Hyperattenuating adrenal lesions in lung cancer: biphasic CT with unenhanced and 1-min enhanced images reliably predicts benign lesions



To investigate usefulness of biphasic computed tomography (CT) in characterizing hyperattenuating adrenal lesions in lung cancer.


This retrospective study included 239 patients with lung cancer who underwent adrenal CT for hyperattenuating (> 10 Hounsfield unit) adrenal lesions. Adrenal CT comprised unenhanced and 1-min and 15-min enhanced images. We dichotomized adrenal lesions depending on benign or metastatic lesions. Reference standard for benignity was histologic confirmation or ≥ 6-month stability on follow-up CT. Two independent readers analyzed absolute (APW) or relative percentage wash-out (RPW) using triphasic CT, and enhancement ratio (ER) or percentage wash-in (PWI) using biphasic CT (i.e., unenhanced and 1-min enhanced CT). Criteria for benignity were as follows: criteria 1, (a) APW ≥ 60% or (b) RPW ≥ 40%, and criteria 2, (a) ER > 3 and (b) PWI > 200%. We analyzed area under the curve (AUC) and accuracy for benignity, and inter-reader agreement.


Proportion of benign adrenal lesion was 71.1% (170/239). For criteria 1 and 2, AUCs were 0.872 (95% confidence interval [CI], 0.822–0.911) and 0.886 (95% CI, 0.838–0.923), respectively, for reader 1 (p = 0.566) and 0.816 (95% CI, 0.761–0.863) and 0.814 (95% CI, 0.759–0.862), respectively, for reader 2 (p = 0.955), and accuracies were 87.9% (210/239) and 86.2% (206/239), respectively, for reader 1 (p = 0.479) and 81.2% (194/239) and 80.3% (192/239), respectively, for reader 2 (p = 0.763). Weighted kappa was 0.725 (95% CI, 0.634–0.816) for criteria 1 and 0.736 (95% CI, 0.649–0.824) for criteria 2.


Biphasic CT can reliably characterize hyperattenuating adrenal lesions in patients with lung cancer.

Key Points

• Criteria from biphasic computed tomography (CT) for diagnosing benign adrenal lesions were enhancement ratio of > 3 and percentage wash-in of > 200%.

• In the analysis by two independent readers, area under the curve between criteria 1 and 2 was not significantly different (0.872 and 0.886 for reader 1; 0.816 and 0.814, for reader 2; p > 0.05 for each comparison).

• Wash-in characteristics from biphasic CT are helpful to predict benign adrenal lesions in lung cancer.

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Absolute percentage wash-out


Contrast-enhanced computed tomography


Computed tomography


Enhancement ratio




Hounsfield unit


Locally estimated scatterplot smoothing


Negative predictive value


Positron emission tomography


Positive predictive value


Percentage wash-in


Region of interest


Relative percentage wash-out


Unenhanced computed tomography


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This study was supported by Samsung Medical Center Grant (SMO1190081).

We would like to thank Editage (www.editage.co.kr) for English language editing.


This study was supported by Samsung Medical Center Grant (SMO1190081).

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Correspondence to Sung Yoon Park.

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The scientific guarantor of this publication is Sung Yoon Park, M.D.

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Lee, H.Y., Oh, Y.L. & Park, S.Y. Hyperattenuating adrenal lesions in lung cancer: biphasic CT with unenhanced and 1-min enhanced images reliably predicts benign lesions. Eur Radiol (2021). https://doi.org/10.1007/s00330-020-07648-1

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  • Adrenal
  • Lung cancer
  • Tomography
  • Metastasis