In Reply: Dr Neumann identifies an important
limitation of studies comparing diagnostic tests when there is no criterion
standard available for conclusive exclusion of disease. In such situations,
how can we be sure of excluding disease and that our calculations of diagnostic
sensitivity are not inflated? Indeed, as better diagnostic tests are developed,
tests that were thought to be highly sensitive invariably are shown to have
lesser sensitivity. We disagree with Neumann's suggestion, however, that screening
for pheochromocytoma should include MRI, or even positron emission tomography.
In our experience, most patients with seemingly "convincing" signs and symptoms
do not have pheochromocytoma. In the absence of biochemical evidence of excess
catecholamine, additional imaging studies are unlikely to yield further benefit.
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