patients, although there was 1 perioperative death due to hypoglycemia. Ten (76.9%) carcinoma patients had recurrences at a mean followup of 33 months. The 3 and 5-year survival rates were 41.5 and 31.2%, respectively. CONCLUSIONS: While presenting signs and symptoms and hormonal analysis may suggest benign or malignant disease, only tumor size and patient age are reliable preoperative indicators of adrenal adenoma versus adrenocortical carcinoma among patients with adrenal Cushing's syndrome. Surgery is curative for adenoma patients, but lifelong steroid replacement may be required. Survival remains poor among carcinoma patients.     

Hypoadrenal crisis caused by disseminated histoplasmosis

We report a case of disseminated histoplasmosis presenting with acute renal impairment due to adrenal insufficiency. The finding of bilateral adrenal gland enlargement on abdominal ultrasound examination led to a diagnostic CT-guided adrenal biopsy. Prolonged therapy with amphotericin and itraconazole resulted in a clinical cure, although the patient still requires adrenal replacement therapy.     

MR lesion detection in a breast cancer population

Implementation of MR imaging of the breast as an extension of the existing imaging modalities in the diagnosis of breast cancer was evaluated in a university cancer center, MR imaging of the breast was performed in 54 patients, in whom the MR results were compared with the triple test (the combination of clinical examination, mammographic evaluation, and cytology) and the final histological diagnosis. MR imaging of the breast depicted 30 of the 33 malignancies (sensitivity, 91%). In two of the malignancies, the carcinoma was clinically and mammographically occult. For the three patients with a false-negative MRI diagnosis, the conventional mammography showed suspicions clustered microcalcifications as a sign of in situ carcinoma. For seven patients, MR imaging of the breast incorrectly suggested the presence of a malignant lesion (specificity, 67%). To improve MR specificity, we perform MR-guided ultrasonographic fine-needle aspiration biopsy (FNAB). Although MR imaging of the breast is a highly sensitive examination, conventional x-ray mammography remains the most efficient imaging modality in the diagnosis of breast cancer. In our patient population, MR imaging of the breast had additional value for women with mammographically dense breast tissue and especially for patients with clinical evidence of breast carcinoma that could not be detected with conventional diagnostic methods.     

Bilateral deoxycorticosterone-secreting adrenocortical adenoma

A case of a 58-year-old man with bilateral deoxycorticosterone (DOC)-secreting adrenocortical adenoma is reported. Before surgery, plasma levels of DOC and corticosterone were markedly elevated, but both adrenal hormone levels normalized after the surgical removal of the bilateral adrenal tumors. The histologic examination revealed bilateral adrenocortical adenoma, but curiously, the tissue concentrations of DOC and corticosterone were elevated only in the right adrenal gland.     

Contrast medium assisted dynamic MR-mammography after diagnostic and therapeutic interventions on the breast

In a retrospective study, the authors evaluated the signal behavior of 150 patients after intervention in the breast (40 fine-needle biopsies, 10 core biopsies, 50 open biopsies, 50 tumor-ectomies with additional irradiation therapy). The MR imaging was performed on 1.5-Tesla whole-body scanners using T1-WI GRE sequences in 2D FLASH technique before and 5 times after i.v. application of 0.1 mmol gadopentetate-dimeglumine per kg body weight. There was no signal enhancement after fine-needle biopsy. Hematoma due to core biopsy caused signal increase in every 5th patient. Enhancement after open biopsy was no more visible 6 months postoperatively. 12 months after tumorectomy and radiation therapy, most patients showed no more signal enhancement. In conclusion, MR mammography can be performed after fine-needle biopsy without problems. In case of core biopsy, hematoma should be excluded by sonography before. MR mammography should not be performed within 6 months after open biopsy, or within 12 months after tumorectomy and radiation therapy.     

False-positive imaging of In-111 labeled monoclonal antibody conjugate CYT-103 in a patient with metastatic colorectal carcinoma

In-111 satumomab whole-body imaging is used in the evaluation of patients with colorectal carcinoma. The authors report a case of false-positive In-111 localization in a nonfunctional adrenal adenoma in a patient with metastatic colon carcinoma.     

Effect of calcium carbonate on clinical compliance of apatitic calcium phosphate bone cement

Incidentally discovered adrenal masses are common since the advent and application of sensitive noninvasive imaging methods. The significance of these so-called "incidentalomas" and the question of further evaluation or treatment remains elusive. This report describes a retrospective study of 86 patients with incidentaloma. Adrenalectomy was performed on 26 patients during initial admission. Histologically, two cortisol-producing adenomas, an adenoma with subclinical cortisol production, and two pheochromocytomas (all of the preceding detected during the preoperative hormonal evaluation), three cystic lesions, one myelolipoma, and one hematoma were found. One primary and two metastatic adrenal carcinomas were also found in this series. Sixty patients with a nonfunctioning incidentaloma smaller than 6 cm were observed in an average of 43 months with serial CT scans performed at 3, 9, and 18 months after the initial diagnosis. Enlargement of the mass was detected in two patients; both proved to be nonfunctioning adenomas. Based on these observations, it is concluded that the initial laboratory evaluation is mandatory in cases of incidentalomas, including parameters of adrenocortical and medullar function. Hormonally active incidentalomas and those suspected for malignancy should be treated surgically. Masses greater than 6 cm should also be removed. Smaller incidentalomas without endocrine activity or signs of malignancy should be followed by CT scan at 3, 9, and 18 months after the initial diagnosis.     

Percutaneous CT guided bone biopsy in patients with suspected bone neoplasm]

Bone biopsy is necessary for the diagnosis of ambiguous skeletal lesions. Although several merits of computed tomography (CT)-guided percutaneous needle biopsy have been documented, few radiologists have performed this procedure in Japan. We performed this procedure with a newly introduced bone biopsy needle (OSTYCUT, angiomed, Karlsruhe, Germany) under CT guidance and evaluated the results. CT-guided bone biopsy (pelvic[n = 11]vertebral[n = 10], femoral[n = 1], sternal[n = 1]) was performed in 19 consecutive patients. Seventeen patients were suspected metastatic disease, and the others were suspected primary bone tumor. All biopsies but one were diagnostic. Malignancy was proved in 11 lesions. Three patients with prostatic carcinoma were proved to show no malignancy of bone lesions after a series of hormonal and chemotherapies. In one patient with both malignant mesothelioma and cervical carcinoma, the biopsy specimen from thoracic vertebra proved metastasis from mesothelioma. CT-guided bone biopsy is useful to evaluate the presence of malignancy and the effect of therapy for it, and to determine the primary site.     

Viral burden and disease progression in HIV-1-infected patients with sickle cell anemia

INTRODUCTION: Magnetic Resonance Imaging (MRI) has been proposed as the diagnostic technique of choice to characterize adrenal tumors. However, the results of the current studies are controversial. MATERIAL AND METHODS: Forty-nine patients with unilateral adrenal masses were submitted to MRI for lesion characterization on the basis of MR signal intensity. Cytology and/or histology demonstrated 14 pheochromocytomas (pheos), 11 adenomas, 3 cysts, 2 myelolipomas, 4 carcinomas, 3 metastases and 1 fibrosarcoma; a clinical diagnosis of adenoma was made in the remaining 11 patients. MR studies were performed using spin-echo (SE) sequences with T1 (TR/TE = 600/17 ms) and T2 (TR/TE = 2000/15-90 ms) weighting. T1-weighted images were also acquired after Gadolinium-DTPA (Gd-DTPA) administration. MR studies were integrated with in- and out-of-phase (TR/TE = 100/4-6 ms) chemical-shift (CS) sequences. MR signal intensity (SI) was analyzed qualitatively and quantitatively; MR results were correlated with tumor type and hormone secretion. RESULTS: The qualitative analysis of T2 images showed high signal intensity in the majority (80%) of adrenal lesions (14 pheos, 12 adenomas, 3 cysts, 2 myelolipomas and 8 malignancies). The quantitative analysis of post-Gd-DTPA T1 images permitted to distinguish adenomas, cysts and myelolipomas from pheos and malignancies. The qualitative analysis of post-Gd-DTPA T2 and T1 images permitted to distinguish pheos and cysts from adenomas and malignancies (p < .05); however, pheos and cysts as well as adenomas and malignancies were not differentiated. MR SI was similar in secreting and nonsecreting adenomas from both a qualitative and a quantitative viewpoints. CS MRI permitted to distinguish adenomas (decreased signal intensity on out-phase relative to in-phase images) from other benign and malignant lesions (no signal change from out-phase to in-phase images). CONCLUSIONS: The qualitative analysis of MR SI on conventional T1 and T2 images does not permit to differentiate adrenal masses. The qualitative evaluation of T1 images after Gd-DTPA administration, the quantitative analysis and CS sequences are technical options improving lesion characterization.     

Differentiating lymphocytic adenohypophysitis from pituitary adenoma in the peripartum patient

Lymphocytic adenohypophysitis (LAH) is an autoimmune disorder of the pituitary gland with a predilection for the peripartum period and often mimics a pituitary adenoma. We sought to define the clinical, endocrinologic and radiographic characteristics differentiating peripartum LAH from pituitary adenoma to enable the use of noninvasive diagnosis and appropriate therapy. From published reports and our own case, the clinical histories and laboratory and radiographic studies of 45 patients fulfilling the diagnosis of peripartum LAH were reviewed. History of infertility or menstrual irregularity, symptomatology, endocrinologic evaluation, diagnostic imaging and associated medical conditions were analyzed. For comparison, 806 patients with pituitary adenoma and pregnancy from published series were evaluated. The spontaneous pregnancy rate in pituitary adenoma patients was 2.4% vs. 100% in LAH patients. Visual disturbances and headaches were significantly more frequent in patients with LAH. Prolactin levels were significantly lower in patients with LAH than in those with pituitary adenomas (34.6 +/- 46.3 [SD] vs. 393.0 +/- 300.4, P < .0001). Abnormalities in thyroid and/or adrenal function were also more common in patients with LAH (57.5% vs. 2.5%, P < .001). There were no distinguishing characteristics on radiographic studies. History and endocrinologic evaluation can differentiate between LAH and pituitary adenoma in the peripartum patient.     

Immunolocalization of dehydroepiandrosterone sulfotransferase in normal and pathologic human adrenal gland

Dehydroepiandrosterone sulfotransferase (DHEA-ST) catalyzes the conversion of dehydroepiandrosterone (DHEA) to dehydroepiandrosterone sulfate (DHEA-S) in the adrenals. Both DHEA and DHEA-S are quantitatively the most important corticosteroids in human. In this study, DHEA-ST was immunolocalized in normal (5 cases) and neoplastic human adrenal glands (33 cases), using a specific IgG fraction raised against the enzyme. DHEA-ST was present in almost all the zona reticularis cells and some cortical cells demonstrating lipid depletion in the zona fasciculata but not in the zona glomerulosa of the normal adrenal. This finding is consistent with adrenocorticotrophic hormone dependency of the enzyme expression. In adrenocortical adenoma, DHEA-ST immunoreactivity was observed in all the cases of Cushing's adenoma, adenoma associated with pre-Cushing's syndrome, nonfunctioning, hormonally inactive adenoma, and two of seven cases of aldosteronoma, but distribution of immunoreactivity was markedly heterogeneous among the adenoma cases. In attached non-neoplastic adrenal glands of the adenoma, intense and diffuse immunoreactivity was observed in the zona reticularis cells in all the cases of aldosteronoma and five of six of the nonfunctioning hormonally inactive adenoma, but DHEA-ST immunoreactivity was not observed or sporadic in the attached adrenal glands of Cushing's adenoma and adenoma with pre-Cushing's syndrome. These results in the attached adrenal gland may be correlated with decreased DHEA-ST expression due to autonomous neoplastic cortisol secretion and subsequent adrenocorticotrophic hormone suppression. In adrenocortical carcinoma, DHEA-ST was observed in all the cases, but the relative immunointensity of carcinoma cells was weak compared to that of the zona reticularis of the normal adrenal and adenoma.     

Cushing's syndrome due to bilateral adrenocortical adenomas with different pathological features

A 48-year-old woman with Cushing's syndrome due to bilateral adrenocortical adenomas is reported. The patient presented with a typical Cushingoid appearance. The serum cortisol level was elevated with loss of the diurnal rhythm and the plasma adrenocorticotropic hormone (ACTH) level was undetectable. Dynamic testing showed no suppression of urinary 17-OHCS by high-dose dexamethasone and no stimulation by metyrapone. An abdominal computed tomography (CT) scan showed bilateral adrenal tumors. Bilateral adrenalectomy was performed. The right adrenal gland contained a tumor that was encapsulated and consisted mainly of compact cells. The surrounding cortex was atrophic. The left adrenal gland contained an encapsulated tumor composed predominantly of clear cells. There were numerous small adrenocortical nodules in the surrounding cortex. Immunohistochemical analysis of steroidogenic enzymes (P450scc, 3beta-HSD, P450c21, P450c17 and P450c11) was performed. Immunoreactivity of all the enzymes was intense in the compact cells of the right adrenocortical adenoma, while the adjacent non-neoplastic cortex was negative for the enzymes. In the left adrenal tumor, the immunoreactivity of 3beta-HSD was intense, while that of P450c17 was weak. In the adrenocortical nodules, 3beta-HSD activity was sporadically observed. G protein genes encoding Gs alpha and Gi2 were examined for activating mutations at codons 201 and 227 (Gs alpha) and codons 179 and 205 (Gi2 alpha) in the bilateral adrenal tumors, but no mutations were found. The bilateral adenomas of this patient showed marked differences in microscopic and immunohistochemical studies, suggesting that the capacity of steroidogenesis differs between the right and left tumors.     

Serum bilirubin distribution and its relation to cardiovascular risk in children and young adults

The discovery of an asymptomatic adrenal mass (incidentaloma) during the investigation of an unrelated condition is relatively common. In this study, we report the clinical, radiologic, and endocrine evaluation of 38 patients (22 women and 16 men aged 24 to 84 years) with adrenal incidentaloma (size, 1 to 12 cm). The patients underwent basal and dynamic evaluation of the hypothalamic-pituitary-adrenal (HPA) axis, renin-angiotensin-aldosterone system, and adrenomedullary function. Moreover, computed tomograpy (CT) scan and 131I-6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol(NP-59) and/or 131I-metaiodobenzylguanidine (MIBG) scintigraphy were performed. The endocrine evaluation indicated two cases of pheochromocytoma and four cases of preclinical Cushing's syndrome, three of which underwent surgery with histologic diagnosis of two adrenocortical adenomas and one carcinoma. Low levels of serum dehydroepiandrosterone sulfate (DHEA-S), associated with a markedly increased 17-hydroxyprogesterone (17-OHP) response to a corticotropin (ACTH) test, were found in patients with incidentaloma. On the basis of endocrine and morphologic data, 13 patients underwent surgical treatment: five adrenocortical adenomas (two functioning), two pheochromocytomas, two ganglioneuromas, one cortisol-secreting adrenal carcinoma, one lymphangiomatous cyst, one myelolipoma, and one hemorrhage were found. Careful diagnostic assessment of incidentally discovered adrenal masses must be performed to exclude the presence of malignant and/or functioning lesions and to verify the possibility that patients with incidentaloma have a genetic or acquired deficit of adrenal steroidogenic activity.     

Leg blood flow during slow head-down tilt with and without leg venous congestion

BACKGROUND AND STUDY AIMS: Endoscopy and biopsy from a suspicious Vater's papilla may establish an early preoperative diagnosis of a periampullary tumor. However, information regarding the diagnostic accuracy of this procedure is limited and variable. The aim of the present study was to evaluate retrospectively the accuracy of this procedure compared to that of other diagnostic methods. PATIENTS AND METHODS: Among 928 patients referred to our institute for endoscopic retrograde cholangiopancreatography (ERCP), a suspicious Vater's papilla was seen in 28. In each case comparison was made between the pre-ERCP clinical diagnosis, endoscopic appearance, histologic interpretation of endoscopic biopsies, and the final diagnosis. Two patients in whom a final diagnosis was not available were excluded from the study. RESULTS: A final diagnosis of an ampullary or periampullary carcinoma was established in 17 patients (65%), a carcinoma within an adenoma of the papilla in three patients (12%), and adenoma and a metastatic gallbladder carcinoma in one patient each. The remaining four patients (15%) were finally diagnosed as having "pseudotumors" (due to choledocholithiasis). Eight (38%) of the 21 patients with ampullary or periampullary neoplasm also had gallstones. A pre-ERCP diagnosis (by clinical evaluation and non-invasive imaging) of tumor versus choledocholithiasis was accurate in only 65% of all 26 patients. In these, the diagnostic accuracy of endoscopic appearance and endoscopic biopsy was 77% and 85%, respectively. Regarding the 21 patients with carcinomas, the diagnosis by endoscopic appearance was more accurate than that by endoscopic biopsy (90% vs 81%). Unlike the positive predictive values, the negative predictive values for malignancy were weak: 33% for the endoscopic appearance and 50% for the endoscopic biopsy. CONCLUSIONS: Because of a high incidence of concurrent cholelithiasis, many patients with a periampullary tumor seen during ERCP are misdiagnosed earlier (by clinical evaluation and non-invasive imaging) as having choledocholithiasis only. However, the accuracy of endoscopy and biopsy is also limited. This limitation must be considered when evaluating the optimal management of patients with suspected periampullary tumor.