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Irogers{at}ajroffice.org
To that end, Dunnick and Korobkin [1] address the bedeviling issue of "incidentalomas" of the adrenal glands. Small nodules and lumps and bumps in the adrenal glands did not previously cause radiologists much concern—because we couldn't see them. Such small lesions were impossible to visualize on radiographs of the abdomen or IVPs. Then along came CT and MR imaging, which unveiled these adrenal abnormalities.
"Incidentalomas" are really quite common. What do you do about them? In their article, Dunnick and Korobkin [1] guide you through this thorny issue. They give sound advice for dealing with the common conundrum of lumps and bumps in the adrenal gland. Check it out; with the guidance of Dunnick and Korobkin, I am sure that the next time you come across an "incidentaloma," dealing with it will prove much more comfortable than your last such encounter.
The search for tissue signature in imaging has been elusive. By tissue signature, I refer to the detection within a lesion of a finding, or constellation of findings, that precisely identifies the pathologic nature of the abnormality depicted on the image. The introduction of each new imaging modality has been accompanied by hopes that the images obtained will prove to have a high degree of sensitivity and specificity for various abnormalities. Sensitivity has certainly improved. With sonography, CT, and MR imaging, we can directly visualize many smaller abnormalities, such as adrenal "incidentalomas," that would go undetected on radiography.
However, specificity, based solely on imaging characteristics of a lesion, has remained elusory. Our hopes rise with the introduction of each new imaging technology and contrast agent, only to be dashed when they are found to be lacking in specificity. And then, as did Sisyphus, we start all over again.
Although we are able to directly visualize many more and smaller abnormalities with the newer imaging modalities, in the absence of a specific tissue signature, we are still required to infer or deduce the precise nature of the abnormality from its location and other imaging characteristics just as we must do when interpreting radiographs. This, as you know, is often not easily accomplished. And, as you are also well aware, these imaging characteristics often prove to be nonspecific, and a precise diagnosis eludes us.
Instead, the diagnostic impression is inferred by triangulation: judgment based on the combination of the patient's medical history and physical examination, pertinent laboratory findings, and the imaging characteristics of the lesion in question. Knowledge of medical history and the physical examination and pertinent laboratory values improves the potential for diagnostic accuracy when interpreting any type of imaging examination. That is, of course, why radiologists request that this information be available to us when studies are interpreted. We can do a better job when we have it. The quality of the diagnostic inference is compromised to the extent that one or more of these limbs of triangulation is unavailable when the diagnostic judgment is rendered. Dunnick and Korobkin [1] show that this is just as true for adrenal "incidentalomas" as it is for so many other abnormalities encountered in imaging.
Making the correct diagnosis often comes down to probabilities: given a lesion in this location with such and such imaging characteristics in a patient of a given age and sex, what is the most likely diagnosis? By knowing the clinical and imaging characteristics for the most common lesions in this location, the radiologist interpreting the examination comes up with the most likely diagnoses.
If you are uncertain of the differential diagnosis or imaging characteristics, you should turn to books and journals. That's what they are for; take the time to look it up. Or surf the Web: try Google. Such efforts should certainly improve your diagnostic specificity. But when it comes down to what to do with adrenal "incidentalomas," this issue of the AJR is the place to go. Dunnick and Korobkin [1] show you the way.
Remember that if you simply give up and say you can't tell the difference and are unable to make a specific diagnosis or recommendation, the patient may be put through a lot of unnecessary procedures and expense that might have otherwise been avoided. Patients and referring physicians will appreciate your extra effort and the resultant added diagnostic specificity.
While teasing apart the Gordian knot of imaging specificity remains an elusive, yet Elysian goal of research in diagnostic imaging, reports on the ongoing efforts to identify tissue signatures and to increase diagnostic specificity appear every month in your AJR. To stay abreast of these developments and improve your diagnostic acumen, stick with the "yellow journal."
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  E. S. Siegelman Myxoid Sarcoma Versus Aggressive Angiomyxoma Am. J. Roentgenol., December 1, 2007; 189(6): W382 - W382. [Full Text] [PDF]
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O. Benjaminov, S. Fichman, and H. Gutman Reply Am. J. Roentgenol., December 1, 2007; 189(6): W383 - W383. [Full Text] [PDF]
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