Richard B. Noto

The adrenal gland is a common site of disease, and detection of adrenal masses has increased with the expanding use of cross-sectional imaging. Radiology is playing a critical role in not only the detection of adrenal abnormalities but in characterizing them as benign or malignant. The purpose of the article is to illustrate and describe the appropriate radiologic work-up for diseases affecting the adrenal gland. The work-up of a suspected hyperfunctioning adrenal mass (pheochromocytoma and aldosteronoma) should start with appropriate biochemical screening tests followed by thin-collimation computed tomography (CT). If results of CT are not diagnostic, magnetic resonance (MR) and nuclear medicine imaging examinations should be performed. CT has become the study of choice to differentiate a benign adenoma from a metastasis in the oncology patient. If the attenuation of the adrenal gland is over 10 HU at nonenhanced CT, contrast material-enhanced CT should be performed and washout calculated. Over 50% washout of contrast material on a 10-minute delayed CT scan is diagnostic of an adenoma. For adrenal lesions that are indeterminate at CT in the oncology patient, chemical shift MR imaging or adrenal biopsy should be performed. Certain features can be used by the radiologist to establish a definitive diagnosis for most adrenal masses (including carcinoma, infections, and hemorrhage) based on imaging findings alone.

Patients with metastatic or unresectable (advanced) pheochromocytoma and paraganglioma (PPGL) have poor prognoses and few treatment options. This multicenter, phase 2 trial evaluated the efficacy and safety of high-specific-activity ¹³¹I-meta-iodobenzylguanidine (HSA ¹³¹I-MIBG) in patients with advanced PPGL. <b>Methods:</b> In this open-label, single-arm study, 81 PPGL patients were screened for enrollment, and 74 received a treatment-planning dose of HSA ¹³¹I-MIBG. Of these patients, 68 received at least 1 therapeutic dose (∼18.5 GBq) of HSA ¹³¹I-MIBG intravenously. The primary endpoint was the proportion of patients with at least a 50% reduction in baseline antihypertensive medication use lasting at least 6 mo. Secondary endpoints included objective tumor response as assessed by Response Evaluation Criteria in Solid Tumors version 1.0, biochemical tumor marker response, overall survival, and safety. <b>Results:</b> Of the 68 patients who received at least 1 therapeutic dose of HSA ¹³¹I-MIBG, 17 (25%; 95% confidence interval, 16%–37%) had a durable reduction in baseline antihypertensive medication use. Among 64 patients with evaluable disease, 59 (92%) had a partial response or stable disease as the best objective response within 12 mo. Decreases in elevated (≥1.5 times the upper limit of normal at baseline) serum chromogranin levels were observed, with confirmed complete and partial responses 12 mo after treatment in 19 of 28 patients (68%). The median overall survival was 36.7 mo (95% confidence interval, 29.9–49.1 mo). The most common treatment-emergent adverse events were nausea, myelosuppression, and fatigue. No patients had drug-related acute hypertensive events during or after the administration of HSA ¹³¹I-MIBG. <b>Conclusion:</b> HSA ¹³¹I-MIBG offers multiple benefits, including sustained blood pressure control and tumor response in PPGL patients.

Iodobenzamide (IBZM) is a D-2 dopamine receptor antagonist. In this paper the results of Phase I clinical studies of iodine-123-(123I)IBZM in humans are reported. Preliminary imaging studies, both planar and single-photon emission tomography (SPECT), of no-carrier added [123I]IBZM in humans show specific localization in the basal ganglia of the brain. At 2 hr after an i.v. injection, the brain uptake was 3.72% of the dose, and at 20 hr later the uptake diminished to 0.7%. Radiation dosimetry calculation indicated that the radiation dose to the brain was minimum, 0.039 rad/mCi, while the large intestine wall received the highest dose, 0.28 mrad/mCi. The radiation dosimetry and pharmacology data suggest that this agent is safe for human use.

Apathy and loss of insight as correlates of behavior in Alzheimer's disease (AD) were studied in 40 patients by using clinical scales and cerebral blood flow measurements from SPECT imaging. Apathy was significantly correlated with decreased right temporoparietal perfusion and problem behaviors. Loss of insight was significantly correlated with decreased right temporo-occipital perfusion and impairment in daily functioning. Dementia severity as measured by the Mini-Mental State Examination (MMSE) was a poor predictor of behavioral problems or daily functioning. These data suggest that global measures of cognitive ability, which are weighted toward measuring left hemisphere function, are less important as indicators of management problems in AD than are measures of right hemisphere function such as motivation and insight.