Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?

European Journal of Endocrinology

Volumn 161, Issue 4, 2009, Pages 513-527

  Cawood, T J ^a   Hunt, P J ^a   O'Shea, D ^b   Cole, D ^a   Soule, S ^a  

^a CHRISTCHURCH HOSPITAL   (New Zealand)

^b ST VINCENT S UNIVERSITY HOSPITAL   (Ireland)

Author keywords

[No Author keywords available]

Indexed keywords

ALDOSTERONE; CORTICOTROPIN; DEXAMETHASONE; METADRENALIN;

ADRENAL CORTEX CARCINOMA; ADRENAL INCIDENTALOMA; ALDOSTERONE BLOOD LEVEL; CANCER RISK; CATECHOLAMINE URINE LEVEL; CLINICAL EVALUATION; COMPUTER ASSISTED TOMOGRAPHY; CUSHING SYNDROME; DIAGNOSTIC ACCURACY; DIFFERENTIAL DIAGNOSIS; DISTRESS SYNDROME; FALSE POSITIVE RESULT; FATALITY; FOLLOW UP; HEALTH CARE COST; HUMAN; HYPOTHALAMUS HYPOPHYSIS ADRENAL SYSTEM; MALIGNANT TRANSFORMATION; METASTASIS; PHEOCHROMOCYTOMA; PLASMA RENIN ACTIVITY; PRACTICE GUIDELINE; PRIORITY JOURNAL; RADIATION CARCINOGENESIS; RADIATION DOSE; RADIATION EXPOSURE; RADIATION HAZARD; REPEAT PROCEDURE; REVIEW; SENSITIVITY AND SPECIFICITY; TUMOR DIAGNOSIS; ADRENAL TUMOR; ARTICLE; CELL TRANSFORMATION; DISEASE COURSE; ECONOMICS; HYPERALDOSTERONISM; LABORATORY DIAGNOSIS; PATHOLOGY; RADIOGRAPHY;

ADRENAL GLAND NEOPLASMS; CELL TRANSFORMATION, NEOPLASTIC; CUSHING SYNDROME; DISEASE PROGRESSION; FALSE POSITIVE REACTIONS; FOLLOW-UP STUDIES; GUIDELINES AS TOPIC; HUMANS; HYPERALDOSTERONISM; PHEOCHROMOCYTOMA; RADIOGRAPHY;

EID: 70349765130     PISSN: 08044643     EISSN: 1479683X     Source Type: Journal    
DOI: 10.1530/EJE-09-0234     Document Type: Review

References (95)

1. NIH. State-of-the-science statement on management of the clinically inapparent adrenal mass ('incidentaloma'). NIH Consensus and State-of-the-Science Statements 2002 19 1-25.
2. Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. New England Journal of Medicine 2007 356 601-610.
3. Young WF Jr & Kaplan NM Eds. The Adrenal Incidentaloma. UpToDate Inc., accessed 08/04/2008, 2008.
4. Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y & Bornstein SR. The clinically inapparent adrenal mass: update in diagnosis and management. Endocrine Reviews 2004 25 309-340. (Pubitemid 38528713)
5. Barzon L, Sonino N, Fallo F, Palu G & Boscaro M. Prevalence and natural history of adrenal incidentalomas. European Journal of Endocrinology 2003 149 273-285. (Pubitemid 37304697)
6. Tutuncu NB & Gedik O. Adrenal incidentaloma: report of 33 cases. Journal of Surgical Oncology 1999 70 247-250.
7. Luton JP, Martinez M, Coste J & Bertherat J. Outcome in patients with adrenal incidentaloma selected for surgery: an analysis of 88 cases investigated in a single clinical center. European Journal of Endocrinology 2000 143 111-117. (Pubitemid 30482208)
8. Aydintug S, Kocak S & Eraslan S. Primary non-functioning tumours of the adrenal cortex: an eight-year experience in Turkey. European Journal of Surgery 1996 162 275-278. (Pubitemid 26150582)
9. Lee JA, Zarnegar R, Shen WT, Kebebew E, Clark OH & Duh QY. Adrenal incidentaloma, borderline elevations of urine or plasma metanephrine levels, and the 'subclinical' pheochromocytoma. Archives of Surgery 2007 142 870-873 (discussion 873-874).
10. Aso Y & Homma Y. A survey on incidental adrenal tumors in Japan. Journal of Urology 1992 147 1478-1481.
11. Murai M, Baba S, Nakashima J & Tachibana M. Management of incidentally discovered adrenal masses. World Journal of Urology 1999 17 9-14.
12. Proye C, Jafari Manjili M, Combemale F, Pattou F, Ernst O, Carnaille B & Wemeau JL. Experience gained from operation of 103 adrenal incidentalomas. Langenbeck's Archives of Surgery 1998 383 330-333. (Pubitemid 28527028)
13. Grumbach MM, Biller BM, Braunstein GD, Campbell KK, Carney JA, Godley PA, Harris EL, Lee JK, Oertel YC, Posner MC, Schlechte JA & Wieand HS. Management of the clinically inapparent adrenal mass ('incidentaloma'). Annals of Internal Medicine 2003 138 424-429. (Pubitemid 36262654)
14. Fontana D, Porpiglia F, Destefanis P, Fiori C, Ali A, Terzolo M, Osella G & Angeli A. What is the role of ultrasonography in the follow-up of adrenal incidentalomas? The Gruppo Piemontese Incidentalomi Surrenalici Urology 1999 54 612-616.
15. Ambrosi B, Peverelli S, Passini E, Re T, Ferrario R, Colombo P, Sartorio A & Faglia G. Abnormalities of endocrine function in patients with clinically 'silent' adrenal masses. European Journal of Endocrinology 1995 132 422-428.
16. Bulow B & Ahren B. Adrenal incidentaloma-experience of a standardized diagnostic programme in the Swedish prospective study. Journal of Internal Medicine 2002 252 239-246.
17. Boland GW, Goldberg MA, Lee MJ, Mayo-Smith WW, Dixon J, McNicholas MM & Mueller PR. Indeterminate adrenal mass in patients with cancer: evaluation at PET with 2-[F-18]-fluoro-2- deoxy-D-glucose. Radiology 1995 194 131-134.
18. Burt M, Heelan RT, Coit D, McCormack PM, Bains MS, Martini N, Rusch V & Ginsberg RJ. Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. Impact of magnetic resonance imaging. Journal of Thoracic and Cardiovascular Surgery 1994 107 584-588 (discussion 588-589). (Pubitemid 24070880)
19. Tsvetov G, Shimon I & Benbassat C. Adrenal incidentaloma: clinical characteristics and comparison between patients with and without extraadrenal malignancy. Journal of Endocrinological Investigation 2007 30 647-652. (Pubitemid 350104093)
20. Kobayashi S, Seki T, Nonomura K, Gotoh T, Togashi M & Koyanagi T. Clinical experience of incidentally discovered adrenal tumor with particular reference to cortical function. Journal of Urology 1993 150 8-12. (Pubitemid 23175959)
21. Xiao XR, Ye LY, Shi LX, Cheng GF, Li YT & Zhou BM. Diagnosis and treatment of adrenal tumours: a review of 35 years' experience. British Journal of Urology 1998 82 199-205.
22. Kasperlik-Zeluska AA, Roslonowska E, Slowinska-Srzednicka J, Migdalska B, Jeske W, Makowska A & Snochowska H. Incidentally discovered adrenal mass (incidentaloma): investigation and management of 208 patients. Clinical Endocrinology 1997 46 29-37. (Pubitemid 27072843)
23. Favia G, Lumachi F, Basso S & D'Amico DF. Management of incidentally discovered adrenal masses and risk of malignancy. Surgery 2000 128 918-924.
24. Nakajo M, Nakabeppu Y, Yonekura R, Iwashita S & Goto T. The role of adrenocortical scintigraphy in the evaluation of unilateral incidentally discovered adrenal and juxtaadrenal masses. Annals of Nuclear Medicine 1993 7 157-166. (Pubitemid 23308856)
25. Virkkala A, Valimaki M, Pelkonen R, Huikuri K, Kahri A, Kivisaari L, Korhonen T, Salmi J & Seppala P. Endocrine abnormalities in patients with adrenal tumours incidentally discovered on computed tomography. Acta Endocrinologica 1989 121 67-72. (Pubitemid 19167533)
26. Terzolo M, Ali A, Osella G & Mazza E. Prevalence of adrenal carcinoma among incidentally discovered adrenal masses. A retrospective study from 1989 to 1994. Gruppo Piemontese Incidentalomi Surrenalici. Archives of Surgery 1997 132 914-919.
27. Angeli A, Osella G, Ali A & Terzolo M. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Hormone Research 1997 47 279-283. (Pubitemid 27196466)
28. Barzon L, Scaroni C, Sonino N, Fallo F, Gregianin M, Macri C & Boscaro M. Incidentally discovered adrenal tumors: endocrine and scintigraphic correlates. Journal of Clinical Endocrinology and Metabolism 1998 83 55-62. (Pubitemid 28498310)
29. Osella G, Terzolo M, Borretta G, Magro G, Ali A, Piovesan A, Paccotti P & Angeli A. Endocrine evaluation of incidentally discovered adrenal masses (incidentalomas). Journal of Clinical Endocrinology and Metabolism 1994 79 1532-1539.
30. Mantero F, Terzolo M, Arnaldi G, Osella G, Masini AM, Ali A, Giovagnetti M, Opocher G & Angeli A. A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. Journal of Clinical Endocrinology and Metabolism 2000 85 637-644.
31. Terzolo M, Osella G, Ali A, Reimondo G, Borretta G, Magro GP, Luceri S, Paccotti P & Angeli A. Adrenal incidentaloma, a five year experience. Minerva Endocrinologica 1995 20 69-78.
32. Flecchia D, Mazza E, Carlini M, Blatto A, Olivieri F, Serra G, Camanni F & Messina M. Reduced serum levels of dehydroepiandrosterone sulphate in adrenal incidentalomas: a marker of adrenocortical tumour. Clinical Endocrinology 1995 42 129-134.
33. Barry MK, van Heerden JA, Farley DR, Grant CS, Thompson GB & Ilstrup DM. Can adrenal incidentalomas be safely observed? World Journal of Surgery 1998 22 599-603 (discussion 603-604).
34. Herrera MF, Grant CS, van Heerden JA, Sheedy PF & Ilstrup DM. Incidentally discovered adrenal tumors: an institutional perspective. Surgery 1991 110 1014-1021.
35. Song JH, Chaudhry FS & Mayo-Smith WW. The incidental indeterminate adrenal mass on CT (> 10 H) in patients without cancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses American Journal of Roentgenology 2007 189 1119-1123.
36. Rossi R, Tauchmanova L, Luciano A, Di Martino M, Battista C, Del Viscovo L, Nuzzo V & Lombardi G. Subclinical Cushing's syndrome in patients with adrenal incidentaloma: clinical and biochemical features. Journal of Clinical Endocrinology and Metabolism 2000 85 1440-1448. (Pubitemid 32289484)
37. Bondanelli M, Campo M, Trasforini G, Ambrosio MR, Zatelli MC, Franceschetti P, Valentini A, Pansini R & degli Uberti EC. Evaluation of hormonal function in a series of incidentally discovered adrenal masses. Metabolism 1997 46 107-113.
38. Seppel T & Schlaghecke R. Subclinical hypercortisolism in incidentally detected adrenal adenoma. Deutsche Medizinische Wochenschrift 1996 121 503-507 (discussion 508). (Pubitemid 26156775)
39. Emral R, Uysal AR, Asik M, Gullu S, Corapcioglu D, Tonyukuk V & Erdogan G. Prevalence of subclinical Cushing's syndrome in 70 patients with adrenal incidentaloma: clinical, biochemical and surgical outcomes. Endocrine Journal 2003 50 399-408. (Pubitemid 37129032)
40. Reincke M, Nieke J, Krestin GP, Saeger W, Allolio B & Winkelmann W. Preclinical Cushing's syndrome in adrenal 'incidentalomas': comparison with adrenal Cushing's syndrome. Journal of Clinical Endocrinology and Metabolism 1992 75 826-832.
41. Bastounis EA, Karayiannakis AJ, Anapliotou ML, Nakopoulou L, Makri GG & Papalambros EL. Incidentalomas of the adrenal gland: diagnostic and therapeutic implications. American Surgeon 1997 63 356-360. (Pubitemid 27152723)
42. 131I-6 betaiodomethylnorcholesterol scintigraphy: an assessment of its role in the investigation of adrenocortical incidentalomas. Clinical Endocrinology 1996 44 587-596.
43. Barzon L, Scaroni C, Sonino N, Fallo F, Paoletta A & Boscaro M. Risk factors and long-term follow-up of adrenal incidentalomas. Journal of Clinical Endocrinology and Metabolism 1999 84 520-526. (Pubitemid 29075678)
44. Bulow B, Jansson S, Juhlin C, Steen L, Thoren M, Wahrenberg H, Valdemarsson S,Wangberg B & Ahren B. Adrenal incidentaloma - follow-up results from a Swedish prospective study. European Journal of Endocrinology 2006 154 419-423.
45. Libe R, Dall'Asta C, Barbetta L, Baccarelli A, Beck-Peccoz P & Ambrosi B. Long-term follow-up study of patients with adrenal incidentalomas. European Journal of Endocrinology 2002 147 489-494. (Pubitemid 35238144)
46. Siren J, Tervahartiala P, Sivula A & Haapiainen R. Natural course of adrenal incidentalomas: seven-year follow-up study. World Journal of Surgery 2000 24 579-582. (Pubitemid 30210849)
47. Grossrubatscher E, Vignati F, PossaM& Lohi P. The natural history of incidentally discovered adrenocortical adenomas: a retrospective evaluation. Journal of Endocrinological Investigation 2001 24 846-855. (Pubitemid 34036714)
48. Bencsik Z, Szabolcs I, Goth M, Voros A, Kaszas I, Gonczi J, Kovacs L, Dohan O & Szilagyi G. Incidentally detected adrenal tumours (incidentalomas): histological heterogeneity and differentiated therapeutic approach. Journal of Internal Medicine 1995 237 585-589.
49. Mantero F & Arnaldi G. Management approaches to adrenal incidentalomas. A view from Ancona, Italy. Endocrinology and Metabolism Clinics of North America 2000 29 107-125 (ix).
50. Sippel RS & Chen H. Subclinical Cushing's syndrome in adrenal incidentalomas. Surgical Clinics of North America 2004 84 875-885. (Pubitemid 38622422)
51. Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM & Montori VM. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism 2008 93 1526-1540.
52. Morioka M, Fujii T, Matsuki T, Jo Y, Kobayashi T, Tanaka H, Ohashi T & Kondo K. Preclinical Cushing's syndrome: report of seven cases and a review of the literature. International Journal of Urology 2000 7 126-132.
53. Bernini G, Moretti A, Iacconi P, Miccoli P, Nami R, Lucani B & Salvetti A. Anthropometric, haemodynamic, humoral and hormonal evaluation in patients with incidental adrenocortical adenomas before and after surgery. European Journal of Endocrinology 2003 148 213-219. (Pubitemid 36305687)
54. Tsagarakis S, Kokkoris P, Roboti C, Malagari C, Kaskarelis J, Vlassopoulou V, Alevizaki C & Thalassinos N. The low-dose dexamethasone suppression test in patients with adrenal incidentalomas: comparisons with clinically euadrenal subjects and patients with Cushing's syndrome. Clinical Endocrinology 1998 48 627-633. (Pubitemid 28253000)
55. Pacak K, Eisenhofer G, Ahlman H, Bornstein SR, Gimenez-Roqueplo AP, Grossman AB, Kimura N, Mannelli M, McNicol AM & Tischler AS. Pheochromocytoma: recommendations for clinical practice from the First International Symposium. October 2005. Nature Clinical Practice. Endocrinology & Metabolism 2007 3 92-102. (Pubitemid 46146962)
56. Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P, Keiser HR, Goldstein DS & Eisenhofer G. Biochemical diagnosis of pheochromocytoma: which test is best? Journal of the American Medical Association 2002 287 1427-1434.
57. Perry CG, Sawka AM, Singh R, Thabane L, Bajnarek J & Young WF Jr. The diagnostic efficacy of urinary fractionated metanephrines measured by tandem mass spectrometry in detection of pheochromocytoma. Clinical Endocrinology 2007 66 703-708. (Pubitemid 46699545)
58. Sawka AM, Jaeschke R, Singh RJ & Young WF Jr. A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. Journal of Clinical Endocrinology and Metabolism 2003 88 553-558. (Pubitemid 36207789)
59. Boyle JG, Davidson DF, Perry CG & Connell JM. Comparison of diagnostic accuracy of urinary free metanephrines, vanillyl mandelic acid, and catecholamines and plasma catecholamines for diagnosis of pheochromocytoma. Journal of Clinical Endocrinology and Metabolism 2007 92 4602-4608.
60. Brain KL, Kay J & Shine B. Measurement of urinary metanephrines to screen for pheochromocytoma in an unselected hospital referral population. Clinical Chemistry 2006 52 2060-2064. (Pubitemid 44658208)
61. Hernandez FC, Sanchez M, Alvarez A, Diaz J, Pascual R, Perez M, Tovar I & Martinez P. A five-year report on experience in the detection of pheochromocytoma. Clinical Biochemistry 2000 33 649-655. (Pubitemid 32146200)
62. Heron E, Chatellier G, Billaud E, Foos E & Plouin PF. The urinary metanephrine-to-creatinine ratio for the diagnosis of pheochromocytoma. Annals of Internal Medicine 1996 125 300-303. (Pubitemid 126449276)
63. Eisenhofer G, Siegert G, Kotzerke J, Bornstein SR & Pacak K. Current progress and future challenges in the biochemical diagnosis and treatment of pheochromocytomas and paragangliomas. Hormone and Metabolic Research 2008 40 329-337. (Pubitemid 351859444)
64. Vaclavik J, Stejskal D, Lacnak B, Lazarova M, Jedelsky L, Kadalova L, Janosova M, Frysak Z & Vlcek P. Free plasma metanephrines as a screening test for pheochromocytoma in low-risk patients. Journal of Hypertension 2007 25 1427-1431.
65. Unger N, Pitt C, Schmidt IL, Walz MK, Schmid KW, Philipp T, Mann K & Petersenn S. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. European Journal of Endocrinology 2006 154 409-417.
66. Nishizaka MK, Pratt-Ubunama M, Zaman MA, Cofield S & Calhoun DA. Validity of plasma aldosterone-to-renin activity ratio in African American and white subjects with resistant hypertension. American Journal of Hypertension 2005 18 805-812.
67. Trenkel S, Seifarth C, Schobel H, Hahn EG & Hensen J. Ratio of serum aldosterone to plasma renin concentration in essential hypertension and primary aldosteronism. Experimental and Clinical Endocrinology and Diabetes 2002 110 80-85.
68. Eng PH, Tan KE, Khoo DH, Tan CE, Lim HS, Lim SC, Koh LK, Ho SC, Tai ES & Fok AC. Aldosterone to renin ratios in the evaluation of primary aldosteronism. Annals of the Academy of Medicine of Singapore 1997 26 762-766.
69. Weinberger MH & Fineberg NS. The diagnosis of primary aldosteronism and separation of two major subtypes. Archives of Internal Medicine 1993 153 2125-2129.
70. Bernini G, Moretti A, Orlandini C, Berti P, Miccoli P, Bardini M, Taurino C, Bernini M & Salvetti A. Plasma and urine aldosterone to plasma renin activity ratio in the diagnosis of primary aldosteronism. Journal of Hypertension 2008 26 981-988.
71. Giacchetti G, Ronconi V, Lucarelli G, Boscaro M & Mantero F. Analysis of screening and confirmatory tests in the diagnosis of primary aldosteronism: need for a standardized protocol. Journal of Hypertension 2006 24 737-745.
72. Vierhapper H. Determination of the aldosterone/renin ratio in 269 patients with adrenal incidentaloma. Experimental and Clinical Endocrinology and Diabetes 2007 115 518-521.
73. Tzanela M, Effremidis G, Vassiliadi D, Szabo A, Gavalas N, Valatsou A, Botoula E & Thalassinos NC. The aldosterone to renin ratio in the evaluation of patients with incidentally detected adrenal masses. Endocrine 2007 32 136-142.
74. Unger N, Lopez Schmidt I, Pitt C, Walz MK, Philipp T, Mann K & Petersenn S. Comparison of active renin concentration and plasma renin activity for the diagnosis of primary hyperaldosteronism in patients with an adrenal mass. European Journal of Endocrinology 2004 150 517-523.
75. Hennings J, Hellman P, Ahlstrom H & Sundin A. Computed tomography, magnetic resonance imaging and (11)C-metomidate positron emission tomography for evaluation of adrenal incidentalomas. European Journal of Radiology 2009 2 314-323.
76. Park SH, Kim MJ, Kim JH, Lim JS & Kim KW. Differentiation of adrenal adenoma and nonadenoma in unenhanced CT: new optimal threshold value and the usefulness of size criteria for differentiation. Korean Journal of Radiology 2007 8 328-335.
77. Blake MA, Kalra MK, Sweeney AT, Lucey BC, Maher MM, Sahani DV, Halpern EF, Mueller PR, Hahn PF & Boland GW. Distinguishing benign from malignant adrenal masses: multidetector row CT protocol with 10-minute delay. Radiology 2006 238 578-585.
78. Miyake H, Takaki H, Matsumoto S, Yoshida S, Maeda T & Mori H. Adrenal nonhyperfunctioning adenoma and nonadenoma: CT attenuation value as discriminative index. Abdominal Imaging 1995 20 559-562.
79. Lumachi F, Borsato S, Tregnaghi A, Basso SM, Marchesi P, Ciarleglio F, Fassina A & Favia G. CT-scan, MRI image-guided FNA cytology of incidental adrenal masses. European Journal of Surgical Oncology 2003 29 689-692.
80. Szolar DH & Kammerhuber FH. Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. Radiology 1998 207 369-375.
81. Boland GW, Hahn PF, Pena C & Mueller PR. Adrenal masses: characterization with delayed contrast-enhanced CT. Radiology 1997 202 693-696.
82. Szolar DH & Kammerhuber F. Quantitative CT evaluation of adrenal gland masses: a step forward in the differentiation between adenomas and nonadenomas? Radiology 1997 202 517-521.
83. Hamrahian AH, Ioachimescu AG, Remer EM, Motta-Ramirez G, Bogabathina H, Levin HS, Reddy S, Gill IS, Siperstein A & Bravo EL. Clinical utility of noncontrast computed tomography attenuation value (Hounsfield Units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland clinic experience. Journal of Clinical Endocrinology and Metabolism 2005 90 871-877.
84. Young WF Jr. Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota. Endocrinology and Metabolism Clinics of North America 2000 29 159-185 (x).
85. Lumachi F, Borsato S, Tregnaghi A, Marino F, Fassina A, Zucchetta P, Marzola MC, Cecchin D, Bui F, Iacobone M & Favia G. High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology. Tumori 2007 93 269-274.
86. UNSCEAR. United Nations Scientific Committee on the Effects of Atomic Radiation. 2006 Report to the General Assembly, vol 1, 2006.
87. Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, Lubin JH, Preston DL, Preston RJ, Puskin JS, Ron E, Sachs RK, Samet JM, Setlow RB & Zaider M. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. PNAS 2003 100 13761-13766.
88. Cardis E, Vrijheid M, Blettner M, Gilbert E, Hakama M, Hill C, Howe G, Kaldor J, Muirhead CR, Schubauer-Berigan M, Yoshimura T, Bermann F, Cowper G, Fix J, Hacker C, Heinmiller B, Marshall M, Thierry-Chef I, Utterback D, Ahn YO, Amoros E, Ashmore P, Auvinen A, Bae JM, Solano JB, Biau A, Combalot E, Deboodt P, Diez Sacristan A, Eklof M, Engels H, Engholm G, Gulis G, Habib R, Holan K, Hyvonen H, Kerekes A, Kurtinaitis J, Malker H, Martuzzi M, Mastauskas A, Monnet A, Moser M, Pearce MS, Richardson DB, Rodriguez-Artalejo F, Rogel A, Tardy H, Telle-Lamberton M, Turai I, Usel M & Veress K. Risk of cancer after low doses of ionising radiation: retrospective cohort study in 15 countries. BMJ 2005 331 77.
89. Kossenko MM, Thomas TL, Akleyev AV, Krestinina LY, Startsev NV, Vyushkova OV, Zhidkova CM, Hoffman DA, Preston DL, Davis F & Ron E. The Techa River Cohort: study design and follow-up methods. Radiation Research 2005 164 591-601.
90. Krestinina LY, Preston DL, Ostroumova EV, Degteva MO, Ron E, Vyushkova OV, Startsev NV, Kossenko MM & Akleyev AV. Protracted radiation exposure and cancer mortality in the Techa River Cohort. Radiation Research 2005 164 602-611.
91. Bauer S, Gusev BI, Pivina LM, Apsalikov KN & Grosche B. Radiation exposure due to local fallout from Soviet atmospheric nuclear weapons testing in Kazakhstan: solid cancer mortality in the Semipalatinsk historical cohort, 1960-1999. Radiation Research 2005 164 409-419.
92. Brenner DJ & Hall EJ. Computed tomography - an increasing source of radiation exposure. New England Journal of Medicine 2007 357 2277-2284.
93. Ware DE, Huda W, Mergo PJ & Litwiller AL. Radiation effective doses to patients undergoing abdominal CT examinations. Radiology 1999 210 645-650.
94. Martin D & Semelka R. Health effects of ionizing radiation from diagnostic CT imaging: consideration of alternative imaging strategies. Applied Radiology 2007 36 20-29.
95. Hidajat N, Maurer J, Schroder RJ, Nunnemann A, Wolf M, Pauli K & Felix R. Relationships between physical dose quantities and patient dose in CT. British Journal of Radiology 1999 72 556-561.