Imaging

Prando, Adilson

doi:10.1590/S1677-55382004000200016

UROLOGICAL SURVEY

Imaging

Changing role of imaging-guided percutaneous biopsy of adrenal masses: evaluation of 50 adrenal biopsies

Paulsen SD, Nghiem HV, Korobkin M, Caoili EM, Higgins EJ.

Department of Radiology, University of Michigan, 1500 E Medical Center Dr., UH B1 D530, Ann Arbor, MI, USA

AJR Am J Roentgenol. 2004; 182: 1033-7

OBJECTIVE: Prior series of percutaneous imaging-guided biopsies of adrenal masses before the advent of dedicated CT and MRI of the adrenal glands have shown that 40-57% of adrenal masses biopsied were adenomas-benign lesions requiring no further evaluation or treatment. This study was performed to assess the effect of dedicated adrenal imaging with CT and MRI on the rate of percutaneous imaging-guided biopsies of adrenal masses.

MATERIALS AND METHODS: We reviewed 50 consecutive adrenal mass biopsies performed during a 48-month period. The patient demographics, technique of biopsy, pathology results, and results of any prior dedicated adrenal imaging with MRI or CT protocols were noted.

RESULTS: Only six (12%) of 50 biopsies were adenomas. Five of these six cases were preceded by dedicated adrenal CT or MRI. Thirty-five cases were metastatic disease, four were adrenal cortical carcinoma, three were pheochromocytoma, and two biopsies were nondiagnostic. Overall, 20 of 50 cases were preceded by a dedicated adrenal CT or MRI examination to exclude an adenoma; in 21 of the remaining 30 cases, the imaging characteristics before biopsy were inconsistent with the potential diagnosis of an adenoma and dedicated adrenal CT or MRI was not recommended.

CONCLUSION: The number of adrenal adenomas biopsied has declined markedly with the introduction of dedicated adrenal CT and MRI for adrenal adenomas. Percutaneous imaging-guided biopsy is useful in confirming the presence and nature of suspected metastatic deposits to the adrenal gland and in diagnosing or excluding adrenal adenomas in patients with equivocal imaging characteristics.

Editorial Comment

Most incidentally found adrenal masses are adenomas even in patients with known primary tumors.For this reason a well stablished radiologic work-up is currently used in this clinical setting. By using a dedicated adrenal radiologic evaluation(CT without contrast, washout-CT and chemical shift imaging by magnetic resonance), nearly all adrenal masses can be correctly categorized as adenomas or non-adenomas.Thus, percutaneous adrenal biopsy may be indicated for the small percentage of lesions that remain indeterminate in nature after CT and MRI. Such lesions include those with a percentage of wash-out near 60% threshold or lesions that have increased in size at follow-up imaging in spite of their benign appearance at prior CT study. As shown in this publication the number of adrenal masses biopsied has significantly reduced and consequently the number of adrenal adenomas. For the same reason the number of unnecessary ressection of adrenal incidentalomas has also declined.

Dr. Adilson Prando

Department of Radiology

Vera Cruz Hospital

Campinas, São Paulo, Brazil

Voiding cystourethrography in boys. Does the presence of the catheter during voiding alter the evaluation of the urethra?

Chaumoitre K, Merrot T, Petit P, Sayegh-Martin Y, Alessandrini P, Panuel M

Service d'Imagerie Medicale, Hopital Nord, Marseille, France

J Urol. 2004; 171: 1280-1

PURPOSE: We determined whether the presence of the catheter during the voiding phase of voiding cystourethrography alters the evaluation of the urethra concerning the normal structures as well as pathological findings, especially posterior urethral valves.

MATERIALS AND METHODS: A total of 123 males 3 days to 16 years old (median age 2.6 months) underwent voiding cystourethrography. Urethral catheterization was performed in all cases. Four views were taken during the voiding phase with and without the catheter in place. Only 80 patients had available results. These examinations were studied with special attention to the normal structures and pathological findings.

RESULTS: A total of 36 examinations (45%) were normal. Pathological findings were observed in 44 patients (55%), with abnormal vesical findings and/or vesicoureteral reflux in 33 (41.25%). In 11 patients (13.75%) 12 urethral abnormalities were found (posterior urethral valves 3, hypospadias 4, prostatic utricle 1, verumontanum polyp 1, prune belly syndrome with urethral dilatation 1, imperforate anus with urethral fistula 1 and urethral duplication 1). In all cases excluding those involving hypospadias there was no difference between the views with and without the catheter. However, concerning the normal structures, the verumontanum and fossa navicularis were better delineated without the catheter in 27% and 33% of cases, respectively.

CONCLUSIONS: Our study shows that a urethral catheter does not alter the diagnosis of abnormalities of the posterior urethra but may hamper the observation of normal structures or abnormalities of the anterior urethra.

Editorial Comment

Voiding cystourethrography is the most common radiologic procedure performed in children for the investigation of urinary tract infection. This article brings back an issue which has not been recently discussed (1). It is a well stablished concept among radiologysts that leaving the catheter in place during voiding cystourethrography does not prevent the diagnosis of urethral disease. The argument that the diagnosis of posterior urethral valves may be missed, due to the effacement of the valve by the catheter is not valid. The catheter should be left in place because simplifies the process of controlling contrast infusion until voiding occurs. If we remove the catheter and after that the child is not able to void, it will be necessary to do a recatheterization. Another benefit is related to technical aspects of this procedure. Voiding cystourethrography is a cyclic procedure. Reflex voiding at the beginning of vesical infusion is not uncommon. When this happens although the urethra will be promptly evaluated, the lack of adequate bladder distention may prevent the detection of vesico-ureteral reflux. By leaving the catheter in place we will be able to refill the bladder in order to perform an adequate search for reflux. After studing the posterior urethra and bladder we can always remove the catheter in order to evaluate the anterior urethra.

Reference

1. Ditchfield MR,Grattan-Smith JD, de Campo J, Hutson J: Voiding cystourethrography in boys: does the presence of the catheter obscure the diagnosis of posterior urethral valves? AJR Am J Roentgenol. 1995;164: 1233-5.