adrenal tumors

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Multimodality Evaluation of Adrenal Masses Peeyush Bhargava MD MBA, Michael C Gates MD, Guillermo Sangster MD, David Wallace MD, Matias Migliaro MD, Jaiyeola Thomas-Ogunniyi MD Louisiana State University Health Science Center, Shreveport, LA ARRS, April 2016, Los Angeles, CA

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Page 1: Adrenal Tumors

Multimodality Evaluation of Adrenal Masses

Peeyush Bhargava MD MBA, Michael C Gates MD,

Guillermo Sangster MD, David Wallace MD,

Matias Migliaro MD, Jaiyeola Thomas-Ogunniyi MD

Louisiana State University Health Science Center, Shreveport, LA

ARRS, April 2016, Los Angeles, CA

Page 2: Adrenal Tumors

Goals and Objectives

•  Review the spectrum of characteristic imaging

findings of adrenal masses using a

multimodality approach

•  Discuss the findings that can differentiate

between benign and malignant adrenal masses

•  Target Audience: Radiology residents and

practicing Radiologists

Page 3: Adrenal Tumors

Benign Adrenal Masses

•  Adenoma

•  Incidentaloma

•  Hemorrhage

•  Myelolipoma

•  Hyperplasia

•  Pheochromocytoma

•  Collision Tumor

•  Ganglioneuroma

•  Lipoma

•  Cyst

•  Oncocytoma

•  Infection / Shock Adrenal

Page 4: Adrenal Tumors

Adenomas

•  Most common adrenal tumor and incidentaloma

•  Benign, most non functional

•  70% lipid rich, 30% lipid poor

•  1-4 cm, well defined, solid, homogenous, smooth

•  Yellow to yellowish-brown in color

•  Vacuolated cells with intra-cytoplasmic lipid

Page 5: Adrenal Tumors

Adenomas

•  CT features:

Unenhanced - < 10 HU

Enhanced - > 60% Absolute percentage washout

Enhanced - > 40% Relative percentage washout

•  MRI features:

Chemical shift imaging - signal drop on out of phase

Adrenal to spleen ratio - < 71%

Adrenal signal intensity index - < 16.5%

Page 6: Adrenal Tumors

Adrenal Adenoma on CT Lipid Rich

Page 7: Adrenal Tumors

Adrenal Adenoma MRI In/Out of Phase

IN IN

OUT OUT

Page 8: Adrenal Tumors

Absolute washout = (110 – 60 / 110 – 50) x 100 = 83%

Relative washout = (110 – 60 / 110 ) x 100 = 45%

Adenoma: APW, RPW

Page 9: Adrenal Tumors

History: Incidental adrenal mass: 50 HU / 110 HU / 60 HU

Absolute washout = (110 – 60 / 110 – 50) x 100 = 83%

Relative washout = (110 – 60 / 110 ) x 100 = 45%

Page 10: Adrenal Tumors

Incidentaloma

•  Adrenal tumors seen in 4 – 10 % of abdominal CTs •  Most common lesion is an adenoma •  Functional vs non-functional – 24 hr urine

metanepnrines, 17 hydroxycorticosteroids, 17 ketosteroids

•  CT / MRI characteristics – size, margins, HU / signal drop on chemical shift / washout, homogeneity, growth, history of cancer

•  PET/CT imaging / Biopsy

Page 11: Adrenal Tumors

Algorithm for Adrenal Incidentaloma

Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol. 2010 Oct;7(10):754-73. doi: 10.1016/j.jacr.2010.06.013.

Page 12: Adrenal Tumors

Hemorrhage

•  Traumatic (non accidental in peds) vs non traumatic

•  Non traumatic causes: coagulopathy, stress (sepsis,

surgery, burns, hypotension, pregnancy), venous

hypertension and hemorrhagic tumor

•  20% are bilateral, 1- 5 cm, well defined, round

Page 13: Adrenal Tumors

Hemorrhage

•  CT: high attenuation (50-90 HU), does not

enhance, decreases in size and attenuation with

time, fat stranding, extension

•  MRI:

Acute (<7 days) – T1 iso to hypo, T2 markedly hypo

Subacute (1-7 wks) – T1 fat sat and T2 hyperintense

Chronic (after 7 wks) – T1 and T2 hypointense rim

Page 14: Adrenal Tumors

Adrenal Hematoma

Sag

Ax

Sag

Ax Cor

Page 15: Adrenal Tumors

Adrenal Hematoma

Cor Sag

Ax

Page 16: Adrenal Tumors

Shock Adrenal (Hypoperfusion complex)

Ax Cor

Page 17: Adrenal Tumors

Myelolipoma

•  Benign and non functioning tumor

•  Mature adipose and hematopoeitic tissue

•  Heterogeneous, pseudo-capsule, calcifications

•  US: hyperechoic lesion

•  CT: macroscopic fat (HU<30)

•  MRI: T1 hyperintense signal suppresses with fat sat

India ink (chemical shift) artifact at myeloma-adrenal

interface and within the mass on out of phase

Page 18: Adrenal Tumors

Myelolipoma

Ax Cor

Page 19: Adrenal Tumors

Myelolipoma

Page 20: Adrenal Tumors

Myelolipoma

Pre Pre

Post Post

Page 21: Adrenal Tumors

Hyperplasia

•  Benign and functional

•  Accounts for 2% cases of Cushings syndrome

and 30% cases of primary hyperaldosteronism

•  Sex steroid over production can lead to

feminization or virilization

•  Diffuse vs macronodular

Page 22: Adrenal Tumors

Adrenal Hyperplasia (2 patients)

Page 23: Adrenal Tumors

Pheochromocytoma

•  Arises from Chromaffin cells in adrenal medulla

•  Stores and releases catecholamines

•  Elevated serum / 24 hr urine metanephrines

•  Hypertension, palpitations, perspiration and headache

•  10% are: bilateral, extra adrenal (paragangliomas), occur

in children, and malignant (local invasion and mets)

•  Association with syndromes: MEN, NF 1, Von Hippel

Lindau, Tuberous sclerosis, Sturge-Weber

Page 24: Adrenal Tumors

Pheochromocytoma

•  CT: homogeneous, well defined, soft tissue attenuation,

avid enhancement with delayed retention

•  MR: T2 bright (light bulb)

•  Take up I123 MIBG, In111 pentetreotide, and F18 FDG

•  Surgical resection

•  Pathology: yellow / tan, hemorrhage, cystic change,

central necrosis, myxoid degeneration. Nest of cells

(zellballen), Salt and pepper chromatin

Page 25: Adrenal Tumors

Pheochromocytoma

Page 26: Adrenal Tumors

Pheochromocytoma

Ax Cor

Page 27: Adrenal Tumors

Metastatic Pheochromocytoma on F-18FDG PET and I-123MIBG

Page 28: Adrenal Tumors

Collision Tumor

•  Two coexisting histologically distinct tumors

•  Benign: adenoma and myelolipoma

•  Malignant: adenoma and metastasis

Page 29: Adrenal Tumors

Cyst

•  Rare, benign, and non functional

•  Cystic, fluid attenuation, septations

•  Rim calcification, non enhancement

•  Prior hemorrhage or infarct

•  Aspirated if clinically indicated

•  Acellular turbid fluid with cholesterol crystals

•  Differentiate from cystic neoplasm (CT / MRI)

Page 30: Adrenal Tumors

Calcified Cystic Adrenal Mass

Ax Ax

Sag Cor

Page 31: Adrenal Tumors

Malignant Adrenal Masses

•  Ganglioneuroblastoma

•  Neuroblastoma

•  Oncocytoma

•  Angiosarcoma

•  Metastasis

•  Pheochromocytoma

•  Adrenocortical carcinoma

•  Lymphoma

•  Collision tumor

Page 32: Adrenal Tumors

Metastasis

•  Common site after lung, liver, and bone

•  Primary: lung, breast, thyroid, colon, melanoma

•  Irregular, poorly defined mass, heterogeneous

•  Rim / nodular enhancement, central necrosis

•  Local invasion, hemorrhage

•  Rapid growth, other mets

•  T2 bright, no change on chemical shift imaging

•  FDG avid on PET/CT (SUV > 2.5 / liver)

Page 33: Adrenal Tumors

Bilateral Adrenal Mets

Cor Ax

Ax

Page 34: Adrenal Tumors

Adrenocortical Carcinoma

•  Arise from adrenal cortex, aggressive tumor

•  1st and 4th/5th decade, rare cancer

•  Large palpable mass with abdominal / flank pain

•  >6 cm at presentation, likely to be functional

•  Invasive (adrenal vein and IVC) and metastasis to

lung, liver, and bone

•  Calcification, central necrosis, hemorrhage

Page 35: Adrenal Tumors

Adrenocortical Carcinoma

•  Associattions: Li-Fraumeni syndrome, Carney

complex, Beckwith-Wiedemann syndrome, familial

adenomatous, polyposis coli, MEN type 1

•  CT: heterogenous / nodular rim enhancement

•  MR: T2 hyperintense, hetergenous enhancement with

slow washout

•  FDG avid on PET/CT

•  Surgical resection, embolization, ablation, no biopsy

Page 36: Adrenal Tumors

Adrenocortical Carcinoma

Ax Cor

Page 37: Adrenal Tumors

Lymphoma

•  Diffuse or focal involvement

•  Primary adrenal lymphoma is rare

•  Usually NHL with other involvement

•  Central necrosis and lymphadenopathy

•  FDG avid on PET/CT

Page 38: Adrenal Tumors

Ganglioneuroblastoma

•  Rare tumors with intermediate malignant potential

•  Mostly seen in children 2-4 yrs of age

•  Cystic to solid depending on the predominant tissue component

•  Encapsulated, with thin calcifications

Page 39: Adrenal Tumors

Neuroblastoma

•  Most common extracranial solid tumor of childhood

•  Arises from adrenal medulla or retroperitoneal

sympathetic ganglia

•  Soft tissue masses, often calcified

•  Often with disseminated disease

Page 40: Adrenal Tumors

Contact Information

Peeyush Bhargava MD MBA

PGY 3 Radiology Resident

Phone: 832-374-2110

[email protected]

Louisiana State University Health Science Center, Shreveport, LA