adrenal tumors
TRANSCRIPT
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
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
Benign Adrenal Masses
• Adenoma
• Incidentaloma
• Hemorrhage
• Myelolipoma
• Hyperplasia
• Pheochromocytoma
• Collision Tumor
• Ganglioneuroma
• Lipoma
• Cyst
• Oncocytoma
• Infection / Shock Adrenal
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
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%
Adrenal Adenoma on CT Lipid Rich
Adrenal Adenoma MRI In/Out of Phase
IN IN
OUT OUT
Absolute washout = (110 – 60 / 110 – 50) x 100 = 83%
Relative washout = (110 – 60 / 110 ) x 100 = 45%
Adenoma: APW, RPW
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%
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
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.
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
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
Adrenal Hematoma
Sag
Ax
Sag
Ax Cor
Adrenal Hematoma
Cor Sag
Ax
Shock Adrenal (Hypoperfusion complex)
Ax Cor
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
Myelolipoma
Ax Cor
Myelolipoma
Myelolipoma
Pre Pre
Post Post
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
Adrenal Hyperplasia (2 patients)
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
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
Pheochromocytoma
Pheochromocytoma
Ax Cor
Metastatic Pheochromocytoma on F-18FDG PET and I-123MIBG
Collision Tumor
• Two coexisting histologically distinct tumors
• Benign: adenoma and myelolipoma
• Malignant: adenoma and metastasis
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)
Calcified Cystic Adrenal Mass
Ax Ax
Sag Cor
Malignant Adrenal Masses
• Ganglioneuroblastoma
• Neuroblastoma
• Oncocytoma
• Angiosarcoma
• Metastasis
• Pheochromocytoma
• Adrenocortical carcinoma
• Lymphoma
• Collision tumor
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)
Bilateral Adrenal Mets
Cor Ax
Ax
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
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
Adrenocortical Carcinoma
Ax Cor
Lymphoma
• Diffuse or focal involvement
• Primary adrenal lymphoma is rare
• Usually NHL with other involvement
• Central necrosis and lymphadenopathy
• FDG avid on PET/CT
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
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
Contact Information
Peeyush Bhargava MD MBA
PGY 3 Radiology Resident
Phone: 832-374-2110
Louisiana State University Health Science Center, Shreveport, LA