Hypertension leads to multiple comorbidities and increased risk for mortality. Endocrine disorders contribute to the development of hypertension, including primary aldosteronism (PA). This article discusses the evaluation and management of PA.

Schwannomas are benign, generally indolent tumors of neural crest origin and comprise the most common histologic tumor of peripheral nerves. Schwannomas are a rare histology for retroperitoneal tumors and very rare histologic findings for tumors of the adrenal gland with fewer than 50 cases in the reported literature. Here we present a case report of a non-hormonally functional but metabolically active adrenal tumor with indeterminate imaging characteristics with final pathology showing a 6.1 cm adrenal schwannoma as well as historical institutional pathology review revealing two additional cases.

Adrenal myelolipomas are benign adrenocortical tumors composed of adipose tissue mixed with hematopoietic precursor cells. An association of myelolipoma with adrenal cortical adenoma is rare and the pathogenesis of these tumors remains unclear. Here we present a case of an incidentally discovered adrenal tumor with radiologic characteristics of a myelolipoma who underwent adrenalectomy due to biochemical suspicion for pheochromocytoma. The final pathology, however, revealed a myelolipoma with a co-existing adrenal cortical adenoma without evidence of pheochromocytoma. Genetic analysis revealed the presence of a hitherto unreported heterozygous variant, c.329C>A (p.Ala110Asp), of the armadillo repeat-containing protein 5 (ARMC5) gene which when inactivated is commonly associated with bilateral adrenal nodularity.

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.
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).
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.
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.

Almost all medical specialities utilise cross-sectional imaging of the abdomen to evaluate many different medical conditions. This ever-increasing use of cross-sectional imaging has led to a dramatic increase in the detection rate of adrenal nodules. Following appropriate biochemical and radiological evaluation, the vast majority of these are shown to be benign adrenal adenomas. A small minority are diagnosed with a functional or malignant lesion that may result in significant morbidity and mortality requiring specialist management.

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.

OBJECTIVE: To assess the impact of using a computer-assisted reporting and decision support (CAR/DS) tool at the radiologist point-of-care on ordering provider compliance with recommendations for adrenal incidentaloma workup.
METHODS: Abdominal CT reports describing adrenal incidentalomas (2014 - 2016) were retrospectively extracted from the radiology database. Exclusion criteria were history of cancer, suspected functioning adrenal tumor, dominant nodule size < 1 cm or ≥ 4 cm, myelolipomas, cysts, and hematomas. Multivariable logistic regression models were employed to predict follow-up imaging (FUI) and hormonal screening orders as a function of patient age and sex, nodule size, and CAR/DS use. CAR/DS reports were compared to conventional reports regarding ordering provider compliance with, frequency, and completeness of, guideline-warranted recommendations for FUI and hormonal screening of adrenal incidentalomas using Chi-square test.
RESULTS: Of 174 patients (mean age 62.4; 51.1% women) with adrenal incidentalomas, 62% (108/174) received CAR/DS-based recommendations versus 38% (66/174) unassisted recommendations. CAR/DS use was an independent predictor of provider compliance both with FUI (Odds Ratio [OR]=2.47, p = 0.02) and hormonal screening (OR=2.38, p = 0.04). CAR/DS reports recommended FUI (97.2%,105/108) and hormonal screening (87.0%,94/108) more often than conventional reports (respectively, 69.7% [46/66], 3.0% [2/66], both p <0.0001). CAR/DS recommendations more frequently included instructions for FUI time, protocol, and modality than conventional reports (all p <0.001).
CONCLUSIONS: Ordering providers were at least twice as likely to comply with report recommendations for FUI and hormonal evaluation of adrenal incidentalomas generated using CAR/DS versus unassisted reporting. CAR/DS-directed recommendations were more adherent to guidelines than those generated without.

Current recommendations using Hounsfield units (HU) ≤ 10 to identify adrenal adenomas on unenhanced computed tomography (CT) miss 10-40% of benign adenomas. We sought to determine if changing HU threshold and adding absolute percent contrast washout (APW) criteria would identify adrenal adenomas better than current recommendations.
Imaging characteristics were compared between patients with adenomas (n = 128) and those with non-adenomas (n = 54) after unilateral adrenalectomy. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated.
Using HU ≤ 10 to identify adenomas had a sensitivity of 47.6%, specificity of 93.3% (AUC = 0.71, p < 0.001), PPV of 95.3%, and NPV of 58.1% for identifying adrenal adenomas. Applying HU ≤ 16 improved sensitivity (65.4%) without reducing specificity (93.3%) (AUC = 0.79, p < 0.001), PPV increased to 96.3%, and NPV decreased to 47.6%. Applying HU ≤ 16 as the initial criterion followed by APW > 60% for lesions exceeding 16 HU, sensitivity increased to 93.4%, specificity was 93.3% and PPV 96.6%, and NPV improved to 85.7% (AUC = 0.96, p < 0.001).
Criteria of initial threshold of HU ≤ 16 followed by APW > 60% for lesions exceeding 16 HU yielded improved sensitivity and specificity in identification of adrenal adenomas.

Primary aldosteronism (PA) is a potentially reversible cause of uncontrolled hypertension. Early diagnosis and timely management of PA can prevent end-organ damage. Aldosteronoma Resolution Score (ARS) is a useful tool to predict cure rates and resolution of hypertension after adrenalectomy.

To investigate whether the histogram analysis method of characterizing adrenal nodules as adenomas is affected by increased noise with modern CT technique, and if an extension that allows for noise correction will improve diagnostic performance.
This is a HIPAA-compliant, IRB-approved retrospective study performed on 58 total patients. The first group of 29 patients had 33 adrenal lesions that were pathology-proven non-adenomas. The second group had 29 patients with 33 pathology-proven or presumed adenomas based on established imaging criteria. The nodules were evaluated using the histogram method, mean attenuation method, and a Gaussian model-based algorithm without (uncorrected Gaussian algorithm) and with correction (corrected Gaussian algorithm) for image noise. Sensitivity, specificity, and accuracy for identifying adenoma were derived.
There were no significant differences in identifying adenoma from non-adenoma when using the histogram analysis method and the uncorrected Gaussian algorithm, both of which had low specificities of 42.4% and 47.0%, respectively (p = 0.30). Adding noise correction to the Gaussian algorithm resulted in a statistically significant increase in specificity relative to the histogram method (86.4% vs. 42.4%, p < 0.001). The corrected Gaussian algorithm improved sensitivity compared to the mean attenuation method (71.2% vs. 54.5%, p < 0.001), but had lower specificity (86.4% vs. 100%, p < 0.001), and similar overall accuracy (78.8% vs. 77.3%, p = 0.74).
With modern low-dose CT technique, the specificity scores of the histogram method for discrimination of adrenal adenomas and non-adenomas are lower than with previous higher dose scans. The specificity and accuracy of a histogram-equivalent method can be increased mathematically through image noise correction, and the corrected Gaussian algorithm has improved sensitivity to the mean attenuation with similar accuracy albeit with lower specificity. Although this suggests limited utility for histogram analysis in adrenal nodule characterization, our study demonstrates the potential mathematical application for other noise-dependent CT characterization methods.