Adrenal and other retroperitoneal masses

ADRENAL AND OTHER

RETROPERITONEAL MASSESModified lecture presented at ESUR fall meeting 2014 in Lisbon

Philipp Steiger, Dr. med.

Oberarzt

Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie

Inselspital Bern, Schweiz

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 2

Adrenal Mass

Adrenals play a roll in imaging in 2 situations

a) adrenal mass is detected on cross-sectional

imaging (rarely on ultrasound)

a) known biochemical abnormality

Normal adrenal Adrenal mass

1. http://radiopaedia.org/articles/adrenal-gland

2. http://radiopaedia.org/cases/adrenal-mass

1 2


Adrenal Mass

a) incidental adrenal mass is detected on cross-sectional


no known neoplasmknown neoplasm


Adrenal Mass





Adrenal Mass

✓ Neoplasm confirmed




Adrenal Mass


Problem: metastasis and adenomas are common

Metastasis yes or no? or something different?




Adrenal Mass


Problem: metastasis and adenomas are common


Most common adrenal metastasis:

Lung, breast, stomach, kidney cancer, melanoma, lymphoma



Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Lam KY et al. Clin Endocrinol (Oxf). 2002 Jan;56(1):95-101


Adrenal Mass





Look carefully:

• Rule in: Other metastasis? Older images? De novo? PET?

• Rule out: Benign imaging characteristics (washout,

chemical shift)?


Adrenal Mass





Look carefully:

• Rule in: Other metastasis? Older images? De novo? PET?

• Rule out: Benign imaging characteristics (washout,

chemical shift)?

Biopsy


Adrenal Mass





Biopsy


Adrenal Mass





Biopsy

Does it alter treatment? Rule out pheochromocytoma!


Adrenal Mass





Biopsy

Does it alter treatment? Rule out pheochromocytoma!

FNA? Core needle biopsy? CT vs. US vs. MR guided


Adrenal Mass



Complications of biopsies:

• adrenal hematoma

• abdominal pain

• hematuria

• pancreatitis

• pneumothorax

• formation of an adrenal abscess

• tumor recurrence along the needle track

Clinical practice. The incidentally discovered adrenal mass. Young WF Jr. N Engl J Med. 2007 Feb 8;356(6):601-10.


Adrenal Mass




Benign imaging characteristics:

1

2

3


Adrenal Mass





1 Cyst

2

1. Image due to legal reasons not shown

3

1


Adrenal Mass





1 Cyst

2 Myelolipoma

2

1. Giant adrenal endothelial cyst associated with acute and chronic morbidity in a young female: a case report. Muhammad Rizwan Khan. Cases J.

2009; 2: 8841.

2. http://radiopaedia.org/articles/adrenal-myelolipoma Case 3

3

1


Adrenal Mass





1 Cyst

2 Myelolipoma

3 Lipid rich adenoma (<10 HU)

1

2


2. http://radiopaedia.org/articles/adrenal-myelolipoma Case 3

3. http://radiopaedia.org/cases/ctadenoma

3

1


Adrenal Mass





1 Cyst

2 Myelolipoma

3 Lipid poor adenoma (>10 HU)???


Adrenal Mass





1 Cyst

2 Myelolipoma

3 Lipid poor adenoma (>10 HU)???

washout


Adrenal Mass


imaging (rarely on ultrasound); ✓ Neoplasm confirmed

Diagnosis of an adenoma (CT washout)

Absolute Percentage Washout (APW)

Relative Percentage Washout (RPW)

100 x venous HU – delayed HU

venous HU


venous HU – precontrast HU

Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.


Adrenal Mass



Diagnosis of an adenoma (CT washout)

Absolute Percentage Washout (APW)

Relative Percentage Washout (RPW)


venous HU


venous HU – precontrast HU

Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.

> 60% adenoma

> 40% adenoma


Drawing shows the enhancement pattern of a lipid-poor adenoma.

RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.295095027

Published in: Pamela T. Johnson; Karen M. Horton; Elliot K. Fishman; RadioGraphics 2009, 29, 1333-1351.

DOI: 10.1148/rg.295095027 © RSNA, 2009

APW: 100%(> 60% adenoma )

RPW: 52%(> 40% adenoma )

Imagesee below

http://www-hsc.usc.edu/~phillimc/calc/adrenal_ct.html

http://www.radiologytutor.com/index.php/cases/endocrine/107-

adrenalcalc

http://www.chestx-ray.com/index.php/calculators/adrenal-

characterization

Google search for “Adrenal wash out”

http://www.radreport.org/template/0000281

http://www.braegelmann.com/bernd/scripts/adrenalgland.html


Adrenal Mass



Diagnosis of an adenoma with MR


Adrenal Mass



Diagnosis of an adenoma with MR

in/out-of-phase


Adrenal Mass



Diagnosis of an adenoma (MR signal in/opp)

Adrenal-to-spleen CSI ratio

Adrenal signal intensity index

100 x lesion SIIP / lesion SIOP

lesion SIIP

lesion SIOP / spleen SIOP

lesion SIIP / spleen SIIP

Comparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. Israel GM et al. AJR 2004; 183:215-219

Characterization of adrenal tumors by chemical shift fast low-angle shot MR imaging: comparison of four methods of quantitative evaluation. Fujiyoshi F. AJR 2002; 180

< 0.71 adenoma

> 16.5% adenoma


Adrenal Mass



Diagnosis of an adenoma

MR vs CT


• 15-DECT: 478 adrenal masses in 453 patients

• CSMR: 235 adrenal masses in 217 patients

RPW calculated from 15-DECT showed the highest diagnostic

performance for characterising hyperattenuating adrenal masses

regardless of underlying malignancy, and the sensitivity,

specificity and accuracy were 91.7 %, 74.8 % and 88.1 %,

respectively in all patients.

Conclusions: 15-DECT was more accurate than CSMR in

characterising hyperattenuating adrenal masses regardless of

underlying malignancy.

The value of 15-minute delayed contrast-enhanced CT to differentiate hyperattenuating adrenal massescompared with chemical shift MR imaging.

Koo HJ et al.

Eur Radiol. 2014 Jun;24(6):1410-20. Epub 2014 Mar 20.


Adrenal Mass




What else is new?


Adrenal Mass




What else is new?

• Shorter protocols (10min vs. 15min)

• Histogram analysis

• Dixon sequences (quantification of absolute fat

content)


10min vs 15min

323 adrenal lesions (213 left, 110 right)

307 adenomas and 16 nonadenomas

RPW test washout of 40%

• Sensitivity 76.9% (83%)

• Specificity 93.7% (93%)

• Accuracy 77.7% (85%)

APW test washout of 60%

• Sensitivity 52.1% (88%)

• Specificity 93.3% (86%)

• Accuracy 54.0% (88%)

„In conclusion the 10 minute delayed adrenal enhancement washout tests have reduced

sensitivity for the detection of adenomas compared with results from prior studies, and the

test sensitivity appears to be clinically suboptimal. This finding might be explained by

insufficient time for the intravenous contrast material to wash out from benign

lesions.“

Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging

protocol revisited in a large patient cohort

Sangwaiya MJ et al

Radiology. 2010 Aug;256(2):504-10

2

Computed Tomographic Histogram Analysis in the Diagnosis of Lipid-Poor Adenomas: Comparison to Adrenal Washout Computed Tomography.Jhaveri, Kartik; Lad, Shilpa; Haider, Masoom; MD, FRCPC

Journal of Computer Assisted Tomography. 31(4):513-518, July/August 2007.Digital Object Identifier: 10.1097/01.rct.0000250105.93423.a2

FIGURE 1 . CT histogram analysis: an ROI drawn on adrenal nodule (left) distributes pixels on a bar graph based on pixel attenuation (right) with pixel attenuation on horizontal axis and number of pixels on vertical axis. Number of pixels with negative attenuation (negative pixels) can be obtained by summing number of pixels with attenuation less than zero HU (left of dotted line).

Histogram analysis

Imagesee right


Histogram analysis

24 lipid-poor adenomas more than 60% absolute enhancement washout

Threshold of more than 5% negative pixels CT histogram analysis

Sensitivity 91.6%

Specificity 100%

Threshold of more than 10% negative pixels CT histogram analysis

Sensitivity 70.8%

Specificity 100%

CONCLUSIONS: Computed tomographic histogram analysis has good

potential in the diagnosis of lipid-poor adenoma and can reduce the

need to perform adrenal washout CT.

Computed tomographic histogram analysis in the diagnosis of lipid-poor adenomas: comparison to adrenalwashout computed tomography.

Jhaveri KS

J Comput Assist Tomogr. 2007 Jul-Aug;31(4):513-8.


Dixon sequence

Dixon sequence (MR spectroscopic imaging) allows discriminating between lipid

and water and further allows calculating the absolut content of fat.

20 patients with 22 adrenal tumors larger than 15 mm

15 Adenomas: Mean percentage of lipid 13.4% (SD 8%)

7 Carcinomas: Mean percentage of lipid 3.5% (SD 2%)

Only one lesion would have been misclassified on the basis of in vivo

measurements of lipid content.

„In vivoMR spectroscopic imaging of adrenal tumors appears to be useful

for differentiating between adrenal carcinomas and adenomas.“

In vivo MR spectroscopic imaging of the adrenal glands: distinction between adenomas and carcinomas larger than 15 mm based on

lipid content.

Leroy-Willig A et al.

AJR Am J Roentgenol. 1989 Oct;153(4):771-3.


Adrenal Mass




Guidelines recommend:

washout


Adrenal Mass





Adrenal Mass

✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)

Incidentaloma



Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.


Adrenal Mass


Incidentaloma

Definition: Newly detected adrenal mass > 1cm

(exclude patient with cancer workup and staging)

Incidence: Up to 8.7%, correlates with number in autopsy





Adrenal Mass


Incidentaloma

- Adenoma 41%

- Metastases 19 %

- Adrenocorctical carcinoma 10%

- Pheochromocytoma 8%

- myelolipoma✓ < -10 HU 9%

- cysts✓ and others 13%



The clinically inapparent adrenal mass: update in

diagnosis and management. Mansmann G et al.

Endocr Rev. 2004 Apr;25(2):309-40.

The clinically inapparent

adrenal mass: update in

diagnosis and management.

Mansmann G. Endocr Rev.

2004 Apr;25(2):309-40.

Imagesee below


Adrenal Mass

b) : incidental adrenal mass is detected on cross-sectional imaging (rarely on

ultrasound); ✓No known neoplasm

Guidelines

• American Association of Clinical Endocrinologists and American Association of

Endocrine Surgeons Medical Guidelines for the Management of Adrenal

Incidentaloma 2009

• NIH state-of-the-science statement on management of the clinically inapparent

adrenal mass ( incidentaloma ) 2002

• Guidelines for the management of the incidentally discovered adrenal mass;

Kapoor et al., Can Urol Assoc J. Aug 2011

American Association of Clinical

Endocrinologists and American

Association of Endocrine Surgeons

Medical Guidelines for the

Management of Adrenal

Incidentaloma AACE/AAES

Adrenal Incidentaloma Guidelines,

Endocr Pract. 2009;15(Suppl 1)

ImageAlgorithm for the evaluation and management of an

adrenal incidentaloma


Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee. Berland LL et al. JACR 2010 7, 754-773

Imagesee below


Adrenal Mass


Incidentaloma

Imaging can not distinguish between functioning

and nonfunctioning adrenal mass





Adrenal Mass


Incidentaloma

Imaging can not distinguish between functioning

and nonfunctioning adrenal mass

Endocrine tests





What happens to our reports?

Adrenal incidentalomas are common and guidelines recommend testing to exclude

functioning lesions and malignancy.

Despite guidance, actual clinical practice appears to differ among centres.

2.4 - 51% (Northern Ireland)

Only a few patients had been tested to exclude a functional lesion and there was

inconsistent terminology in reporting adrenal lesions. Therefore, we support

comprehensive reporting of AIs and a selective testing strategy.

Radiology reporting of adrenal incidentalomas - who requires further testing?

Paterson F

Clin Med. 2014 Feb;14(1):16-21.

CT scans Adenomas Newly

identified

Seen by an

endocrinologist

2011 690 17 (2.46%) 7 (1.01%) 5 (29.4%)

2012 1264 26 (2.01%) 12 (0.95%) 4 (15.4%)


Adrenal Mass

Adrenals play a roll in imaging in 2 situations

a) adrenal mass is detected on cross-sectional imaging

(rarely on ultrasound)


Normal adrenal Adrenal mass


Adrenal Mass

b) known biochemical abnormality

Clinicians tell you: “We performed blood and urine tests and found the following

biochemical abnormalities. We have a patient with…”

1) with primary hyperaldosteronism (Conn syndrome)

2) with elevated cortisol levels in urine or blood plasma (Cushing syndrome)

3) with suspicion of hyperandrogenism

4) with elevated catecholamines in urine or blood plasma


Adrenal Mass

b) known biochemical abnormality







Adrenal cortex is producing either aldosterone, glucocorticoids or androgens

and the adrenal medulla is producing catecholamines.

Mineralcorticoids (Aldosterone)

Glucocorticoids (Cortisol)

Glucocorticoids, Androgens,

Estrogens

Adrenaline, Noradrenaline

Grey‘s Anatomy


Adrenal Mass








Clinicians ask you:


Adrenal Mass








Clinicians ask you:

Is there an adrenal mass or extraadrenal mass?


Adrenal Mass








Clinicians ask you:

Is there an adrenal mass or extraadrenal mass?

Which imaging modality do we use best?


Adrenal Mass


1) with primary hyperaldosteronism.

Which imaging modality do we use?

Clinical symptoms: Drug resistance, refractory

hypertension, muscle cramping and weakness

Screening: Plasma renin activity to plasma

aldosterone concentration

Confirmation: Lack of suppression of

aldosterone levels after salt loadingAmerican Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of

Adrenal Incidentaloma AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15(Suppl 1)


Adrenal Mass




Primary hyperaldosteronism


Adrenal Mass




Primary hyperaldosteronism ✓ confirmed


Adrenal Mass





Imaging modality?


Adrenal Mass





Imaging modality?

MR vs. CT?


interobserver agreement CT (k=0.71) and MR (k=0.67)

In conclusion, we have demonstrated comparable sensitivity and

specificity on CT and MR imaging for the detection of aldosterone-

producing adenoma in primary hyperaldosteronism. We therefore

suggest that the use of CT or MR imaging be based on the

radiologist’s experience or confidence in detecting aldosterone-

producing adenomas on these modalities.

Diagnostic performance of CT versus MR in detecting aldosterone-producing adenoma in primary hyperaldosteronism (Conn's

syndrome)

Lingam RK et al.

Eur Radiol. 2004 Oct;14(10):1787-92. Epub 2004 Jul 6.

Observer 1

CT

Observer 2

CT

Observer 1

MR

Observer 2

MR

Sensitivity 87% 85% 83% 92%

Specificity 93% 82% 83% 92%

Aldosterone-producing adenoma CT vs. MR

34 Patients: CT (n=30) and MR (n=24)


Adrenal Mass




• Primary hyperaldosteronism


Adrenal Mass




• Primary hyperaldosteronism ✓confirmed


Adrenal Mass





• Imaging modality: MR or CT


Adrenal Mass





• Imaging modality: MR or CT ✓clear


Adrenal Mass






Adrenal mass ✓


Adrenal Mass






• Adrenal mass ✓

problem solved?


Adrenal Mass







Clinicians ask you now:

1. Is the nodule on your scan the aldosterone

producing adenoma?

2. Idiopathic primary adrenal hyperplasia?


Adrenal Mass







What could you offer?


Adrenal Mass







What could you offer?

Adrenal venous sampling

American Association of Clinical

Endocrinologists and American Association of

Endocrine Surgeons Medical Guidelines for

the Management of Adrenal Incidentaloma

AACE/AAES Adrenal Incidentaloma

Guidelines, Endocr Pract. 2009;15(Suppl 1)

ImageAlgorithm for confirmation of primary aldosteronism

ImageDue to legal reasons not shown


Adrenal venous sampling• 203 patients with primary aldosteronism

• prospectively selected for AVS and CT findings

• 194 patients both adrenal veins were catheterized

• 110 patients unilateral aldosterone hypersecretion

CONCLUSIONS:

On the basis of CT findings alone, 42 patients (21.7%) would have been

incorrectly excluded as candidates for adrenalectomy, and 48 (24.7%)

might have had unnecessary or inappropriate adrenalectomy. AVS is an

essential diagnostic step in most patients to distinguish between unilateral

and bilateral adrenal aldosterone hypersecretion.

Role for adrenal venous sampling in primary aldosteronism.

Young WF

Surgery. 2004 Dec;136(6):1227-35.

N= CT findings unilateral aldosterone hypersecretion

58 normal 24 (41.4%)

47 unilateral micronodule (< or =10 mm) 24 (51.1%), 7 from the contralateral adrenal

32 unilateral macronodule (>10 mm) 21 (65.6%), 1 from the contralateral adrenal)


Adrenal Mass


2) with elevated cortisol levels in urine or blood plasma (Cushing

Syndrom, subclinical cushing syndrom)


Clinical SymptomsRapid weight gain, Moodiness, irritability, or depression Muscle and bone weakness, Memory and

attention dysfunction, Osteoporosis, Diabetes mellitus, Hypertension, Immune suppression, Sleep

disturbances, Menstrual disorders such as amenorrhea in women, Decreased fertility in men,

Hirsutism, Baldness, Hypercholesterolemia

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of



Adrenal Mass





Screening & diagnosis: • Late-night salivary cortisol

• Overnight 1mg dexamethasone suppression test

• 24-hour urine free cortisol




Adrenal Mass








Biochemical diagnosis




Adrenal Mass








Biochemical diagnosis

Imaging still needed or what clinicians want to know ?




Adrenal Mass









Adrenal Mass






Unilateral disease (adenoma, adenoma within a myelolipoma, adenoma of

uncertain malignant potential, carcinoma)

Bilateral disease (including primary pigmented nodular adrenal dysplasia

(PPNAD)

(ACTH-independent macronodular hyperplasia (AIMAH))




Adrenal Mass


3) with suspicion hyperandrogenism, hyperestrogenism



Adrenal Mass


3) with suspicion hyperandrogenism, hyperestrogenism


Condition which is rarely caused by a primary

adrenal mass

Imaging is not the main diagnostic workup


Adrenal Mass





Adrenal Mass




Clinical symptomsSkin sensations. Flank pain. Elevated heart rate. Elevated blood pressure, including paroxysmal (sporadic, episodic)

high blood pressure. Orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in

diastolic blood pressure greater than 10 mmHg upon standing) Palpitations. Anxiety, often resembling that of a panic

attack- Diaphoresis (excessive sweating) Headaches – most common symptom: Pallor. Weight loss. Localized

amyloid deposits found microscopically. Elevated blood glucose levels.

http://en.wikipedia.org/wiki/Pheochromocytoma


Adrenal Mass




Clinical symptomsSkin sensations. Flank pain. Elevated heart rate. Elevated blood pressure, including paroxysmal (sporadic, episodic)

high blood pressure. Orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in

diastolic blood pressure greater than 10 mmHg upon standing) Palpitations. Anxiety, often resembling that of a panic

attack- Diaphoresis (excessive sweating) Headaches – most common symptom: Pallor. Weight loss. Localized

amyloid deposits found microscopically. Elevated blood glucose level

Suspicion of pheochromocytoma

http://en.wikipedia.org/wiki/Pheochromocytoma


Adrenal Mass




Diagnosis

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal

Incidentaloma AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15(Suppl 1)


Adrenal Mass




Diagnosis

a) 24 hour urine collection

for catecholamines

for total or fractionated metanephrine




Adrenal Mass




Diagnosis


for catecholamines


b) More recently plasma free metanephrine and normetanephrine




Adrenal Mass




Diagnosis


for catecholamines



Why imaging?




Adrenal Mass




Diagnosis


for catecholamines



Why imaging?

Localisation DD Paraganglioma




Adrenal Mass




Recommendations:

Endocrine Society: Suggest CT rather than MRI as the first-choice imaging

modality because of its excellent spatial resolution for thorax, abdomen, and pelvis

American Association of Clinical Endocrinologists and American Association

of Endocrine Surgeons Medical Guidelines for the Management of Adrenal

Incidentaloma: Either may be used as the definitive imaging study, depending on

availability, cost, and patient preference., MIBI not mentioned

The North American Neuroendocrine Tumor Society Consensus Guideline for

the Diagnosis and Management of Neuroendocrine Tumors (NANTES) Either

computed tomography (CT) or magnetic resonance imaging (MRI) is recommended

for initial tumor localization, with MRI preferred in children and pregnant or lactating

women because of concerns regarding radiation exposure.


Pheochromocytoma

1. http://radiopaedia.org/cases/pheochromocytoma


1


Pheochromocytoma

“First, adenomas usually are more enhancing in the venous

than in the arterial phase or have equivalent enhancement

across phases. Second, a mass that is greater than 110-HU

enhancing in the arterial phase, particularly with higher

enhancement in the arterial phase, is most likely a

pheochromocytoma. Third a pheochromocytoma are more

likely to be heterogeneous than are adenomas.”

MDCT of Adrenal Masses: Can Dual-Phase Enhancement Patterns Be Used to Differentiate Adenoma and Pheochromocytoma-

Northcutt BG et al.

AJR 2013; 201:834-839


Pheochromocytoma

~ 10% extra-adrenal

~ 10% bilateral

~ 10% malignant

~ 10% found in children

~ 10% familial

~ 10 % not associated with hypertension


Other retroperitoneal masses:

Figure 1 Drawing of the anatomy of the retroperitoneal spaces at the level of the kidneys. The anterior pararenal space (APRS) is located between the

parietal peritoneum (PP) and the anterior renal fascia (ARF) and contains the pancreas (Pan), the ascending colon (AC), and the descending colon

(DC). The posterior pararenal space (PPRS) is located between the posterior renal fascia (PRF) and the transversalis fascia (TF). The perirenal space

(PRS) is located between the anterior renal fascia and the posterior renal fascia. Ao = aorta, IVC = inferior vena cava, LCF = lateroconal fascia.

RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.314095132

Published in: Prabhakar Rajiah; Rakesh Sinha; Carlos Cuevas; Theodore J. Dubinsky; William H. Bush Jr; Orpheus Kolokythas; RadioGraphics 2011,

31, 949-976. DOI: 10.1148/rg.314095132 © RSNA, 2011

Imagesee below

RadioGraphics,

http://pubs.rsna.org/doi/abs/10.1148/

rg.314095132

Published in: Prabhakar Rajiah;

Rakesh Sinha; Carlos Cuevas;

Theodore J. Dubinsky; William H.

Bush Jr; Orpheus Kolokythas;

RadioGraphics 2011, 31, 949-976.

DOI: 10.1148/rg.314095132 ©

RSNA, 2011

Imagesee below


Other retroperitoneal masses:

• MR vs. CT?

• Complications: Infiltration / Mass effect on adjacent organs

• Orphan disease! Evidence?

• Core needle biopsy

• Referral to a more specialised centre


Take home message

• Adenoma and metastasis are common

know how to differentiate them

• Other adrenal lesion are rare

use the right imaging technique

• Other retroperitoneal masses

biopsy

Adrenal and other retroperitoneal masses

Health & Medicine

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