Imaging Pearls ❯ Adrenal ❯ Cinematic Rendering
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- Cinematic rendering (CR) is a novel CT post-processing technique that utilizes advanced light modeling to generate highly photorealistic anatomic visualization. This generates unique prospects in the evaluation of adrenal masses. As one of the first large tertiary care centers to incorporate CR into routine diagnostic workup, our preliminary experience with using CR has been positive, and we have found CR to be a valuable adjunct during surgical planning. Herein, we highlight the unique utility of CR techniques in the workup of adrenal lesions and provide commentary on the opportunities and obstacles associated with the application of this novel display method in this setting.
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - “Recently, a novel method of 3D visualization, known as cinematic rendering (CR) has been introduced. While CR shares many similarities with VR, it utilizes a more complex global lighting model that incorporates elements of ray tracing and scatter to generate images that are photorealistic. Through more realistically modeling the complex interactions of photons passing through the imaged volume, CR images attain improved levels of surface detail and shadow realism. CR also allows for highly adjustable real-time post processing and windowing, enabling tailored visualization of any given region of interest, its vascular supply, and its adjacent structures. n region of interest, its vascular supply, and its adjacent structures. ”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - “Pheochromocytomas are neuroendocrine tumors that arise from the chromaffin cells of the adrenal medulla and are present in 0.1% to 0.2% of adults with hypertension. Although typically associated with the triad of new-onset, refractory or paroxysmal hypertension, palpitations, and headache, up to 10% of patients may remain asymptomatic. Pheochromocytomas have a number of syndromic associations, most notably multiple endocrine neoplasia 2, von Hippel-Lindau syndrome, neurofibromatosis, Sturge-Weber syndrome, and tuberous sclerosis. While the up to 95% of pheochromocytomas are typically benign, 10%–15% may be malignant. Diagnosis is established on the basis of elevated urinary and plasma fractioned metanephrines and catecholamines alongside characteristic imaging features. ”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - “CR visualizations in the workup of pheochromocytomas can accentuate the dynamic enhancement pattern through more distinctly highlighting the anatomy of the enhanced components within the mass .Additionally, CR confers the added benefit of dynamic window width and level adjustment, which can aid in delineating cystic regions and septations within the tumor. Beyond tissue characterization, CR vascular mapping can also potentially improve visualization of the vascular supply, which is especially important in laparoscopic resection of vascular tumors such as pheochromocytomas. It can also be useful for surgical planning of adrenal sparing procedures.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - “ACC is a highly malignant neoplasm arising from the adrenal cortex ACC is a rare tumor with an annual incidence of 0.5–2 per million per year that peaks in the fourth and fifth decades of life, with a slight female preponderance. ACC can present as either a functional or nonfunctional tumor. Sixty p. cent of ACCs are functional and present with characteristic clinical manifestations, with Cushing syndrome being the most common manifestation . Alternatively, patients with nonfunctional tumors most commonly present with pain, a palpable mass or gastrointestinal complaints . Thirty p. cent of (nonfunctional ACCs present with metastatic disease at detection, due to their late presentation .”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - Soft tissue sarcomas (STS) are a heterogenous group of mesenchymal tumors [28]. While STS can arise virtually anywhere within the body, involvement of the adrenals is exceedingly rare, and ascertaining definitive epidemiological data on adrenal involvement is difficult. Prior retrospective reviews have reported STSs to account for only 1.3% of all adrenal tumors . Among adult STSs, undifferentiated pleomorphic sarcoma, liposarcoma and leiomyosarcoma are the most common histological subtypes and typically present in the elderly [41]. Typically, undifferentiated pleomorphic sarcoma appears as heterogenous soft tissue masse with irregular margins and attenuate similarly to muscle. Soft tissue areas within the mass enhance following intravenous administration of contrast material. Areas of decreased attenuation, representing hemorrhage and necrosis, are often centrally present, which can complicate radiological differentiation from ACC .”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14. - “CR has promising potential in the characterization of adrenal masses and can influence surgical planning. CR can potentially improve the appreciation of the spatial relationship between the adrenal mass and adjacent structures and delineation of the major vascular supply. Enhanced surgical planning is particularly important with laparoscopic surgeries, in which the surgeons’ real-time intraoperative visualization may be limited. Results from preliminary studies applying cinematic rendering to imaging of non-adrenal pathology to assess clinical benefit have been promising .In one study, orthopedic surgeons and radiologists performed significantly better in the assessment of pelvic instability when using combined dual-energy CT with cinematic rendering (AUC = 0.82) over single-energy CT alone (AUC = 0.67). While this generates optimism, and is in agreement with our initial institutional observations of using CR, a prior study reported that radiologists, in fact, had lower accuracy in diagnosing vascular invasion in deep soft tissue sarcomas with CR imaging compared to standard contrast-enhanced axial imaging and VR imaging.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management.
Ahmed TM, Rowe SP, Fishman EK, Soyer P, Chu LC.
Diagn Interv Imaging. 2024 Jan;105(1):5-14.
- Objectives: To evaluate the diagnostic utility of adrenal mass biopsy (AMB) in patients without known or suspected extra-adrenal primary malignancy
Conclusion: AMB had low diagnostic yield, with low sensitivity and low specificity for malignancy. A biopsy result of adrenocortical neoplasm did not reliably differentiate benign and malignant adrenal masses.
Clinical Impact: Biopsy appears to have limited utility for evaluation of incidental adrenal masses in patients without primary extra-adrenal malignancy.
Adrenal Mass Biopsy in Patients Without Extra-Adrenal Primary Malignancy: A MulticenterStudy.
Krishna S, Moloney BM, Bao B, et al.
AJR 2023 Oct 25 [published online]. Accepted manuscript. doi:10.2214/AJR.23.29826 - “In the present study, AMB was limited in the characterization of adrenocortical neoplasms (i.e., in differentiation between adrenocortical adenoma and adrenocortical carcinoma). Biopsies of nine patients were reported as adrenocortical neoplasm without further classification as benign or malignant; six of these masses were found to be malignant based on resection or imaging follow-up. An additional mass reported as adenoma on biopsy was found to be malignant on imaging follow-up. Thus, a biopsy diagnosis of adenoma or adrenocortical neoplasm could provide false reassurance, leading to a management delay and possible poor clinical outcome. Rather, a biopsy result of adenoma or of adrenocortical neoplasm appears limited in providing confidence in the absence of ACC for purposes of guiding further management. Nonetheless, an approach of resecting adrenal masses found to be adrenal cortical neoplasm on biopsy would potentially lead to overtreatment given the fraction of such masses that were benign adenoma on resection.”
Adrenal Mass Biopsy in Patients Without Extra-Adrenal Primary Malignancy: A MulticenterStudy.
Krishna S, Moloney BM, Bao B, et al.
AJR 2023 Oct 25 [published online]. Accepted manuscript. doi:10.2214/AJR.23.29826
- “The adrenal gland is home to an array of complex physiological and neoplastic disease processes. While dedicated adrenal computed tomography (CT) is the gold standard imaging modality for adrenal lesions, there exists significant overlap among imaging features of adrenal pathology. This can often make radiological diagnosis and subsequent determination of the optimal surgical approach challenging. Cinematic rendering (CR) is a novel CT post-processing technique that utilizes advanced light modeling to generate highly photorealistic anatomic visualization. This generates unique prospects in the evaluation of adrenal masses. As one of the first large tertiary care centers to incorporate CR into routine diagnostic workup, our preliminary experience with using CR has been positive, and we have found CR to be a valuable adjunct during surgical planning. Herein, we highlight the unique utility of CR techniques in the workup of adrenal lesions and provide commentary on the opportunities and obstacles associated with the application of this novel display method in this setting.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management,
T.M. Ahmed, S.P. Rowe, E.K. Fishman et al.
Diagnostic and Interventional Imaging (2023), https://doi.org/10.1016/j.diii.2023.09.004 - “CR has promising potential in the characterization of adrenal masses and can influence surgical planning. CR can potentially improve the appreciation of the spatial relationship between the adrenal mass and adjacent structures and delineation of the major vascular supply. Enhanced surgical planning is particularly important with laparoscopic surgeries, in which the surgeons’ real-time intraoperative visualization may be limited. Results from preliminary studies applying cinematic rendering to imaging of non-adrenal pathology to assess clinical benefit have been promising. In one study, orthopedic surgeons and radiologists performed significantly better in the assessment of pelvic instability when using combined dual-energy CT with cinematic rendering (AUC = 0.82) over single-energy CT alone (AUC = 0.67). While this generates optimism, and is in agreement with our initial institutional observations of using CR, a prior study reported that radiologists, in fact, had lower accuracy in diagnosing vascular invasion in deep soft tissue sarcomas with CR imaging compared to standard contrast-enhanced axial imaging and VR imaging.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management,
T.M. Ahmed, S.P. Rowe, E.K. Fishman et al.
Diagnostic and Interventional Imaging (2023), https://doi.org/10.1016/j.diii.2023.09.004 - “While CR has demonstrated potential to improve the characterization and treatment planning of adrenal lesions at our institution, there remain several limitations to its widespread implementation. As previously discussed, availability of good quality, volumetric CT is a prerequisite to generating CR images. CR images are therefore critically dependent on the quality of the CT data set and optimization of the acquisition parameters from which they are generated. Secondly, since the CR global lighting model inherently produces shadowing effects, it is important to note that significant pathology may potentially be concealed by shadows or obscuration by overlying structures. This necessitates that CR images be reviewed from multiple viewpoints and be read in conjunction with the axial and multiplanar reformatted images.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management
T.M. Ahmed, S.P. Rowe, E.K. Fishman et al.
Diagnostic and Interventional Imaging (2023), https://doi.org/10.1016/j.diii.2023.09.004 - “CR allows depicting adrenal pathologies in a highly photorealistic manner. Generating representations that are as realistic as possible has the potential to help physicians make the most appropriate management decisions. As CR technology becomes more widely available, it is likely to play an increasingly important role in diagnostics and treatment planning.”
Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management
T.M. Ahmed, S.P. Rowe, E.K. Fishman et al.
Diagnostic and Interventional Imaging (2023), https://doi.org/10.1016/j.diii.2023.09.004
- "Compared with traditional black and white two-dimensional images and three-dimensional volume rendering (VR) images, CR images were more colorful, layered, and closer to the truth. CR has potential in diagnosing and preoperative planning of adrenal tumors, allowing vivid and realistic visualization of tumor location, morphology, different components (solid, cystic, fat, calcification, etc.), the pattern of enhancement, and the relationship with surrounding tissues and organs.”
Virtual or real: lifelike cinematic rendering of adrenal tumors
Lei Tang et al.
Quant Imaging Med Surg 2021;11(8):3854-3866 - “CR simulates the physical transmission of light in different environments in the real world, giving colorful vitality to the black-and-white image world. It presents the fine anatomical structures of different parts of the human body realistically and vividly, giving clinicians and patients a deeper perception. It also shows good potential application value in adrenal tumor localization, diagnosis, differential diagnosis, preoperative planning, teaching, and doctor-patient communication, which needs to be further verified in future studies.”
Virtual or real: lifelike cinematic rendering of adrenal tumors
Lei Tang et al.
Quant Imaging Med Surg 2021;11(8):3854-3866