Adrenal Metastasis Research Articles

A Rare Primary Renal Lymphoma with Liver and Adrenal Gland Metastasis: A Case Report

Extra-nodal lymphomas include about 25%–35% of non-Hodgkin lymphomas (NHL), with the most frequent sites being the skin, small intestine, and stomach. Renal involvement by a lymphomatous tumor is rare, the majority of these tumors are nonHodgkin lymphomas and in more than 90% of cases this renal location is secondary. This neoplasm is frequently misdiagnosed initially as renal cell carcinoma. In this article we report a very unusual case of primary renal lymphoma (PRL) with hepatic and adrenal gland metastases in a 65-year-old woman.

Factors associated with prolonged progression-free survival of patients treated with first-line afatinib for advanced epidermal growth factor receptor-mutated non-small cell lung cancer.

This study aimed to investigate the factors associated with prolonged progression-free survival (PFS) (>36 months) of advanced non-small cell lung cancer (NSCLC) patients harboring epidermal growth factor receptor (EGFR) mutations treated with first-line afatinib. We performed a retrospective analysis of data of patients with advanced EGFR-mutated NSCLC receiving first-line afatinib at two tertiary care referral centers, Linkou and Kaohsiung Chang Gung Memorial Hospital, in Taiwan between June 2014 and April 2022. The data of 546 treatment-naïve EGFR-mutated advanced NSCLC patients were analyzed. Median PFS and overall survival were 14.5 months and 27.2 months, respectively. The PFS of 462 patients (84.6%) was less than 36 months and of 84 patients (15.4%) was more than 36 months. The PFS > 36 months group had a significantly higher percentage of patients with uncommon mutations (p = 0.002). The PFS ≤36 months group had significantly higher incidences of bone, liver, and adrenal metastases (all p < 0.05) and a higher rate of multiple distant metastases. Multivariate logistic regression analysis showed that liver metastasis was negatively and independently associated with prolonged PFS (adjusted odds ratio = 0.246 [95% CI: 0.067-0.908], p = 0.035). The median overall survival of the PFS >36 months group was 46.0 months and that of the PFS ≤36 months group was 22.9 months (log-rank test, p < 0.001). We found that EGFR-mutated NSCLC patients receiving first-line afatinib were prone to shorter PFS if they had distant organ metastasis, especially liver metastasis.

Enlarged Cervical Lymph Nodes as a First Presentation of Metastatic CA Prostate

Prostate cancer is one of the common cancers in the world. It often metastasizes to the regional lymph nodes, bones, lungs, pleura, liver, and adrenal glands but metastasis to supraclavicular lymph nodes is very uncommon. Cervical lymph node metastasis as the first clinical manifestation of the prostate carcinoma has been reported only a few times till date. We present an unusual case of a 70- year old male who presented with enlarged swellings on the left side of his neck and was diagnosed with carcinoma prostate.

Multi-institutional experience of MR-guided stereotactic body radiation therapy for adrenal gland metastases

PurposeWhile dose escalation is associated with improved local control (LC) for adrenal gland metastases (AGMs), the proximity of gastrointestinal (GI) organs-at-risk (OARs) limits the dose that can be safely prescribed via CT-based stereotactic body radiation therapy (SBRT). The advantages of magnetic resonance-guided SBRT (MRgSBRT), including tumor tracking and online plan adaptation, facilitate safe dose escalation. MethodsThis is a multi-institutional review of 57 consecutive patients who received MRgSBRT on a 0.35-T MR linac to 61 AGMs from 2019 to 2021. The Kaplan-Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and LC, and the Cox proportional hazards model was utilized for univariate analysis (UVA). ResultsMedian follow up from MRgSBRT was 16.4 months (range [R]: 1.1–39 months). Median age was 67 years (R: 28–84 years). Primary histologies included non-small cell lung cancer (N = 38), renal cell carcinoma (N = 6), and melanoma (N = 5), amongst others. The median maximum diameter was 2.7 cm (R: 0.6–7.6 cm), and most AGMs were left-sided (N = 32). The median dose was 50 Gy (R: 30–60 Gy) in 5–10 fractions with a median BED10 of 100 Gy (R: 48–132 Gy). 45 cases (74 %) required adaptation for at least 1 fraction (median: 4 fractions, R: 0–10). Left-sided AGMs required adaptation in at least 1 fraction more frequently than right-sided AGMs (88 % vs 59 %, p = 0.018). There were 3 cases of reirradiation, including 60 Gy in 10 fractions (N = 1) and 40 Gy in 5 fractions (N = 2). One-year LC, PFS, and OS were 92 %, 52 %, and 78 %, respectively. On UVA, melanoma histology predicted for inferior 1-year LC (80 % vs 93 %, p = 0.012). There were no instances of grade 3+ toxicity. ConclusionsWe demonstrate that MRgSBRT achieves favorable early LC and no grade 3 + toxicity despite prescribing a median BED10 of 100 Gy to targets near GI OARs.

Percutaneous ablation for adrenal metastasis from non-small-cell lung cancer: comparison between cryoablation and microwave ablation.

While cryoablation (CA) and microwave ablation (MWA) have both been implemented as approaches to the treatment of adrenal metastasis (AM), the outcomes associated with these two therapeutic strategies remain unclear. To compare the safety and efficacy of CA and MWA as treatments for AM in patients with non-small-cell lung cancer (NSCLC). Consecutive patients with AM secondary to NSCLC from January 2015 to December 2020 underwent CA or MWA. Treatment-related outcomes and complications were retrospectively compared between these groups. In total, 68 NSCLC patients with isolated AM were enrolled in this study, of whom 35 and 33 underwent treatment with CA and MWA, respectively. Primary complete ablation rates in the CA and MWA groups were 91.4% (32/35) and 93.9% (31/33) respectively (p = 1.000), while a 100% secondary complete ablation rate was observed for both groups. Hypertensive crisis incidence affected 11.4% (4/35) and 9.1% (3/33) of patients in the CA and MWA groups (p = 1.000), respectively, while 8 (22.9%) and 8 (24.2%) patients in these corresponding groups experienced local progression after ablation that was detected during the follow-up period (p = 0.893). Patients in the CA and MWA groups exhibited a median progression-free survival of 18 and 22 months, respectively (p = 0.411), while the corresponding median overall survival of patients in these groups was 25 and 29 months (p = 0.786). CT-guided CA and MWA appear to exhibit similar safety and efficacy profiles when employed to treat isolated AM in NSCLC patients.

Local imaging to interpret tumor size in F18 fluorodeoxyglucose positron emission tomography/CT in lung cancers.

This study aimed to determine the thoracic and extra-thoracic extension of the disease in patients diagnosed with lung cancer and who had whole-body F18-fluorodeoxyglucose positron emission tomography/CT imaging and to investigate whether there is a relationship between tumor size and extrathoracic spread. A total of 308 patients diagnosed with lung cancer were included in this study. These 308 patients were first classified as group 1 (SPN 30 mm>longest lesion diameter ≥10 mm) and group 2 (lung mass (longest lesion diameter ≥30 mm), and then the same patients were classified as group 3 (nodular diameter of ≤20 mm) and group 4 (nodular size of >20 mm). Group 1 was compared with group 2 in terms of extrathoracic metastases. Similarly, group 3 was compared with group 4 in terms of frequency of extrathoracic metastases. F18 fluorodeoxyglucose positron emission tomography/CT examination was used to detect liver, adrenal, bone, and supraclavicular lymph node metastasis, besides extrathoracic metastasis. Liver, bone, and extrathoracic metastasis in group 1 was statistically lower than in group 2 (p<0.001, p<0.01, and p=0.03, respectively). Liver, extrathoracic, adrenal, and bone metastasis in group 3 was statistically lower than that in group 4 (p<0.001, p=0.01, and p=0.04, p<0.01, respectively). The extrathoracic extension was observed in only one patient in group 3. In addition, liver, adrenal, and bone metastases were not observed in group 3 patients. Positron emission tomography/CT may be more appropriate for cases with a nodule diameter of ≤20 mm. Performing local imaging in patients with a nodule diameter of ≤20 mm could reduce radiation exposure and save radiopharmaceuticals used in positron emission tomography/CT imaging.

Clinical analysis of 13 colorectal cancer patients with adrenal metastasis and a brief literature review.

Clinical analysis of 13 colorectal cancer patients with adrenal metastasis and a brief literature review.

Diagnostic efficiency of single source dual energy CT in differentiating adrenal adenoma from adrenal metastasis

Background: The distinction between incidental adrenal lesions is still difficult in diagnostic imaging whereas Dual energy CT has not been thoroughly tested for its ability to diagnose adrenal lesions. This study utilizes dual energy CT to identify between the two most prevalent adrenal neoplasms, adrenal metastasis and adrenal adenomas.Objective:To evaluate the efficacy of non-enhanced single-source dual-energy computed tomography (ssDECT) in differentiating metastases from adenomas in adrenal glands Materials and methods :This is a retrospective study conducted in the department of radio diagnosis of Mysore medical college and research institute after receiving the approval from our institutional ethical committee.A total of fifty six patients (32 men,24 women) with 31 adrenal metastases (AMs) and 32 adrenal adenomas (AAs) underwent a plain dual-energy CT imaging from March 2021 to October 2022 were included. The CT number from the virtual monochromatic spectral (VMS) image sets were measured for the AMs and AAs. The difference of CT numbers between AMs and AAs was statistically compared by P value and the box plot curve. Results: The CT number (medium, range) of metastases (50.47, 29.93 HU at 40 keV and 29.00, 9.36 HU at 140 keV) was significantly higher than that of adenomas (0.76, 33.04 to 13.73, 18.96 HU) at each energy level from 40 to 140 keV (P &lt;.05).Conclusion: Using CT numbers obtained from virtual monochromatic images of single source dual energy CT can be used to differentiate adenomas from adrenal metastasis. The Median CT number of metastases was higher than that of adenomas at 40 Kev and 140 Kev. The median CT number of metastases decreased with increase in incident photon energy in Kev and median CT number of adenomas increased with increase in incident photon energy in Kev. Keywords- Virtual monochromatic spectral (VMS) image,Dual energy computed tomography, adrenal lesions, differential diagnosis.

Stereotactic body radiation therapy for adrenal gland metastases: A multi-institutional outcome analysis

AimThe adrenal gland is a common site of metastasis with a rate of up to 27% in autopsy series. The incidence of these metastases is increasing due to greater use of Positron Emission Tomography scans and improved overall survival of patients with metastatic cancers. Stereotactic body radiation therapy (SBRT) is a non-invasive treatment option for metastasis. The aim of this study is to assess prognostic factors influencing local control, progression-free and overall survival in oligometastatic patients treated with SBRT for an adrenal metastasis. MethodsIn this multicentric retrospective study, we included patients with adrenal metastases treated with SBRT between 2010 and 2021 in eleven french centers. All primary tumors were included. ResultsA total of 110 patients treated for 121 adrenal lesions were included. Non-small-cell lung cancer was the predominant histologic type (55.4 %). Eighty-two percent of patients had at least 2 metastatic sites. The median Planning Target Volume was 70 cm3 with a median prescription dose of 40 Gray (Gy). The mean Biologically Effective Dose (BED) 10 dose was 74.2 Gy. Local control at 1 and 2 years was 85.9 % and 72.5 % respectively. The median overall survival and progression-free survival were 31.6 and 8.5 months respectively. Local control was significantly improved by systemic treatment one month before or after SBRT (p = 0.009) and by a BED10 greater than or equal to 50 Gy (p = 0.003).In multivariate analysis, oligometastatic presentation (p = 0.009) and a metachronous metastatic presentation (p = 0.008) were independent factors for progression-free survival.Tolerance was excellent, no grade 3 and 4 toxicities were described due to SBRT. ConclusionStereotactic radiotherapy of adrenal metastases makes possible a local control of more than 85% at one year and was well tolerated. The factors influencing survival in oligometastatic patients still need to be found in order to better select those who benefit the most from this type of treatment.

Steroidogenic acute regulatory (StAR) protein is a useful marker for sex-cord-stroma tumors and normal/neoplastic adrenocortical tissue

Abstract Introduction/Objective Steroidogenic acute regulatory (StAR) protein is a mitochondrial transport protein with a critical regulatory role for steroid hormone production. As its expression is limited to few normal tissues, the immunohistochemical analysis of StAR was proposed to be diagnostically useful. Methods/Case Report To comprehensively evaluate the diagnostic utility of immunohistochemical StAR expression analysis, a tissue microarray containing 19,202 samples from 152 different tumor types and subtypes and 608 samples of 76 different normal tissue types was analyzed by immunohistochemistry (IHC). Melan-A “cross-reactive” data were available from a previous study for comparison. Results (if a Case Study enter NA) StAR immunostaining occurred in 198 (1.2%) of the 17,135 analyzable tumors. StAR expression was observed in 27 of 152 tumor categories, 9 of which included at least one strongly positive case. The highest rate of StAR positivity occurred in Leydig cell tumors of the testis and the ovary (100%), steroid cell tumors of the ovary (100%), adrenocortical carcinomas (93%) and adenomas (87%), Sertoli-Leydig cell tumors (67%) and granulosa cell tumors of the ovary (56%) as well as in seminomas (7%). As compared to Melan A, StAR was more often positive in adrenocortical neoplasms and in Leydig cell tumors while StAR (but not Melan-A) was negative in Sertoli cell tumors. Conclusion Our data provide a complete overview on the patterns of StAR immunostaining in human tumors and suggest a diagnostic utility of StAR immunohistochemistry for supporting a diagnosis of Leydig cell tumors or of normal or neoplastic adrenocortical tissue. In contrast to Melan A, StAR appears to be more sensitive for these tumors while StAR is always negative in malignant melanoma, a frequent source of adrenal metastasis.

Primary adrenal diffuse large B cell Lymphoma with Tumor thrombus in central adrenal vein: a case report and literature review

BackgroundPrimary adrenal lymphoma (PAL) is a rare disease confined wholly or chiefly to extramural involvement. Tumor thrombus in the central adrenal vein, renal vein, and inferior vena cava has been reported in adrenal pheochromocytoma, adrenocortical carcinoma, adrenal metastasis carcinoma, and adrenal leiomyosarcoma. Primary adrenal diffuse large B cell lymphoma with tumor thrombus in the central adrenal vein has rarely been reported in the current study. ( We searched in PubMed, Web of Science databases, Embase, and Medline in the English language from 1970 to December 2022. The keywords used were “Primary adrenal lymphoma " and " tumor thrombus”.)Case presentationIn this report, we discuss the case of a 57-year-old woman who complained of abdominal discomfort following cold stimulation, low back pain, anorexia, fatigue, and weight loss for 1 year. Contrast-enhanced spiral computed tomography (CT) showed mild-to-moderate enhancement of the bilateral masses and central adrenal vein tumor thrombus. After an exhaustive study, the patient was diagnosed with primary adrenal diffuse large B-cell lymphoma. In the diagnosis of PAL, the possibility of a tumor embolism in the central adrenal vein, renal vein, or inferior vena cava should be considered, although this is rare.

Diagnosis and Treatment of Adrenal Metastasis in Modern Era

The adrenal glands are a common site of metastases in many advanced stages of cancers such as lung cancer and breast cancer. Given the frequent asymptomatic nature of these adrenal metastatic tumors, patients seldom get screened for adrenal metastases unless otherwise medically indicated for. Therefore, it is essential that screening methods should be as accurate and precise as possible. In this review, we summarize the pivotal role of modern screening in the early detection of adrenal metastatic lesions and detail the advancements that have contributed to improved detection. Through our review, we reaffirm that there has yet to be a “gold standard” in the screening process for adrenal metastases. Such a study can help medical professionals more comprehensively understand the contemporary screening methods, promoting early detection and better prognosis of adrenal metastases.

A combined encoder–transformer–decoder network for volumetric segmentation of adrenal tumors

BackgroundThe morphology of the adrenal tumor and the clinical statistics of the adrenal tumor area are two crucial diagnostic and differential diagnostic features, indicating precise tumor segmentation is essential. Therefore, we build a CT image segmentation method based on an encoder–decoder structure combined with a Transformer for volumetric segmentation of adrenal tumors.MethodsThis study included a total of 182 patients with adrenal metastases, and an adrenal tumor volumetric segmentation method combining encoder–decoder structure and Transformer was constructed. The Dice Score coefficient (DSC), Hausdorff distance, Intersection over union (IOU), Average surface distance (ASD) and Mean average error (MAE) were calculated to evaluate the performance of the segmentation method.ResultsAnalyses were made among our proposed method and other CNN-based and transformer-based methods. The results showed excellent segmentation performance, with a mean DSC of 0.858, a mean Hausdorff distance of 10.996, a mean IOU of 0.814, a mean MAE of 0.0005, and a mean ASD of 0.509. The boxplot of all test samples' segmentation performance implies that the proposed method has the lowest skewness and the highest average prediction performance.ConclusionsOur proposed method can directly generate 3D lesion maps and showed excellent segmentation performance. The comparison of segmentation metrics and visualization results showed that our proposed method performed very well in the segmentation.

Texture Analysis of Adenomatous and Metastatic Adrenal Lesions on Native and Contrast-enhanced Computed Tomography

Differentiating lipid-poor adrenal adenomas from adrenal metastases is not possible without performing a dedicated contrast-enhanced CT (CECT) protocol. Our purpose is to evaluate the possible role of texture analysis in classifying adrenal lesions.&#x0D; This is a retrospective study. We evaluated 33 patients with 47 metastases and 43 patients with 47 adenomas. Seven of the adenomas were lipid-poor, and the rest – lipid-rich adenomas. We used commercially available software for lesion segmentation and texture analysis on native and arterial phase CT images with a slice thickness of 2 mm. The segmentation was semi-automated, and features were computed on the resulting regions of interest (ROI) for each lesion on both native and arterial phases. Two conventional (HU standard deviation, Histogram Entropy) and six second-order texture features (GLCM – Homogeneity, Energy, Entropy log 10, Contrast, Dissimilarity, NGDLM–Busyness) were calculated. For statistical analysis the IBM SPSS 19 package was used to compare the following groups in both phases: 1. Adenomas--Metastasis; 2. Lipid-rich adenomas (LRA)--metastases; 3. Lipid-rich--lipid-poor adenomas (LPA); 4. Lipid-poor adenomas--metastases.&#x0D; There was a statistically significant difference in the distribution of some conventional (Histogram Entropy) and second-order features (GLCM – Homogeneity, Energy, Entropy log 10, Dissimilarity) in the first group on the native as well as on the enhanced images. The results were similar when comparing lipid-rich adenomas to metastases. Only native phase derived features were discriminative between lipid-rich and lipid-poor adenomas, with no difference between parameters on CECT. No difference was found between any of the texture features in lipid-poor adenomas and metastases for both phases.&#x0D; First- and second-order texture features were graded based on their potential for serving as classifier tools. Unenhanced features ranked higher. Further research and validation are needed to discover the most robust set of features for differentiating between lipid-poor adenomas and metastases.

Adrenal Metastases Are Associated with Poor Outcomes in Patients with Metastatic Clear Cell Renal Cell Carcinoma Treated with Nivolumab in the GETUG-AFU-26 NIVOREN Phase 2 Trial

BackgroundGlandular metastases (GMs; adrenal gland, pancreas, thyroid, ovary, breast, or prostate) are rare in metastatic clear cell renal cell carcinoma (mccRCC). Previous studies have indicated that GM patients treated with antiangiogenic therapy experience significantly longer overall survival (OS). ObjectivesTo assess outcomes for mccRCC with or without GMs treated with nivolumab. Design, setting, and participantsThe GETUG-AFU-26 NIVOREN phase 2 trial evaluated the activity and safety of nivolumab in patients with mccRCC who experienced failure of antiangiogenic therapies (NCT03013335). In this ancillary study, patients were divided into two groups according to the presence or absence of at least one GM. Outcome measurements and statistical analysisThe primary outcome was OS; secondary outcomes were progression-free survival (PFS) and the objective response rate (ORR). Survival was estimated using the Kaplan-Meier method. Univariate and multivariable Cox regression models are used to estimate the hazard ratio (HR) with 95% confidence interval (CI) for survival outcomes. Subgroup analyses were performed for patients with pancreatic metastases and patients with adrenal metastases. Results and limitationsAmong 720 patients treated with nivolumab between February 2016 and July 2017, 217 had GMs, of whom 151/217 had adrenal metastases and 86/217 had pancreatic metastasis. Patients with adrenal metastases had worse 12-mo OS (64% vs 71.1%) and 6-mo PFS (27.2% vs 36.6%) and a lower objective response rate (12.5%, 95% CI 7.6%–19.0%, vs 23.2%, 95% CI 19.8–27.0%; p = 0.005) than patients without adrenal metastases. Conversely, univariate analysis showed that patients with pancreatic metastases had significantly better 12-mo OS (82.3% vs 67.9%; HR 0.59, 95% CI 0.40–0.85) in comparison to patients with nonpancreatic GMs. On multivariable analysis, only adrenal metastasis remained associated with adverse prognosis. ConclusionsAdrenal metastasis is an independent prognostic factor for poor response and survival in the GETUG-AFU-26 NIVOREN trial. Limited activity with nivolumab was observed for patients with mccRCC with adrenal metastases. These results warrant an evaluation of the prognostic value of adrenal metastases in patients treated with immunotherapy combinations with ipilimumab or tyrosine kinase inhibitors. Patient summaryOur study showed that metastasis in the adrenal glands could be an independent factor associated with poor response to immunotherapy and survival for patients with metastatic kidney cancer. It would be useful to evaluate the prognostic value of adrenal gland metastasis in patients treated with immunotherapy combinations or immunotherapy agents combined with drugs called tyrosine kinase inhibitors.

Performance of EUS-FNA and EUS-B-FNA for the diagnosis of left adrenal glands metastases in patients with lung cancer: A systematic review and meta-analysis

ObjectivesFor diagnosing left adrenal gland metastasis in lung cancer, clinical guidelines recommend to perform EUS, but EUS-B (EUS using an EBUS-scope) is increasingly being used. We evaluated the diagnostic performance of both procedures. Materials and MethodsWe did a systematic review (PROSPERO, CRD42023416205) and searched MEDLINE and EMBASE on 04-July-2023 for studies evaluating EUS and/or EUS-B in diagnosing left adrenal gland metastases in adults with (suspected) lung cancer. Outcomes were: (1) ability to visualize the left adrenal gland, (2) ability to sample (in those with successful visualization and in whom sampling was attempted), (3) ability to obtain adequate material (in those with successful sampling), (4) malignancy detection rate (in those with successful sampling), and (5) remaining risk of malignancy (in those with a negative EUS(-B)-FNA and undergoing a reference standard). We performed random-effects meta-analyses. ResultsWe included 19 studies (EUS: n = 11, EUS-B: n = 6, both: n = 2), covering 1712 patients. All studies had high (n = 18) or unclear (n = 1) risk of bias (QUADAS-2). Average ability to visualize the left adrenal gland was 0.94 (95 %CI 0.82–0.98; n = 7 studies). Average ability to sample was 1.00 (95 %CI 0.99–1.00; n = 9). Average ability to obtain adequate material was 0.96 (95 %CI 0.93–0.98; n = 18). Average malignancy detection rate was 0.42 (95 %CI 0.34–0.49; n = 18). Remaining risk of malignancy was 0.07 (95 %CI 0.04–0.12; n = 8). Ability to visualize was slightly higher for EUS (0.99; 95 %CI 0.90–1.00) than EUS-B (0.84; 95 %CI 0.70–0.92; p = 0.025), but the other performance characteristics were similar. No major complications were reported. ConclusionBoth EUS and EUS-B have good performance and are safe for left adrenal gland analysis in patients with lung cancer, but the number of high-quality studies is limited and further well-constructed prospective studies are needed.

Isolated Castrate-resistant Prostate Cancer Metastasis to Both Adrenal Glands Detected on 68Ga PSMA PET/CT.

A 61-year-old male patient, who had undergone radical prostatectomy, underwent 68Ga labeled prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) for evaluation of suspected biochemical recurrence of prostate cancer (PCa). PET/CT scan showed increased 68Ga PSMA expressions in hypodense mass lesions in both adrenal gland localizations. An adrenal gland tru-cut biopsy was performed for the right side, which showed poor-differentiated carcinoma metastases associated with the patient's high-grade PCa. As far as we could determine based on an extensive literature search, this is the second case in which isolated adrenal metastasis was detected by 68Ga PSMA PET/CT study in a patient with PCa.

S2379 Brain and Adrenal Metastasis Resulting from Unexpected Recurrence After Endoscopic Resection of Low-Risk T1 Colon Cancer: A Case Report

S2379 Brain and Adrenal Metastasis Resulting from Unexpected Recurrence After Endoscopic Resection of Low-Risk T1 Colon Cancer: A Case Report

Volumes Changes in Adrenal Metastases during Delivery of 5-Fraction Stereotactic Magnetic Resonance-Guided Adaptive Radiotherapy

Stereotactic MR-guided adaptive radiotherapy (SMART) improves adrenal target coverage and reduces organ at risk doses. Changes in adrenal tumor volumes were observed during contouring for daily-adaptive planning. We hypothesized that such changes in GTV may correlate with long-term outcomes. An Ethics approved institutional database was accessed for details of 5-fraction adrenal SABR treatments on a 0.35T MR-Linac between 2016-2023. Volumetric MR-scans were acquired at baseline, and prior to each of 5 fractions. Manually contoured GTVs were accessed. Volume changes between simulation and first fraction (ΔPF1), as well as between first and subsequent fractions (ΔF1F2 to ΔF1F5) were computed. Daily relative adrenal volume change (DRVC) and the absolute volume change (DAVC) before treatment, were calculated by dividing ΔPF1 by the number of days between simulation and F1. Paired Wilcoxon tests were used to compare volumes at different timepoints. Univariate linear regression (LinR) models were created to study per-treatment volume changes. A logistic regression (LogR) analysis explored associations between baseline characteristics and volumetric changes with radiological complete response (CR) at the date of last news. Adrenal SMART in 5 fractions of either 8 or 10Gy was delivered to 70 patients. The median interval between simulation and F1 was 13 days (range, 2-35), and 13 days between F1-F5 (range, 9-31). Solitary metastasis comprised 44%; metastases were mainly from non-small cell lung (64%) or renal (9%) primaries. Concurrent systemic therapy (± 3 months) was delivered in 41% of patients. Mean baseline GTV at simulation and F1 were respectively 38.5 and 41.4cc (p<0.001). Mean ΔPF1 was +9.1% (-10.2% to +50.1%) or +2.9cc (-4.4 to +27.4cc). Mean DRVC was +0.8% per day (-1.0% to +8.4%), and did not correlate with histology, GTV or concurrent systemic treatment. Mean DAVC was +0.26cc per day (-0.31 to +2.4cc), and was associated with GTV size (p = 0.04). In total, 47% of adrenal GTVs decreased in volume at F5 compared to F1. A ≥10% increase in GTV was observed in 39% of patients during SMART. GTV variations of ≥20% occurred in 36% patients at some point during SMART. At a median follow-up of 20.3 months, radiological CR was seen in 23% of 64 evaluable patients. Radiological CR was significantly associated with baseline GTV (p = 0.03) and ΔF1F5 (p = 0.03), but not DRVC (p = 0.6) or ΔF1F3 (p = 0.3). Local relapses were seen in 6% of patients. Changes in adrenal volumes during SMART were common, with variations ≥20% occurring in 36% patients. The probability of a radiological CR correlated with both baseline GTV size and median relative volume decline between fractions 1 and 5. These changes support use of daily SABR plan adaptation.

18F-FDG-PET/CT-based machine learning model evaluates indeterminate adrenal nodules in patients with extra-adrenal malignancies

BackgroundTo assess the value of an 18F-FDG-positron emission tomography/computed tomography (PET/CT)-based machine learning model for distinguishing between adrenal benign nodules (ABNs) and adrenal metastases (AMs) in patients with indeterminate adrenal nodules and extra-adrenal malignancies.MethodsA total of 303 patients who underwent 18F-FDG-PET/CT with indeterminate adrenal nodules and extra-adrenal malignancies from March 2015 to June 2021 were included in this retrospective study (training dataset (n = 182): AMs (n = 97), ABNs (n = 85); testing dataset (n = 121): AMs (n = 68), ABNs (n = 55)). The clinical and PET/CT imaging features of the two groups were analyzed. The predictive model and simplified scoring system for distinguishing between AMs and ABNs were built based on clinical and PET/CT risk factors using multivariable logistic regression in the training cohort. The performances of the predictive model and simplified scoring system in both the training and testing cohorts were evaluated by the areas under the receiver operating characteristic curves (AUCs) and calibration curves. The comparison of AUCs was evaluated by the DeLong test.ResultsThe predictive model included four risk factors: sex, the ratio of the maximum standardized uptake value (SUVmax) of adrenal lesions to the mean liver standardized uptake value, the value on unenhanced CT (CTU), and the clinical stage of extra-adrenal malignancies. The model achieved an AUC of 0.936 with a specificity, sensitivity and accuracy of 0.918, 0.835, and 0.874 in the training dataset, respectively, while it yielded an AUC of 0.931 with a specificity, sensitivity, and accuracy of 1.00, 0.735, and 0.851 in the testing dataset, respectively. The simplified scoring system had comparable diagnostic value to the predictive model in both the training (AUC 0.938, sensitivity: 0.825, specificity 0.953, accuracy 0.885; P = 0.5733) and testing (AUC 0.931, sensitivity 0.735, specificity 1.000, accuracy 0.851; P = 1.00) datasets.ConclusionsOur study showed the potential ability of a machine learning model and a simplified scoring system based on clinical and 18F-FDG-PET/CT imaging features to predict AMs in patients with indeterminate adrenal nodules and extra-adrenal malignancies. The simplified scoring system is simple, convenient, and easy to popularize.