OBJECTIVES: The aim of the study was to evaluate the CT features of adrenal tumors in an effort to identify features specific to pheochromocytomas and second, to define a feasible probability calculation model. METHODS: This multicentric retrospective study included patients from the period 2003 to 2017 with an appropriate CT examination and a histological diagnosis of an adrenal adenoma, pheochromocytoma, adrenocortical carcinoma, or metastasis. In total, 346 patients were suitable for the CT image analysis, which included evaluation of the largest diameter, the shape of the lesion, the presence of central necrosis and its margins, and the presence of an enhancing peripheral rim ("ring sign"). RESULTS: Pheochromocytomas have a significantly more spherical shape (P<0.001), whereas an elliptical shape significantly reduces the probability of a pheochromocytoma (odds ratio = 0.015), as does another shape (odds ratio = 0.006). A "ring sign" is also more frequent in pheochromocytomas compared to other adrenal tumors (P=0.001, odds ratio = 6.49). A sharp necrosis also increases the probability of a pheochromocytoma more than unsharp necrosis (odds ratio 231.6 vs. 20.2). The probability calculation model created on the basis of the results confirms a high sensitivity and specificity (80% and 95%). CONCLUSION: This study confirms the value of anatomical features in the assessment of adrenal masses with the ability to significantly improve the identification of pheochromocytomas. Advanced assessment of the tumor shape was defined and a original comprehensive calculating tool of the pheochromocytoma probability was created on the basis of the results presented here and could be used in clinical routine.

2nd Department of Internal Medicine 3rd Faculty of Medicine Charles University and Royal Vinohrady Teaching Hospital Prague Czech Republic

2nd Radiology Department Faculty of Medicine Comenius University in Bratislava and St Elizabeth Cancer Institute Bratislava Slovakia

Department of Algebra and Geometry Faculty of Science Palacky University Olomouc Czech Republic

Department of Endocrinology and Metabolism 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Endocrinology Slovak Medical University and St Elizabeth Cancer Institute Bratislava Slovakia

Department of Imaging Methods University Hospital Pilsen and Faculty of Medicine in Pilsen Charles University Czech Republic

Department of Internal Medicine 3 Nephrology Rheumatology and Endocrinology University Hospital Olomouc and Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Radiology 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Radiology University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove Charles University Czech Republic

Department of Radiology University Hospital Olomouc and Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Urology Faculty Hospital Pilsen and Faculty of Medicine in Pilsen Charles University Czech Republic

Department of Urology University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove Charles University Czech Republic

Department of Urology University Hospital Olomouc and Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Section on Medical Neuroendocrinology Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD USA

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Diagnostic Value of Unenhanced CT Attenuation and CT Histogram Analysis in Differential Diagnosis of Adrenal Tumors

Genetics, diagnosis, management and future directions of research of phaeochromocytoma and paraganglioma: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension