Diagnostic Imaging of Adrenal Glands

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  • Genito-Urinary System

    Adrenal Glands

  • Mohamed ZaitounAssistant Lecturer-Diagnostic Radiology Department , Zagazig University HospitalsEgyptFINR (Fellowship of Interventional Neuroradiology)-Switzerlandzaitoun82@gmail.com

  • Knowing as much as possible about your enemy precedes successful battle and learning about the disease process precedes successful management

  • Adrenal Glandsa) Incidental Adrenal Massb) Bilateral Adrenal Massesc) Adrenal Calcification

  • Anatomy of the Adrenal Glanda) Arterial Supply :-Superior adrenal artery: branch of inferior phrenic artery-Middle adrenal artery: branch of the aorta-Inferior adrenal artery: branch of the renal artery

  • b) Venous Drainage :-Each gland is drained by a single vein that enters into the :Inferior vena cava on the rightRenal vein on the left

  • c) Physiology :-Cortex divided into 3 zones :Zona glomerulosa (aldosterone)Zona fasciculata (ACTH dependent)Zona reticularis (cortisol)-Medulla (epinephrine, norepinephrine)

  • d) Imaging Appearance :-Y configuration : each adrenal gland consists of an anteromedial ridge (body) and two posterior limbs best seen by CT/MR-Posterior limbs are close together superiorly but spread out inferiorly-Right adrenal lies adjacent to IVC throughout its extent-Left adrenal lies adjacent to splenic vessels at its cephalad margin-Size :Limbs: 3 to 6 mm thickLength of entire adrenal: 4 to 6 cmWidth of entire adrenal:

  • Coronal T1-weighted, three-dimensional, GRE MR image obtained with VIBE shows the normal inverted Y shape of the right adrenal gland (arrow)

  • a) Incidental Adrenal Mass :1-Functioning Tumors2-Malignant Tumors3-Benign

  • 1-Functioning Tumors :a) Pheochromocytomab) Conns Adenomac) Cushings Adenomad) Adrenal Carcinoma

  • a) Pheochromocytoma :1-Incidence2-Associations3-Radiographic Features

  • 1-Incidence :-Is an uncommontumor of the adrenal gland-The tumors are said to follow a10%rule :10% are extra-adrenal 10% are bilateral10% are malignant10% are found in children10% are familial10 % arenotassociated with hypertension

  • 2-Associations :-The majority of cases are sporadic-In 5-10% of cases , a pheochromocytoma is a manifestation of an underlying condition including :a) MEN II (bothMEN IIaandMEN IIb) :-MEN IIa : medullary thyroid carcinoma , pheochromocytoma & parathyroid adenoma-MEN IIb : medullary thyroid carcinoma , pheochromocytoma , oral ganglioneuromas & other soft tissue tumors b) VHLc) Sturge-Weber Syndromed) TS

  • 3-Radiographic Features :-Usually large > 5 cm with marked contrast enhancement-It should be noted that in patients with suspected pheochromocytoma contrast may be contraindicated as it could precipitate a hypertensive crisisa) CT :-On CT pheochromocytomas are large usually heterogeneous masses with areas of necrosis and cystic change with marked contrast enhancement

  • Pheochromocytomas in a 35-year-old woman with hypokalemia, a family history of pheochromocytoma, and a new diagnosis of von HippelLindau syndrome, axial arterial phase(a) and coronal arterial phase volume-rendered(b)CT images, obtained for evaluation of right upper quadrant pain, show small incidental bilateral adrenal masses (arrow), the degree of vascularity resulted in a differential diagnosis of metastatic hypervascular tumor or pheochromocytoma, pathologic analysis revealed bilateral pheochromocytomas; the lesion on the right measured 2 cm, and the two masses in the left adrenal gland measured 0.4 cm and 0.6 cm

  • Pheochromocytoma with pathologically proved hemorrhage and necrosis in a 39-year-old woman, coronal precontrast volume-rendered(a)and axial postcontrast(b)CT images show a large, well-defined mass with higher attenuation inferiorly that compresses the liver and right kidney, on the contrast-enhanced image, enhancing septa and multiple cystic areas are seen. Classically a vascular mass, pheochromocytoma can also be cystic, particularly when the tumor is large, as in this case

  • Pheochromocytomas in a 47-year-old woman with a history of neurofibromas resected from both wrists who presented with abdominal pain, axial(a)and coronal multiplanar reformation (b)images from contrast-enhanced CT show bilateral adrenal masses (arrows), which are predominantly cystic on the left (white arrowheads) and solid with cystic components (black arrowheads) on the right, fine-needle aspiration performed in one mass demonstrated a pheochromocytoma

  • Pheochromocytoma with rapid washout, axial portal venous phase(a)and delayed phase(b)CT images show a small solid mass in the right adrenal gland, the RPW of the adrenal nodule is 52%, a value that can be seen with adenoma; however, the portal venous phase attenuation of 164 HU suggests a pheochromocytoma, such high enhancement levels are not characteristic of adenoma but are seen with some pheochromocytomas

  • Necrotic pheochromocytoma in a 42-year-old man, coronal arterial phase(a)and venous phase(b)volume-rendered images from contrast-enhanced CT show a large (>20 cm) hypervascular right suprarenal mass, the mass has central necrosis and compresses the right kidney inferiorly

  • b) MRI :*T1 :-Slightly hypointense to the remainder of the adrenal*T2 :-Markedly hyperintense (lightbulb sign) , this is a helpful feature*T1+C :-Heterogenous enhancementc) Nuclear Medicine : MIBG-Abnormal uptake

  • Axial T1-weighted in-phase MR image(a), out-of-phase MR image(b), and three-dimensional GRE contrast-enhanced MR image with VIBE(c)show a pheochromocytoma (arrow), the pheochromocytoma shows the typical features of no loss of signal intensity on the out-of-phase image and intense enhancement on the contrast-enhanced image

  • b) Conns Adenoma :1-Incidence2-Radiographic Features

  • 1-Incidence :-Accounts for 70 % of Conns syndrome-30 % of Conns syndrome due to hyperplasia which can be occasionally nodular and mimic an adenoma2-Radiographic Features :-Usually small < 2 cm-Relatively low dense

  • c) Cushings Adenoma :1-Incidence2-Radiographic Features

  • 1-Incidence :-Accounts for 20 % of Cushing syndrome-80 % of Cushing syndrome is due to excess ACTH from pituitary tumor or ectopic source (small cell carcinoma , pancreatic islet cell , carcinoid medullary carcinoma of the thyroid & thymoma) 2-Radiographic Features :-Usually > 2 cm in diameter

  • d) Adrenal Carcinoma :-50 % are present as functioning tumor-Cushing's syndrome most common clinical manifestation

  • 2-Malignant Tumors :a) Metastasesb) Carcinomac) Lymphomad) Neuroblastoma

  • a) Metastases :1-Primary sites2-Radiographic Features

  • 1-Primary sites :-Lung :Small cell carcinoma : 90% of adrenal masses detected by CT screening represent metastasesNonsmall cell carcinoma : 60% of adrenal masses-Breast-Kidney-Bowel-Ovary-Melanoma

  • 2-Radiographic Features :-Adrenal mass usually > 2-3 cm with irregular margins-Bilateral adrenal masses-Heterogeneous enhancement-In the presence of a known primary malignant tumor many adrenal masses are benign (40 % are metastases)

  • Adrenal metastases in a 61-year-old man with hepatocellular carcinoma, axial(a)and coronal volume-rendered(b)images from contrast-enhanced CT show primary hepatic carcinoma in the right lobe, along with large bilateral adrenal masses, the high-attenuation components of the adrenal lesions probably represent contrast material from prior chemoembolization or calcifications

  • Metastatic renal cell carcinoma in a 67-year-old woman, coronal arterial phase(a)and venous phase(b)volume-rendered CT images show widespread metastatic disease involving the liver, lung, adrenal gland, and bones, the liver metastases are hyperattenuating and are well seen on the arterial phase image but become less conspicuous on the venous phase image

  • Adrenal metastasis in a 61-year-old man with a history of left nephrectomy for renal cell carcinoma, coronal arterial phase(a)and delayed phase(b)volume-rendered images from contrast-enhanced CT show a hypervascular right adrenal mass with central necrosis, a finding consistent with pheochromocytoma or a metastasis from renal cell carcinoma, the latter diagnosis was proved at pathologic analysis after resection; however, the enhancement pattern is similar to that of necrotic pheochromoctyoma

  • b) Carcinoma :1-Incidence2-Radiographic Features

  • 1-Incidence :-50 % are present as functioning tumor-Cushing's syndrome most common clinical manifestation

  • 2-Radiographic Features :-Mass usually >5 cm at time of diagnosis-Central area of low attenuation due to tumor necrosis-Heterogeneous enhancement because of areas of necrosis , hemorrhage-50% have calcifications-Hepatic , nodal or venous spread

  • Adrenocortical carcinoma in a 62-year-old woman with hypertension, virilization, and an enlarging abdominal mass, coronal arterial phase(a)and venous phase(b)volume-rendered CT images show a large left suprarenal mass with hypervascularity and necrosis on the arterial phase image and some areas of mild enhancement on the venous phase image, the mass abuts the left hemidiaphragm, with left pleural effusion and left lung atelectasis, and is inseparable from the left kidney, at surgery, which included left nephrectomy, a portion of the left hemidiaphragm was resected and the left lower lobe was partially decorticated, pathologic analysis revealed a malignant adrenocortical neoplasm

  • Primary adrenocortical carcinoma in a 55-year-old woman, coronal volume-rendered images from contrast-enhanced CT show a nearly 15-cm right adrenal mass that displaces the right kidney i