Adrenal Pathology Research Articles

Texture analysis can predict response to etoposide-doxorubicin-cisplatin in patients with adrenocortical carcinoma.

The adrenocortical carcinoma (ACC) is a rare and highly aggressive malignancy originating from the adrenal cortex. These patients usually undergo chemotherapy with etoposide, doxorubicin, cisplatin and mitotane (EDP-M) in case of locally advanced or metastatic ACC. Computed tomography (CT) radiomics showed to be useful in adrenal pathologies. The study aimed to analyze the association between response to EDP-M treatment and CT textural features at diagnosis in patients with locally advanced or metastatic ACCs. We enrolled 17 patients with advanced or metastatic ACC who underwent CT before and after EDP-M therapy. The response to treatment was evaluated according to RECIST 1.1, Choi, and volumetric criteria. Based on the aforementioned criteria, the patients were classified as responders and not responders. Textural features were extracted from the biggest lesion in contrast-enhanced CT images with LifeX software. ROC curves were drawn for the variables that were significantly different (p < 0.05) between the two groups. Long-run high grey level emphasis (LRHGLE_GLRLM) and histogram kurtosis were significantly different between responder and not responder groups (p = 0.04) and the multivariate ROC curve combining the two features showed a very good AUC (0.900; 95%IC: 0.724-1.000) in discriminating responders from not responders. More heterogeneous tissue texture of initial staging CT in locally advanced or metastatic ACC could predict the positive response to EDP-M treatment. Adrenal texture is able to predict the response to EDP-M therapy in patients with advanced ACC.

12572 Incidental Adrenal Enlargement On Ct Scan In South Brooklyn Health, How Often Is It Functional?

Abstract Disclosure: R. Ruggiero: None. N. Simon: None. Background: Incidental findings of adrenal hyperplasia are increased due to the widespread rise in cross sectional imaging, as well as improvement of imaging modalities. There is a lack of literature reporting on the prevalence of incidental adrenal hyperplasia. One study reported a prevalence of 11.3%. Adrenocortical hyperplasia can result from endocrine disorders such as ACTH dependent and independent Cushing syndrome, primary aldosteronism, Multiple Endocrine Neoplasia type 1, and congenital adrenal hyperplasia. Other reported causes are radiographic adrenal enlargement of unknown cause and without clinical or biochemical manifestations, inflammation, neoplasms, and depression. Most cases are a radiographic finding with no clinical significance. One study reported that 69.23% of cases were nonfunctional. There are currently no guidelines in place for biochemical evaluation of incidental adrenocortical hyperplasia. Patients are typically referred to endocrinology services. Objective: The purposes of this study was to: 1. Evaluate the number of patients referred to endocrinology clinic for incidental abnormal adrenal imaging. 2. Examine the percentage of abnormal adrenal imaging findings on CT scan, in particular adrenal hyperplasia, that are hormonally active. Methods: This was a retrospective study of patients who were referred to endocrinology clinic or electronic endocrine consult for incidental abnormal adrenal imaging, excluding those with clear diagnosis of masses, nodules, adenomas, or cysts. Data collected included demographics, type of study imaging and radiologist reader, hormonal studies, comorbid conditions such as diabetes mellitus, hypertension, obesity, osteoporosis, as well as visit type to endocrinology service (e-consult vs in person). Results: The total number of consults referred to endocrinology during this period was 138. Due to repeat referral or having an adrenal pathology other than hyperplasia, 83 patients were excluded from analysis. There were 55 patients with isolated adrenal hyperplasia, 86% of whom were Caucasian, 11% Hispanic, and 78% of patients were female. Median age 63 years old. Hypertension was noted in 69% of patients, 36% had diabetes mellitus or dysglycemia, 36% were obese, and 1.8% had osteoporosis. Imaging reading was performed by 3 radiologists, 75% of cases reported by one reader. Only 5% of referrals were answered as an e-consult. About 27% of patients did not show up to establish care. Hormonal workup was completed by 60% of the patients, with 16 % having abnormal findings. One patient required confirmatory workup. No patients required treatment. Conclusion: Adrenal Hyperplasia is often an incidental radiologic finding, that can be reader dependent. Most cases are nonfunctioning without abnormal findings on hormonal workup. E-Consultation can be an efficient tool to help PCP and reduce endocrine clinic visits. Presentation: 6/1/2024

7667 Cushing’s Puzzle: Echinococcal Pituitary Cyst In A Rare Encounter

Abstract Disclosure: E. Sari: None. F. Erenler: None. Introduction: Echinococcus is a rare parasitic infection endemic in the Mediterranean, Middle East, South America and Africa, which can cause cystic disease in several organs. Central nervous system involvement is known to comprise 1-2% of all cystic echinococcal disease. Hereby, we report a case of an opportunistic pituitary echinococcus infection in a patient with hypercortisolism due to adrenocortical adenoma with initial misdiagnosis of Cushing’s disease. Clinical Case: A 40-year-old South American female with poorly controlled T2DM on oral agents and hypertension presented to the ER with abdominal pain and subsequent CT of the abdomen with contrast showed a right adrenal mass measuring up to 2.8 cm. A follow up CT with adrenal protocol confirmed 3.3 cm right adrenal mass, 46 HU in precontrast images with &amp;gt;50% washout. Review of records revealed that a recent MRI brain with contrast was performed for headache evaluation and showed an incidental 5x7x4 mm lesion in the pituitary gland. Endocrinology evaluation revealed 24-hour urine volume 1800 mL, elevated free cortisol levels 277.6 mcg/24hr (RR: 4.0-50.0 mcg/24hr), creatinine of 0.67g/24hr (RR: 0.50-2.15g/24hr). 1 mg dexamethasone suppression test showed AM cortisol of 28.7 mcg/dL. ACTH was elevated at 67 pg/mL (RR: 6-50 pg/mL). FSH, LH, and GH were normal. Presumed diagnosis of ACTH-dependent hypercortisolism was made and she underwent bilateral inferior petrosal sinus sampling with confirmed successful cannulation but this was inconclusive due to low ACTH levels. Follow-up MRI of the pituitary gland showed T1 bright, T2 isointense circumscribed lesion measuring 7x6x3 mm at anterior pituitary gland with a thin rim of peripheral enhancement consistent with cystic features. She underwent transsphenoidal resection of the pituitary lesion and the pathology specimen showed parasites consistent with echinococcosis. Infectious disease was consulted, and the patient started on albendazole. Post-operative laboratory evaluation was notable for persistently elevated AM cortisol, 24-hour urine free cortisol levels, and low ACTH levels, confirming ACTH independent hypercortisolism. She underwent right adrenal nodule resection and pathology was consistent with adrenocortical adenoma. Post-adrenalectomy AM cortisol levels were &amp;lt; 2 mcg/dL, indicating the resolution of hypercortisolism along with substantiating the diagnosis of primary adrenocortical hyperfunction. Conclusion: To the best of our knowledge, this is the first case report of an opportunistic echinococcus infection presenting as a pituitary lesion in the setting of Cushing Syndrome. We would like to highlight the importance of recognizing opportunistic infections, including Echinococcus as a potential etiology in the setting of hypercortisolism, especially for patients from endemic regions. Presentation: 6/2/2024

Disruptions to protein kinase A localization in adrenal pathology.

Cell signaling fidelity requires specificity in protein-protein interactions and precise subcellular localization of signaling molecules. In the case of protein phosphorylation, many kinases and phosphatases exhibit promiscuous substrate pairing and therefore require targeting interactions to modify the appropriate substrates and avoid cross-talk among different pathways. In the past 10 years, researchers have discovered and investigated how loss of specific interactions and subcellular targeting for the protein kinase A catalytic subunit (PKAc) lead to cortisol-producing adenomas and the debilitating stress disorder adrenal Cushing's syndrome. This article reviews classical studies regarding PKA localization in glucocorticoid-producing adrenal cells and synthesizes recent evidence of disrupted PKA localization and selective regulatory interactions in adrenal pathology.

Integrated 68Ga-Pentixafor and 68Ga-FAPI-04 PET/MR for Diagnosing Adrenal Aldosterone-Producing Adenoma and Accessory Splenic Nodules.

A 57-year-old man with primary aldosteronism exhibited multiple nodules in the left adrenal, pancreatic tail, and splenic region. The left adrenal nodule showed positive 68Ga-pentixafor and negative 68Ga-FAPI-04 uptake, suggesting an aldosterone-producing adrenal adenoma. The nodule in the pancreatic tail exhibited high 68Ga-pentixafor and low 68Ga-FAPI-04 uptake, similarity with the nodule in splenic region, indicating accessory splenic nodule. Postoperative pathology confirmed an adrenal cortical adenoma and an accessory splenic nodule in the pancreas. This case underscores the complementary role of 68Ga-pentixafor and 68Ga-FAPI-04 PET/MR in diagnosing complex adrenal and pancreatic pathologies.

The Spectrum of Adrenal Lesions in a Tertiary Referral Center.

Adrenal tumors are a common finding in clinical practice, and only detailed evaluation may reveal secretory and metabolic abnormalities or their malignant character. We aimed to highlight epidemiological data, rates of malignancy, clinical or secretory characteristics, and the cardiometabolic implications of adrenal masses. We conducted a retrospective analysis using data from the medical files of 474 patients with adrenal pathology hospitalized between January 2007 and January 2020, before the COVID-19 pandemic, using the ICD-10 codes. After applying inclusion and exclusion criteria, a total of 264 patients with adrenal tumors were enrolled in the study. Patients underwent clinical examination, abdominal imaging, and hormonal evaluation, and some of them underwent a pathological exam after adrenalectomy. Median age at diagnosis was 56 (17) years, with 81.06% of patients being female. The median follow-up period was 41.5 (70) months, ranging from 6 months to 13 years. Adrenal tumors were most frequently seen in older female patients, with 83.47% of them being over 40 years old. The malignancy rate was 4.54%. Hormonally nonfunctioning tumors (71.95%) predominated, and overt hypercortisolism was present in 10.61% of patients, as was mild autonomous cortisol secretion in 5.31% of patients, primary hyperaldosteronism in 8.71% of patients, and adrenal paraganglioma in 3.41% of patients. Cardiometabolic comorbid conditions were similar in patients with functioning and nonfunctioning tumors. All patients with adrenal tumors should receive a complete hormonal workup and detailed malignancy risk assessment. Even though a hormonally active tumor predisposes to cardiometabolic comorbid conditions, a nonfunctioning lesion may also be associated with such disorders and needs thorough assessment.

Somatic Molecular Heterogeneity in Bilateral Macronodular Adrenocortical Disease (BMAD) Differs Among the Pathological Subgroups.

Bilateral macronodular adrenocortical disease (BMAD) is an uncommon cause of Cushing's syndrome leading to bilateral macronodules. Isolated BMAD has been classified into three molecular groups: patients with ARMC5 alteration, KDM1A alteration, and patients without known genetic cause. The aim of this study was to identify by NGS, in a cohort of 26 patients with BMAD, the somatic alterations acquired in different nodules after macrodissection from patients with germline ARMC5 or KDM1A alterations and to analyze potential somatic alterations in a panel of five other genes involved in adrenal pathology (GNAS, PDE8B, PDE11A, PRKAR1A, and PRKACA). Twenty-three patients (7 ARMC5, 3 KDM1A, and 13 BMAD with unknown genetic cause) were analyzable. Somatic ARMC5 or KDM1A events were exclusively observed in patients with germline ARMC5 and KDM1A alterations, respectively. Six out of 7 ARMC5 patients have a high heterogeneity in identified somatic events, whereas one ARMC5 and all KDM1A patients show a loss of heterozygosity (LOH) in all nodules. Except for passenger alterations of GNAS, no genetic alteration susceptible to causing the disease was detected in the BMAD with unknown genetic cause. Our study reinforces our knowledge of the somatic genetic heterogeneity of ARMC5 and the somatic homogeneity of KDM1A. It reveals the absence of purely somatic events in these two genes and provides a new tool for detecting KDM1A alterations by FISH 1p36/1q25.

What's new in adrenal gland pathology: WHO 5th edition for adrenal cortex.

The 5th edition of WHO Classification of Endocrine and Neuroendocrine Tumors (2022) introduced many significant changes relevant to endocrine daily practice. In this newsletter, we summarize the notable changes to the adrenal cortex based on the 5th edition of the WHO classification [1].

PRECOCIOUS PUBERTY: EPIDEMIOLOGY, CLINICAL PRESENTATION, DIAGNOSIS, AND ETIOLOGIES

Precocious puberty, defined as the onset of sexual characteristics before the age of 8 in girls and 9 in boys, can arise from various causes, including central and peripheral mechanisms. While central precocious puberty (CPP) originates from premature activation of the hypothalamic-pituitary axis, peripheral precocious puberty (PPP) results from gonadal or adrenal hormone secretion independent of hypothalamic control. We conducted a retrospective study spanning eight years, from 2015 to 2023, at the Mohamed 6 University Hospital in Marrakech, Morocco, to investigate the epidemiological, clinical findings, laboratory, and etiological aspects of precociuos puberty in 12 children. We found a predominance of CPP, particularly in girls, with breast development being the most common clinical sign. In boys, early puberty typically presented with pubic hair development and increased penile size. Diagnostic evaluation included hormonal assays and imaging studies, with elevated levels of gonadal hormones confirming the diagnosis. CPP was predominantly idiopathic in girls, while traumatic brain injury and CNS lesions were common causes in boys. Adrenal disorders, including congenital adrenal hyperplasia, accounted for PPP cases. Brain imaging was crucial for identifying central lesions, while adrenal imaging aided in diagnosing adrenal pathologies. Despite limitations such as retrospective design and incomplete data, our study emphasizes the importance of early recognition and appropriate diagnostic procedures for children showing signs of early puberty to optimize management and outcomes.

A Comparison of Near-Infrared Autofluorescence Findings in Benign Versus Malignant Adrenal Tumors

BackgroundMany adrenal tumors are deemed radiologically indeterminate and surgically removed. Adrenal tissue, like parathyroid glands, exhibits near-infrared autofluorescence (NIRAF) properties. This study was designed to investigate the potential of NIRAF to differentiate benign versus malignant adrenal tumors.MethodsPatients undergoing adrenalectomy between October 2021 and May 2023 were prospectively studied. Adrenalectomy specimens were inspected with NIRAF imaging. Specimen autofluorescence (AF) characteristics were recorded. Comparisons were made between different tumor types and a logistic regression model was constructed to differentiate benign versus malignant tumors. A receiver operating characteristic curve was used to identify an optimal AF threshold differentiating benign versus malignant tumors.ResultsA total of 108 adrenal specimens were examined: adrenocortical adenomas/other benign lesions (n = 72), pheochromocytomas (n = 18), adrenocortical neoplasms of uncertain behavior (n = 4), and malignant tumors (n = 14). A significant difference in normalized AF intensity was identified when comparing adrenocortical adenomas (3.08 times background) with pheochromocytomas (1.95, p = 0.001) and malignant tumors (1.11, p < 0.0001). The Area Under the Curve differentiating benign vs malignant tumors was 0.87, with an optimal normalized AF threshold at 1.93.ConclusionsDifferent adrenal pathologies exhibit diverse AF properties. These findings suggest a potential intraoperative utility of NIRAF in predicting benign versus malignant nature for radiologically indeterminate adrenal tumors.

Cardiovascular Dynamics in HIV: The Influence of Adrenal Function and Nutritional Status.

This interdisciplinary review explores the intricate nexus between HIV infection, nutrition, adrenal gland function, and cardiovascular health, highlighting a critical aspect of HIV management often overlooked in current literature. With the advent of antiretroviral therapy, the life expectancy of people living with HIV has dramatically improved, transforming HIV into a manageable chronic condition. However, this success brings forth new challenges, notably an increased risk of cardiovascular diseases among people living with HIV. We examine the normal physiology of the adrenal gland, including its role in mineral metabolism, a crucial facet of nutrition. We discuss the evolution of knowledge tying adrenal pathology to cardiovascular disease. We explore the impact of HIV on adrenal gland findings from a gross pathology perspective, as well as the clinical impact of adrenal insufficiency in HIV. The review further elucidates the role of nutrition in this context, considering the double burden of undernutrition and obesity prevalent in regions heavily affected by HIV. By aggregating findings from longitudinal studies and recent clinical trials, the review presents compelling evidence of increased cardiovascular disease among people living with HIV compared with people without HIV. It highlights the critical role of the adrenal glands in regulating nutrient metabolism and its implications for cardiovascular health, drawing attention to the potential for dietary interventions and targeted therapies to mitigate these risks. This review urges a paradigm shift in the management of HIV, advocating for a holistic approach that incorporates nutritional assessment and interventions into routine HIV care to address the complex interplay between HIV, adrenal function, and cardiovascular health. Through this lens, we offer insights into novel therapeutic strategies aimed at reducing cardiovascular risk in people living with HIV, contributing to the ongoing efforts to enhance the quality of life and longevity in this population.

Bilateral adrenal cortical rests: An interesting innocuous intruder in the fallopian tubes.

Ectopic adrenal rests refer to the presence of adrenal tissue outside its normal anatomical location and are usually discovered incidentally on microscopic examination. Literature suggests its occurrence in diverse extrarenal sites, like the genitourinary system and pelvis. Our case describes the rare occurrence of ectopic adrenal rests in the walls of bilateral fallopian tubes of a 43-year-old female patient who presented with a complaint of heavy menstrual bleeding. A total hysterectomy with bilateral salpingo-oophorectomy was performed. Gross examination revealed adenomyosis with multiple fibroids, and the same was confirmed on microscopy. Additionally, the finding of a well-encapsulated lesion on the walls of both tubes made us relook at the fallopian tubes, which showed a small bright yellow area measuring less than 0.3 cm in the walls, which was consistent with ectopic adrenal rests after ruling out the morphological differentials of Walthard cell nests, aggregates of foamy histiocytes, metastatic renal clear cell carcinoma, displaced ovarian luteinized theca cells, heterotopia of ovarian hilus cells. Immunohistochemistry showed positivity for Melan A and CK7 was negative. The present case helps in investigating the lesser-explored aspect of adrenal rest pathology. It also reiterates need for detailed observation of fallopian tubectomy specimens by pathologists during grossing to avoid overlooking of potentially intriguing entities.

Retrospective application of a validated algorithm for estimation of adrenal gland volume after computed tomography on 46 dogs undergoing adrenalectomy.

Canine adrenal gland volume can be predicted based on body weight and computed tomography (CT) measurements using a validated algorithm. Use of this algorithm to detect adrenal pathology, including hyperplasia, hypoplasia and neoplasia, in clinical cases has not been described. The objective of this study was to illustrate application of the algorithm by estimating subject-specific adrenal gland volume in a historical cohort of dogs with known adrenal disease. Forty-six dogs that underwent CT and subsequent adrenalectomy were included. Clinical records and CT images from dogs that underwent adrenalectomy and histologic examination of the excised adrenal gland(s) were reviewed. Normal adrenal gland volumes for each dog were estimated using the algorithm, and compared with measured volumes of the affected glands. Linear measurement of the largest lesion diameter was also recorded. Fifty-eight adrenal glands were removed from 46 dogs, with pathology confirmed in all glands. Pathology included 28 adenomas, 13 carcinomas, 11 pheochromocytomas and 6 other benign pathologies. The volume of all removed adrenal glands was measured to be larger than the expected normal volume estimated by the algorithm, ranging from 1.1 to 212.9 times larger than estimated. Adrenal glands with malignant and benign pathology showed variable volumes with overlapping ranges recorded. Assessment of the dimensions of any focal lesion against a cut-off of 20 mm failed to discriminate malignancy. This study illustrates and supports the application of a validated volumetric algorithm for estimation of subject-specific adrenal gland volume to identify the presence of pathology and as a tool to assist clinical decision-making.

Study of Morphofunctional Relationships Between Adrenal Pathology and Hypothyroidism and Iodine Deficiency (Review)

Hormones that produce the adrenal glands affect most of the functional and metabolic processes in the human body, and also ensure its stability under stress. Since the adrenal glands are a stress-sensitive organ in the endocrine regulation system of all body functions, the development of adaptation mechanisms under the conditions of stress factor action can be characterized by their morphological state. However, thyroid diseases associated with a persistent lack of hormones are the cause of impaired homeostasis, metabolism and oxygen exchange. Since the adrenal glands belong to the vital target organs of the thyroid gland, of particular interest is the study of their functional relationships in normal and pathological conditions.

The importance of novel histopathological classification and its association with outcomes of primary aldosteronism: What you need to know from a urologist’s perspective

Primary aldosteronism (PA), the most important cause of secondary endocrine hypertension, is hallmarked by excessive aldosterone secretion. There were 2 subtypes of PA—unilateral aldosterone-producing adenoma and bilateral adrenal hyperplasia, which are now outdated. Since conventional adrenal pathological reports only examined hematoxylin and eosin staining, the secretory function of the structural adenoma(s) could not be determined. Several enzymes produce aldosterone-related steroids, and 2 isoforms of 11β-hydroxylase, namely CYP11B1 and CYP11B2 (aldosterone synthase), are responsible for producing cortisol and aldosterone, respectively. Since the availability of specifically selective antibodies for targeting CYP11B1 and CYP11B2, the diagnosis/nomenclature of PA-related adrenal pathology has been revolutionized by using immunohistochemistry staining for CYP11B2 to identify the aldosterone production site in the human adrenal cortex. The significance of immunohistochemical staining of formalin-fixed paraffin-embedded adrenal tissue sections has become “mandatory” for precisely detecting the lesions responsible for PA. Recently, the histopathology of PA consensus, based on immunochemical findings, was established to define the nomenclature and adrenal histopathological features in unilateral PA. In this study, we further investigate the association between the pathological subtypes and the surgical outcomes of PA as per the criteria of the Primary Aldosteronism Surgery Outcome consensus. Unfortunately, a significant lag is seen in the adaptation of Taiwan’s pathologists to the histopathology of PA consensus. Furthermore, a strong push from all urologists across Taiwan and the governmental health care authorities is required to elevate the care level provided to all patients with PA in Taiwan to exceptional.

Adrenal ablation as a treatment for hypertension: analyzing the dielectric properties of adrenal glands for microwave ablation technologies

Abstract Adrenal gland-induced hypertension, also known as secondary hypertension, is a medical condition caused by an underlying adrenal pathology, most typically adrenocortical adenomas. Current clinical practices involve pharmacotherapy or surgical resection to treat adrenal gland diseases that cause hypertension. However, due to the limitations of these treatment options, microwave ablation (MWA) has emerged as a promising minimally invasive alternative. An accurate understanding of the dielectric properties of adrenal glands would support the further development and optimization of MWA technology for treating adrenal tumors. Only a few studies have examined the dielectric properties of both human and animal adrenal glands, and the sample sizes of these studies have been relatively small. Therefore, further dielectric data of human and animal adrenal glands are warranted. This paper presents the ex vivo dielectric properties of the ovine adrenal glands (medulla and cortex) and summarizes the published literature on dielectric data of adrenal glands from porcine, bovine, ovine, and human samples in the microwave frequency range to analyze the consistency and reliability of the reported data. The dielectric properties of the ovine adrenal glands (N = 8) were measured using an open-ended coaxial probe measurement technique at frequencies ranging from 0.5 to 8.5 GHz. This study also investigated the temperature-dependent dielectric properties of the ovine adrenal medulla ranging from 37 to 64°C at frequencies ranging from 0.5 to 8.5 GHz. The dielectric properties of the ovine adrenal medulla measured in this study were found to be consistent with the literature. Moreover, the review suggests that variations exist in the dielectric properties of the adrenal medulla and cortex among species. The study also found that the dielectric properties of the adrenal medulla decrease with increasing temperature, similar to other tissues for which temperature-dependent dielectric data have been reported. This summary of dielectric data of adrenal glands and the temperature-dependent dielectric properties of the ovine adrenal medulla will accelerate the development of MWA technologies for hypertension treatment.

Adrenalectomy approach and outcomes according to surgeon volume

BackgroundThis study assessed the relationship between surgeon volume, operative management, and resource utilization in adrenalectomy. MethodsIsolated adrenalectomies performed within our health system were identified (2016–2021). High-volume surgeons were defined as those performing ≥6 cases/year. Outcomes included indication for surgery, perioperative outcomes, and costs. ResultsOf 476 adrenalectomies, high-volume surgeons (n ​= ​3) performed 394, while low-volume surgeons (n ​= ​12) performed 82. High-volume surgeons more frequently operated for pheochromocytoma (19% vs. 16%, p ​< ​0.001) and less frequently for metastasis (6.4% vs. 23%, p ​< ​0.001), more frequently used laparoscopy (95% vs. 80%, p ​< ​0.001), and had lower operative supply costs ($1387 vs. $1,636, p ​= ​0.037). Additionally, laparoscopic adrenalectomy was associated with shorter length of stay (−3.43 days, p ​< ​0.001), lower hospitalization costs (-$72,417, p ​< ​0.001), and increased likelihood of discharge to home (OR 17.03, p ​= ​0.008). ConclusionsHigh-volume surgeons more often resect primary adrenal pathology and utilize laparoscopy. Laparoscopic adrenalectomy is, in turn, associated with decreased healthcare resource utilization.

FRI260 Adrenal Hemangioma, Mimicker Or Malignant?

Abstract Disclosure: C. Pham: None. C.E. Chiu: None. B. Barnett: None. Background: Adrenal hemangioma is a rare condition that can mimic other adrenal pathologies. Clinical Case: A 49 year old male with history of heart failure presented with cardiogenic shock requiring inotropes and heart transplant evaluation. On CT patient was noted to have a 2.2 cm left adrenal nodule containing calcifications. Initial tests had indeterminate 1 mg overnight DST, normal plasma free metanephrines and elevated plasma free normetanephrines 2.06 nmol/L (0-0.89 nmol/L). PRA was 22.82 ng/mL/hr (0.25-5.82 ng/ml/hr) with aldosterone 10.8 ng/dL (&amp;lt;16 ng/dL) on spironolactone. 24 hour urine tests showed normal free cortisol 9.8 mcg/24hr (4-50 mcg/24hr) and elevated total metanephrines at 1245 mcg/24hr (182-739 mcg/24hr), metanephrines at 303 mcg/24hr (58-283 mcg/24hr), and normetanephrines at 942 mcg/24hr (88-649 mcg/24hr). Adrenal CT demonstrated HU of 59 units on noncontrast phase, with -86.7% absolute washout and -17.6% relative washout. I-123 MIBG Scan was obtained with no radiotracer uptake noted. Patient underwent laparoscopic adrenalectomy for definitive diagnosis and was found to have adrenal hemangioma with CD31 and ERG with hemosiderin laden macrophages on pathology. Adrenal hemangioma is rare and can mimic other adrenal pathology. Most patients present with abdominal symptoms such as flank pain or are found to have an adrenal incidentaloma on imaging. CT findings are associated with heterogenous internal structure, peripheral patchy enhancement, or calcifications, which are also seen in malignancy and pheochromocytoma. In all cases, HU if recorded are noted to be &amp;gt;10 on the unenhanced phase and &amp;lt;60% absolute washout. In one case series of 52 adrenal hemangiomas, only 3 patients had positive biochemical tests and on average were 11 cm in size. Formal diagnosis is made pathologically. Treatment for adrenal hemangioma is typically resection for symptomatic relief, with some patients with small lesions electing to observe. In all surgical cases reviewed in a case series adrenalectomy was pursued as opposed to needle biopsy due to large size of lesion and concern for possible malignancy. In this specific case, biochemical testing was falsely positive given the patient’s presentation of cardiogenic shock and inotropes causing elevated catecholamine levels and given imaging findings could not fully rule out pheochromocytoma. Given the small size of lesion, the patient in a non-transplant setting likely could have pursued close observation as opposed to resection. Conclusion: Adrenal hemangioma can have imaging characteristics that can mimic several other adrenal pathological conditions, such as malignancy or pheochromocytoma. Treatment through surgical management is likely not necessary in patients with hemangioma, though would be important in ruling out other adrenal pathology. Presentation: Friday, June 16, 2023

THU608 Evaluation Of Incidental Adrenal Masses After Initial Radiographic Diagnosis

Abstract Disclosure: V. Williams: None. N. Wazzan: None. M. Abu Limon: None. J.O. Abdelkarim: None. M.G. Jakoby: None. G. Sydney: None. A. Gagen: None. H. O'neil: None. U. Tarabichi: None. Background. Incidental adrenal masses (IAM’s) are masses of the adrenal glands ≥ 1 cm in diameter discovered during imaging for an indication other than adrenal pathology. Diagnosis of IAM’s has increased with improved resolution of computed tomography (CT), but little is published on how often IAM’s are appropriately evaluated and factors that predict if assessment will occur. This study was conducted to determine the frequency with which IAM’s are evaluated according to American Association of Clinical Endocrinologists (AACE) guidelines when diagnosed on CT scans ordered by providers at the Southern Illinois University (SIU) School of Medicine, an academic medical center in rural Central Illinois. Methods. A retrospective single cohort study was performed. Patients age ≥ 18 years undergoing CT from January 1 - December 31, 2017 were eligible. Potential cases were screened by searching for “adrenal mass,” “adrenal nodule,” “adrenal lesion,” or “adrenal adenoma.” Cases were excluded if the mass had been noted before January 1, 2017, imaging was ordered for an adrenal disorder or cancer staging, or the adrenal mass was &amp;lt; 1 cm in largest diameter. Cases were reviewed to determine if recommended metabolic screening and imaging was conducted. Demographic data, insurance status, reason for imaging, type of CT scan, clinical setting, radiology description of the adrenal mass, selected comorbidities (hypertension, hypokalemia, type 2 diabetes mellitus, obesity, and osteoporosis), and referral to an endocrinologist were included as potential predictors of guideline compliant evaluation. Results. A total of 86 IAM’s were identified among 801 CT scans for a prevalence of 10.7%. Only 10 patients (11.6%) underwent metabolic evaluation, 22 had imaging follow-up (25.6%), and only 6 received both (7.0%). All patients with metabolic evaluation were referred to an endocrinologist (P &amp;lt; 0.001). Patients who underwent evaluation were more likely to have CT scans of the abdomen or abdomen and pelvis (P = 0.004) and be diagnosed with hypertension (P = 0.01). Notably, there was no difference in IAM size (evaluated 2.2 ± 1.1 cm, unevaluated 2.0 ± 1.2), and the descriptors “benign” or “benign adenoma” were included in the radiology reports of 88.9% and 88.1% of evaluated and unevaluated patients, respectively. Imaging follow-up was more likely in patients with an endocrine referral (p=0.03), on public insurance (p=0.02), and who were obese (p=0.02). Conclusion. The rate at patient’s with IAM’s were evaluated in accordance with AACE guidelines in this study was very low and may have been strongly influenced by inclusion of the descriptors “benign” or “benign adenoma” in nearly 90% of radiology reports. Providers at SIU who order CT scans need education and guidance on evaluation of IAM’s for metabolic activity and monitoring for changes in size that could indicate adrenocortical carcinoma. Presentation: Thursday, June 15, 2023

FRI179 Etiology And Morphology Of Adrenal Calcifications: Single Center Retrospective Study Of 540 Patients

Abstract Disclosure: A. Kittithaworn: None. P. Dogra: None. L. Rahimi: None. R. Sandooja: None. I. Bancos: None. Background: Adrenal calcification is discovered incidentally on imaging performed for reasons other than adrenal pathology and represents &amp;lt;1% of benign adrenal lesions. Data on the etiology and morphology of adrenal calcifications are scarce. Objective: To determine the etiology and imaging characteristics of adrenal calcification. Methods: We conducted a single-center retrospective study of patients with adrenal calcification on abdominal computed tomography between January 1st,2017 and December 31st, 2021. Medical records were reviewed for demographics, discovery mode, etiology and morphology. Subgroup analysis of patients with calcification/s associated with an adrenal mass was performed. Results: Adrenal calcification was reported in 540 patients (245, 45% women, median age 65 years (IQR 54-74). Only a minority of patients with adrenal calcifications were evaluated by an endocrinologist (167, 31%). Adrenal calcifications were discovered incidentally in 472 (87%) patients, during cancer staging imaging in 66 (12%), and evaluation of other symptoms in 2 (&amp;lt;1%). The etiology of adrenal calcification was most commonly idiopathic (390, 72%), followed by adrenal mass (112, 21%), hemorrhage (20, 6%), and granulomatous disease (8, 1.5%). Adrenal calcifications were bilateral in 34 (6%) patients and unilateral in 506 (94%), with a similar left and right distribution. Unilateral calcifications were more frequently single (399, 79%) with punctate (60%), coarse (28%), linear/curvilinear (9%), or eggshell (3%) morphology. Bilateral adrenal calcifications presented more frequently with multiple lesions (53% vs 21% in unilateral calcifications, p &amp;lt;0.0001), and were coarse (59%), punctate (29%), or linear (9%). When associated with either unilateral or bilateral adrenal mass, calcifications were either central (50, 45%), peripheral (44, 39%), septal (10, 9%), or both central and peripheral (7, 7%) in relation to the adrenal mass. Adrenal masses associated with adrenal calcifications were: adrenal adenomas in 63 (56%), myelolipomas or cysts in 28 (23%), metastases in 12 (11%), adrenal carcinomas in 4 (4%), pheochromocytomas in 2 (2%), and other rare masses in 3 (3%) patients. Patients with adrenal calcifications associated with an adrenal mass were younger at the time of diagnosis (median of 63 vs 66 years, p=0.014), and had a higher proportion of women (61% vs. 41%, p=0.0002), and were more likely to be discovered during cancer staging imaging (21% vs. 10%, p=0.003). Adrenal mass-associated calcifications were more frequently multiple rather than single lesions (46% vs. 17%, p&amp;lt;0.0001). Conclusion: Adrenal calcifications are usually unilateral single punctate or coarse lesions of unclear etiology. The majority of the adrenal masses that demonstrated calcifications were benign, however adrenal malignancy or pheochromocytomas were diagnosed in 17% of cases. Presentation: Friday, June 16, 2023