Endo Radiology

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ENDOCRINE IMAGING9/7/2014Endocrine Imaging119/7/2014ENDOCRINE IMAGINGIX PGES COURSECase No: 160 yrs old lady presented to us with:Gradually increasing 6x4 cm swelling involving left thyroid lobe x 1yrsNo compressive features, no recent change in voiceNo rapid increase in sizeNo h/o thyroid swelling in familyNo palpable Cervical lymphadenopathyNo RSE9/7/2014Endocrine Imaging2

InvestigationsHR-USG neck: 7X3 cm NODULE in Left lobe of thyroid extending to isthmus with heterogeneous calcification with mild to significant vascularity. No significant LAPFNAC Left lobe thyroid and Isthmus: c/w PTCIDL:Left VC in para-median position, Rt. VC compensatory movements

9/7/2014Endocrine Imaging3TT with CCLND + Left MRND(12th may 2009)Per-op Findings:Hard and calcified nodule of size 4x3 cm in Left thyroid lobe infiltrating overlying deep strap muscles and with tracheal invasion (Shin 1) over 2cm areaRt. Lobe unremarkableLarge (upto 2cm) cystic LNs in left Level 2,3,4, and 5 Multiple small sub-centimetric level 6 LNs

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Histopathology5x4x4 cm size single left lobe nodule: PTC with strap muscles infiltration5/10 Level 6 LNs: Metastatic PTC2/7 Left MRND LNs:Metastatic PTC9/7/2014Endocrine Imaging5FU: Scan negative with rising S.TgOn TSH suppressive LT4 therapy 20th March 2010:WBRAI Scan: negative, S.Tg-55.7 ng/mL23rd Oct.2010:WBRAI Scan: negative,S.Tg-181 ng/mLUSG Neck: Small LN(1cm) left lower deep cervical region

9/7/2014Endocrine Imaging6Radioiodine Remnant ablation(17th Aug 2009)WBRAI Scan with 5 mCi 131-I (3 months post-op): Increase tracer uptake in thyroid bedHigh dose 40 mCi 131-I: Remnant ablation9/7/2014Endocrine Imaging7


18-FDG PET/CT Whole Body Scan Hypermetabolic LNs noted:Left level 4 cervicalPretrachealRight Tracheobroncheal Left level 2 Axillary regions9/7/2014Endocrine Imaging9









IX PGES COURSE9/7/2014ENDOCRINE IMAGING179/7/2014Endocrine Imaging18









CECT Neck and Chest

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9/7/2014Endocrine Imaging32Surgical Details (25th jan. 2011)Selective LN excision form Right Tracheobroncheal and Rt. Pulmonary artery region (via open Anterolateral Thoracotomy), Left level 4 LNs in neck (via Lower lateral incision) and Left level 2 Axillary LN (via Axillary crease incision) Per-op findings: 3 black colored LNs each at right lower thymic horn, adjacent to pulmonary vein and along Rt. Pulmonary artery and Rt .main bronchus found (largest 2x1 cm)2 LNs in left level 4 region of 2 and 1cm sizeSingle 2 cm LN in left level 2 Axillary region9/7/2014Endocrine Imaging33



9/7/2014Endocrine Imaging36HistopathologyCervical LN: Metastatic PTCLeft Axillary LN: Free of tumorMediastinum LNs: Free of tumor with numerous charcoal laden foamy histiocytes

On TSH suppression and calcium/ vit.D replacement follow Tg normalised 9/7/2014Endocrine Imaging37Case 2Known HTN x 15 yrs on single drug antihypertensiveHuge Anterior neck swelling x 12 yrsProtrusion of both eye balls with redness and pain in eyes(right>left) x 11 yrsPalpitations, tremor x 5-6 yrsChange in voice and difficulty in swallowing food x 4-5 yrsDyspnea (NYHA class 3) x 1-1.5 yrsWatering from both eyes with photophobia x 0.5-1 yrOn NMZ 10 mg TDS 12 yrsFamily h/o:Younger brother-thyroid noduleDaughter-hypothyroidism Endocrine Imaging389/7/2014O/e:PR: 96/min irregularly irregularBP:170/100 mmHgExamination of neck:Diffuse asymmetrical (left>right) bosselated thyroid swelling (10x11 cm) with left lobe RSEB/L Carotids palpable and displaced laterallyNo cervical LNs palpableEye examination:B/L Proptosis (Rt-27 mm,Lt-26 mm), conjunctival congestion, eyelid edema + (CAS-6/7)-Active Graves ophthalmopathyGraves dermopathy and acroptchy presentSystemic examination:Proximal muscle weakness+Hyperdynamic precordium, apex beat in left 7th ICS in anterior axillary line

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Endocrine Imaging439/7/2014Investigations:fT4-11.1 pmol/L (10.3-25.7)T3-4.88 nmol/L (1.3-2.8)TSH-0.02 mIU/L (0.3-5)Thyroid scan:X-Ray neck:X-Ray chest PA view:CECT Neck and superior mediastinum:Endocrine Imaging449/7/2014



Surgery: Total thyroidectomyIncreased vascularity with surface bosselationNo gross adhesionsEndocrine Imaging489/7/2014

Endocrine Imaging49Gross: size-Left lobe-10x8x4 cmRight lobe-8x7x4 cmIsthmus-1x1x0.5 cmWeight-200 gms9/7/2014

Endocrine Imaging50Cut section: fleshy with pseudo-nodule formation9/7/2014Case 3Apparently normal till 15 years ago

Recurrent episodes of headache/drowsiness/dizziness, progressing to loss of consciousness

1998 - Pt. realized that his complaints were relieved by intake of sweetened beverages2008- Hospitalized and investigated at Kota , Delhi ; Blood Sugar -30mg% S. Insulin 57.21( 2.6-24.9) C. Peptide 7.94( 0.48-5.05 ng/ml)Diagnosed as case of Organic Hypoglycemia but lesion could not be localized

9/7/201451Endocrine ImagingThese episodes were increased by prolonged fasting/physical exertion

Gradual increase in weight 10-15 kgs over 12 years

No Diabetics in family

Hypertension was detected in 2008, on treatment

No symptoms suggestive of other components of MEN 1

No previous surgery/addictions / significant family history

9/7/201452Endocrine ImagingClinical ExaminationHt -175 cm , Wt -81 kg , BMI 26.45

BP 140/90 mm Hg

General Examination WNL

Systemic Examination WNL

Provisional Diagnosis Organic Hypoglycemia

9/7/201453Endocrine ImagingInvestigationsHemogram WNL

Clinical Chemistry WNL

Hypoglycemia on Supervised fasting at 10.5 hours

CECT Abdomen, ASVS, Intra operative USG for discussion9/7/201454Endocrine Imaging9/7/2014Endocrine Imaging55









Exploratory Laparotomy with IOUSG And proceed on 23-Jan-2011

2.1x1.4 cm vascular fleshy tumor over anterior surface of body of Pancreas Main Pancreatic duct atleast 4 mm away from ennucleated margin No multi focality detectedBlood sugar after enucleation 92mg%

9/7/201464Endocrine ImagingPost operative courseNo fluctuations in Blood sugars

Orally allowed on POD 3

Right ( Sub hepatic drain) was removed on POD 8

POD 12, Patient is being discharged with with no specific complaints or residual complications9/7/201465Endocrine ImagingCase No 49/7/2014Endocrine Imaging66

Pulse-90/minBP-140/100mmHg on medicationsL/E neck-no palpable nodule

InvestigationsHemogram 14.3 mg/dlS.Creat-1.1BUN-10PTH- 133.6 pg/ml (15-65)25 (OH)Vit D: 56.45 ng/ml (9-47)S. Inorganic Phosphorus-2.9S.Calcium- total 13,ionized 6.7mg/dl

9/7/2014Endocrine Imaging67USG neck(elsewhere)-normal studyUSG neck-heterogenous lesion post-inf aspect rt lobe thyroid-?parathyroid?LNMIBI(Kolkata)- rt inf parathyroid adenomaMRI/SPECT (Kolkata)- Rt submandibular gland enlargement and Rt inf parathyroid adenomaMIBI-SPECT-CT(SGPGI)-Lt inf parathyroid adenoma

9/7/2014Endocrine Imaging68BMD-L1 L4 -1.2,Z=-0.9Hip T=-1.4, Z= -1.0Forearm T= -4.5, Z= -4.2

9/7/2014Endocrine Imaging69IMAGING FOR DISCUSSION9/7/2014Endocrine Imaging70























SurgeryEquivocal imaging-B/L neck explorationLeft inf parathyroid enlarged,firm,maroonWt-600mg,1.7x0.7x0.4 cmIOPTH-curative fallPost-op Ca2+ -9.3(total) on POD1Post op course-smoothFollow up-doing well9/7/2014Endocrine Imaging94

KKV, 44/M, 2010131533Morbid obesity- 4 yearsSnoring and obstructive sleep apnea- 4 yearsHypertension- 3 yearsPoorly controlled on single drug No episodic hypertension, sweating, palpitationsP/R- 80/min, BP- 160/120 mm HgNo Cushingoid featuresUSG- Right adrenal massProvisional diagnosis- Pheo/ Cuhsings9/7/2014Endocrine Imaging95Work up24-hour Urinary fractionated metanephrines- Raised (224 & 70254 miug/24 hours)

Overnight dexamethasone suppression test- Normally suppressible (35.61 nmol/L)

Serum Potassium- Normal (4.3 mmol/L)9/7/2014Endocrine Imaging96CECT abdomenFor discussion9/7/2014Endocrine Imaging97DiagnosisRight adrenal pheochromocytoma9/7/2014Endocrine Imaging98Right open trans-peritoneal adrenalectomy08-Feb-2011After adequate -blockade and blood pressure control, patient was taken up for surgeryAbdominal viscera- NormalNo peritoneal deposits, free fluid, retroperitoneal lymphadenopathyNo gross adhesions, invasion to adjacent structuresBlood pressure fluctuations present-Max- 130/80 mm HgMin- 80/50 mm Hg (after ligation of adrenal vein)9/7/2014Endocrine Imaging99GrossWell defined highly vascular tumor8x7x3.5 cm, Weight 280 gmCut section- fleshy with areas of hemorrhagic necrosis9/7/2014Endocrine Imaging100

Postoperative courseUneventfulGradual oral feeds, toleratedDischarged on 9th post op day on Amlodipine (BP controlled on single drug)9/7/2014Endocrine Imaging101HistopathologyRight adrenal pheochromocytoma with capsular invasion and extension into periadrenal fatNo vascular invasionNo necrosis, increased mitotic activity9/7/2014Endocrine Imaging102Follow upMIBG scan advised as there was capsular and periadrenal fat invasion on Histopathology- for discussionUSG abdomen- Focal fat stranding seen in liverPost MIBG- CECT abdomenfor discussion24 hour urinary fractionated metanephrines- Normal9/7/2014Endocrine Imaging103

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9/7/2014118Endocrine ImagingUP, 38/M, 2004363622Right STN- 4 x 5 cm25-Aug 2004 (BHU)-Right hemithyroidectomy + berry picking of paratracheal and level VII LNHPE-MTC (4.5 cm)Lymphatic emboliCapsular invasion9/9 LN + for metastases22-Sep-2004 (BHU)-Completion thyroidectomy + right MRNDSternocleidomastoid muscle cut to get access to left lobeLeft lobe normalRight jugular chain multiple LNNo left jugular LNHPE-Resected thyroid normal7/7 LN + for metastasesStriated muscles show dense fibrosis9/7/2014Endocrine Imaging119









9/7/2014128Endocrine ImagingSerum Calcitonin

9/7/2014Endocrine Imaging129Clinical course10-Feb-2005 (BHU)-Small right posterior triangle cervical LN biopsy (1 cm)HPE- Reactive25-Jan-2006 (BHU)-Cervical LN biopsy (1.5 cm)HPE- ReactiveCervical LN with persistent hypercalcitoninemia, referred to SGPGI2007-FNAC right cervical LN- +ve for metastases (MTC)IDL- Right cord paralyzedBone scan- NormalCT neck + thorax-Bilateral enlarged multiple jugular LNEnlarged LN in posterior triangle, pretracheal, paratracheal, prevertebral and supraclavicular spaceThyroid not visualizedMediastinum and lungs normal9/7/2014Endocrine Imaging130Clinical course (SGPGI)30-Oct-2007 (SGPGI)-Diagnostic laparoscopy- No peritoneal or liver metastasesCCLND with B/L MRND with transcervical thymectomy (Multiple bilateral LN in level 3,4,5,6, Maximum- 1.5 x 1 cm)HPE-CCLND- 2/4 LN +Right MRND- 6/21 LN +Left MRND- 1/6 LN +Thymus- unremarkable18-Feb-2008-Bone scan- Increased tracer uptake in right supraclavicular joint (degenerative)21-Aug-2009-USG neck-7-10 mm LN in left jugular chain17 x 10 mm LN in substernal location24-Aug-2009-Guided FNA Substernal LN- +ve for metastases (MTC)For discussion-CECT neck68Ga-DOTANOC PET scan9/7/2014Endocrine Imaging131Surgery, 23-Aug-2011Excision of thyroid bed recurrence with paratracheal LN resection with right cervical thymectomy with intraoperative neuromonitoringSize of lesion- 2.5 x 1.5 cm9/7/2014Endocrine Imaging132

Post operative period- UneventfulDrain removed on day 5Discharged on day 6

Histopathology-3/4 LN +ve for metastatic MTC with lymphovascular emboli present9/7/2014Endocrine Imaging133Preop prepAdequately alpha blocked withPlenty of fluids & extra saltBP the day before Surgery 150/90 mm Hg supine140/80 mm Hg standingPR : 82 /mtWeight increased from 49 kg 51 Kg 9/7/2014Endocrine Imaging1349/7/2014Endocrine Imaging135

Rt paraganglioma situated between IVC & AortaWith PV antr to massDense vascular adhesions between mass and IVCPeriportal & precaval nodes disssected outLeft adrenal mass minimally adhered to kidney & surrounding structures, The renal vein was Strectched over the mass9/7/2014Endocrine Imaging136

Rt PGL : 5.5x6x3.5 cm mass, weight :62 gmsLeft Adrenal mass : 10x 7x 5.5 cm mass, weight: 185 gmsMax BP : 150/100 mm HG Min BP : 90/50 mm HGRight Adrenal was normal & left insituCut section


Rt PGL :fleshy with areas of calcificationLeft Adrenal mass : fleshy with yellow areas Post opStable: monitored for 1 day in ICUDrain removed on 6th PODBP : 140/ 90 mm HG with T. Amlodipine 10 mg 0 5 mgAlternate sutures removed on 8th POD and all sutures on 10th PODStable at the time of dischargePost op 24 hour Urinary metanephrinesMN : 380 miug/ 24 hrs ( 0 350 )NMN : 243 miug/ 24 hrs ( 0 600 )Post op follow up done on 25 th POD : wound healed well, BP normal with Amlodipine 10 5 mg

9/7/2014Endocrine Imaging138Case No 79/7/2014Endocrine Imaging139

BP-120/70 mmHg supine, 100/50 mmHg standing, PR-92/minPlaque over interscapular areaRt lobe thyroid-3x3cm nodule,Lt lobe 1x1 cm nodule upper poleNo Cushingoid features


T3-1.23nmol/L (1.3-2.8)T4-23.9 nmol/L (60-160)TSH- 1.35 mIU/L (0.3-5)S. Inorganic Phosphorus- 3.5 mg/dl (2.5-4.5)S. CalciumTotal 8.8 mg/dl (8.5-10.8)Ionised 4.4 mg/dl (4.6-5.3)

S. Calcitonin-1866 pg/mlUrine Metanephrine-5847 miug/24hrs (0-350)Urine Nor-metanephrine-3929 miug/24hrs (0-600)S. Cortisol- >1380 nmol/L (110-520)








USG abd-bilateral supra-renal massesUSG thyroid- multiple hypo-echoic nodulesCECT abd- bilateral adrenal solid cystic massesEcho-concentric LVH,Grade I diastolic dysfunction

9/7/2014149Endocrine ImagingFNAC-s/o medullary thyroid carcinoma9/7/2014150Endocrine Imaging9/7/2014Endocrine Imaging151







9/7/2014Endocrine Imaging158SPOTTERS9/7/2014159Endocrine Imaging

Case 1: A 42 YR. OLD FEMALE WITH COMPLAIN OF LETHARGY AND NECK SWELLING9/7/2014160Endocrine Imaging

Case 2: 9/7/2014161Endocrine ImagingUSG

Hypoechoic area Tiny punctate hyperechoic area representing microcalcificationDisorganised hypervascularity with tortous vessels and a-v shuntsInvasion to adjacent muscles on usgCervical LN are enlarged with punctate hyperechogenicity.


Case 3: 9/7/2014163Endocrine ImagingADENOMA5% -10% of nodular diseasesFemales > malesUsually encapsulated solitary nodule with adjacent compression of adjacent tissues.No thyroid dysfunction but may be hyperfunctioningDifficult to d/f from folicular caUSGSolid masses that may be hyperechoic,isoechoic or hypoechoicPeripheral thick and smooth hypoechoic halo is seenDOPPLERvessel are seen in the halospoke and wheel pattern appearance

9/7/2014164Endocrine ImagingROLE OF USG-

ESTABLISH THE PRECISE ANATOMIC LOCATION OF NODULEWITHIN THE GLAND OR OUTSIDE

DIFFERENTIATE B/W OTHER CERVICAL MASSESCYSTIC HYGROMATHYROGLOSSAL CYSTENLARGED LYMPH NODES

DETECT OCCULT THYROID NODULES CLINICAL SOLITARY NODULESH/O HEAD AND NECK IRRADIATIONH/O MEN TYPE II SYNDROME

9/7/2014165Endocrine ImagingBENIGN V/s MALIGNANT NODULENODULE INTERNAL CONSISTENCY ECHOGENICITY RELATIVE TO ADJACENT THYROID MARGIN CALCIFICATION PERIPHERAL SONOLUCENT HALODISTRIBUTION PATTERN OF BLOOD VESSELS



Case 4: 9/7/2014168Endocrine ImagingANAPLASTIC CARCINOMAElderly Age Group less than 2% of all casesWorst PrognosisPresents As Rapidly Enlarging Mass Infiltrating Adjacent StructureMean survival 6 months and 5 year survival rate 7%CT-Heterogenous Mass Invading The Vessels And Neck Muscles9/7/2014169Endocrine Imaging

Case 5: 9/7/2014170Endocrine ImagingMEDULLARY CARCINOMADerived from para follicular cells ,secrets hormone calcitoninRelated to men type 2 syndromeusually is multicenteric or bilateralmetastasis is to LN

CT-Heterogenously enhancing Mass posteriorly displacing The rt. CCA and IJV with minimal retrotracheal extension.9/7/2014171Endocrine Imaging

50 YR MALE WITH H/O THYROIDECTOMT, NOW COMPLAINS OF BACK PAINCase 6: 9/7/2014172Endocrine Imaging

Case 7: 9/7/2014173Endocrine Imaging

42 YE OLD FEMALE WITH CERVICAL PAIN AND NECK SWELLING; X-RAY C- SPINE9/7/2014174Endocrine Imaging



Cervico thoracic sign9/7/2014177Endocrine Imaging

Ant. Sup. Mediastinum

Thyroid / Parathyroid LesionTortuous innominate vesselsThymomaTeratodermoidTerrible lymphoma 9/7/2014178Endocrine Imaging

A 60 YR OLD FEMALE, RESIDENT OF BIHAR CAME WITH WEAKNESS; CECT NECK 9/7/2014179Endocrine Imaging


9/7/2014181Endocrine ImagingDEGENERATIVE APPEARANCE OF GOITROUS NODULES

PURE ANECHOIC AREA (SEROUS OR COLLOID FLUID)ECHOGENIC FLUID WITH F-F LEVEL (HAEMORRHAGE)BRIGHT ECHOGENIC FOCI WITH COMET TAIL ARTIFACTS (MICROCRYSTALS)INTRACYSTIC THIN SEPTATIONS PERIPHERAL EGG SHELL CALCIFICATION


Case 10:


9/7/2014184Endocrine ImagingGRAVES DISEASE diffuse abnormality of gland characterised by hyperfunctioninhomogenous echotexture d/t presence of large intraparenchymal vessels.Dopplerhypervascularity is seen-thyroid infernohigh peak systolic velocity exceeding 70cm/sec9/7/2014185Endocrine Imaging


X-RAY SKULLCase 12: 9/7/2014187Endocrine Imaging

48 YR OLD MALE PRESENTED WITH RENAL FAILURECase 13: 9/7/2014188Endocrine Imaging7

KNOWN C/O HUPERPARATHYROIDISM ON TREATMENT; X-RAY PELVIS SHOWS:Case 14: 9/7/2014189Endocrine ImagingBrown tumorsRadiologically appear as thin walled expansile lesions and are indistinguishable from bone malignancies and pagets diseaseCommonly seen in long bones but may be seen in unusual locations like mandible, maxilla, vertebrae, hard palate, iliac crest and ribs.9/7/2014190Endocrine Imaging

A 35 YR OLD MALE WITH COMPLAINS OF BONE PAIN, WEIGHT LOSS AND DISPEPSIACase 15: 9/7/2014191Endocrine Imaging

Case 16 9/7/2014192Endocrine Imaging

Case 17: 9/7/2014193Endocrine ImagingAetiologyPrimary( PTH, normal or Ca 2+ ) Adenoma 90%Hyperplasia10%Carcinoma < 0.1%

Secondary( PTH appropriate to low Ca 2+ ) Chronic Renal FailureVitamin D DeficiencyTertiaryContinued excess PTH secretion following prolonged secondary hyperparathyroidism.9/7/2014194Endocrine Imaging194

9/7/2014195Endocrine ImagingVascular arc- finding in parathyroid adenomaenvelops 90 to 270 degrees of massdiff from LN- central hilar flow pattern

9/7/2014196Endocrine ImagingSpectrum of adrenal and pancreatic lesions

Coronal reformatted image CT characteristic inverted Y, V, shapeCase 18: 9/7/2014197Endocrine ImagingAlthough no strict measurements have been standardized, any area thicker than 10 mm is abnormal.A useful rough estimate of normal size is that the thickness of the gland's limbs should not exceed the thickness of the ipsilateral diaphragmatic crus at the same level.9/7/2014198Endocrine Imaging

NORMAL9/7/2014199Endocrine ImagingCharacterization of an AdrenalMass: Is It Benign or Malignant?

Adrenal masses are common, estimated to occur in 9% of the population. However adrenal gland is also a common site of metastasis, particularly from lung carcinomaIn patients with no known primary cancer, an adrenal mass is almost always a benign adenoma.in a patient with a known neoplasm, particularly lung cancer, the finding of an adrenal mass is problematic.

9/7/2014200Endocrine ImagingCT in Differentiating Benignfrom Malignant Adrenal MassesLarger lesions have a greater likelihood of being malignant. (lesions greater than 4 cm)

Change in lesion size is a useful indicator of malignancy (adenomas are slow growing and tend not to change size).

Adenomas tend to have smooth margins and a homogeneous density, whereas metastases can be heterogeneous and have an irregular shape


The left adrenal adenoma (arrow) has smooth margins, is well defined, and has a attenuation of 5 HU, all findings characteristic of an adenoma.the right adrenal gland (arrow) is enlarged, has irregular contours, and has an attenuation of 36 HU, all findings characteristic of metastasis. 9/7/2014202Endocrine Imaging202Typical nonenhanced CT findings of an adrenal adenoma in a 64-year-old man with no known malignancy. The left adrenal adenoma (arrow) has smooth margins, is well defined, and has a attenuation of 5 HU, all findings characteristic of an adenoma. (12) Typical nonenhanced helical CT findings of metastasis in a 76-year-old man with lung carcinoma. On the CT scan, the right adrenal gland (arrow) is enlarged, has irregular contours, and has an attenuation of 36 HU, all findings characteristic of metastasis. Adrenal masses with attenuation values over 10 HU at nonenhanced CT require further evaluation with either CT contrast material washout, chemical shift MR imaging, or adrenal biopsy.

Histologically adenomas have abundant intracytoplasmic fat in the adrenal cortex and thus have low attenuation at CT metastases have little intracytoplasmic fat and thus do not have low attenuation at nonenhanced CT.9/7/2014203Endocrine ImagingCushing adenomassolitary well defined, homogenous , 2-3cm.Aldosteronism (conns syndrome) adenomassmall mean size 1.6-1.8cm and may have central low attenuation due to high lipid content.9/7/2014204Endocrine Imaging

Aldosteronoma. Computed tomography image shows a 1-cm mass in the medial limb of the left adrenal (arrow). The mass has an attenuation value slightly lower than that of adjacent normal adrenal tissue.Case 19: 9/7/2014205Endocrine ImagingWell defined hypo-attenuated lesion (-16.7 HU)Shows homogenous enhancement of contrast (+51 HU)Size 2.2 x 2.1 x 1.8 cm

9/7/2014206Endocrine ImagingNonenhanced CT

Mean attenuation of adenomas was 2.2 HU and metastasis was 29 HU. Thresholds to differentiate benign from malignant lesions have ranged from 0 to 18 HU Lee et al. Radiology 1991; 179:415418.

Threshold of 10 HU had a 71% sensitivity and 98% specificity for characterizing adrenal masses. This specificity approached 100% when other features such as adrenal size, shape, and change in lesion size were considered Boland et al AJR Am J Roentgenol1998; 171:201204

9/7/2014207Endocrine ImagingNeed of Contrast-enhanced CT

30% of adenomas do not contain sufficient lipid to have low attenuation at CTAlthough nonenhanced CT can be used to identify 70% of adenomas, it does not allow the 30% that do not contain lipid to be reliably differentiated from metastases

9/7/2014208Endocrine ImagingPhysiologicDifferences in perfusion.Adenomas enhance rapidly with intravenous contrast media and wash out the agent rapidlyMetastases also enhance vigorously with contrast material, but the washout of the agent is more prolonged than with adenomas

9/7/2014209Endocrine Imaging209The second imaging parameter to differentiate adenomas from metastases relies on(either iodinated agents used at CT or gadolinium chelates used at MR imaging)A Hounsfield unit of less than approximately 30 at 10 minutes after injection has been shown to be diagnostic of a lipid-rich adenoma

percentage of washout of contrast material in which the attenuation of the adrenal gland at delayed CT is compared with its attenuation at dynamic CT. Loss of 50% of the attenuation value of the adrenal mass at delayed CT is specific for an adenoma; less than 50% washout is indicative of either a metastasis or an atypical adenoma

9/7/2014210Endocrine Imaging210more useful parameter is the percentage of washout of contrast material in which the attenuation of the adrenal gland at delayed CT is compared with its attenuation at dynamic CT. Loss of 50% of the attenuation value of the adrenal mass at delayed CT is specific for an adenoma; less than 50% washout is indicative of either a metastasis or an atypical adenoma

(a) NCCT demonstrates enlarged left adrenal gland with irregular margins and attenuation of 40 HU. (b) Dynamic enhanced CT scan of the adrenal gland obtained 60 seconds after intravenous administration of contrast material demonstrates an increase in attenuation to 53 HU. (c) Ten-minute delayed image of the left adrenal gland demonstrates persistent enhancement of the adrenal gland (56 HU). There is no significant washout of contrast media at 10 minutes, a finding consistent with an adrenal metastasis.

acb9/7/2014211Endocrine Imaging211Typical attenuation and washoutcharacteristics of a left adrenal metastasis in a 65-year-old man with lung carcinoma. (a) NonenhancedCT scan demonstrates an enlarged leftadrenal gland (arrow) with irregular margins andattenuation of 40 HU. (b) Dynamic enhancedCT scan of the adrenal gland (arrow) obtained 60seconds after intravenous administration of contrastmaterial demonstrates an increase in attenuationto 53 HU. (c) Ten-minute delayed image ofthe left adrenal gland (arrow) demonstrates persistentenhancement of the adrenal gland (56HU). There is no significant washout of contrastmedia at 10 minutes, a finding consistent with anadrenal metastasis.

if a lesion in an oncology patient cannot be definitively called an adenoma after CT examination, the patient should undergo further evaluation with MR imaging or an adrenal biopsy to confirm a benign or malignant adrenal lesionChemical shift imaging is an MR imaging technique used to detect lipid within an organ and is the most sensitive method for differentiating adenomas from metastases


74-year-old man with lung cancer(a) T1-weighted in-phase MR image demonstrates a left adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows no significant signal loss in the adrenal gland compared with that of the spleen. The mass is either a metastasis or atypical adenoma, and biopsy was recommended.Case 20: 9/7/2014213Endocrine Imaging213Figure 16. Left adrenal metastases in a 74-year-old man with lung cancer. (a) T1-weighted in-phase MR imagedemonstrates a left adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows no significant signal loss inthe adrenal gland compared with that of the spleen. The mass is either a metastasis or atypical adenoma, and biopsywas recommended.

45-year-old woman with breast cancera) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow). (b) T1-weighted out-of-phase MR imageshows signal drop-off in the adrenal gland (arrow), which is diagnostic of an adenoma.

Case 21: 9/7/2014214Endocrine Imaging214Figure 15. Indeterminate right adrenal mass found at CT in a 45-year-old woman with breast cancer. (a) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow). (b) T1-weighted out-of-phase MR imageshows signal drop-off in the adrenal gland (arrow), which is diagnostic of an adenoma.


.Addison disease CECT shows both adrenal glands, which appear small and with dense calcification.The cause of the calcification was not known butmay have been due to remote hemorrhage or tuberculosis. Adrenal carcinoma .CECT demonstrates an 11-cm necrotic mass in the left adrenal gland, which causes inferior displacement of the leftkidney. Case 22: Case 23: 9/7/2014216Endocrine Imaging216Figure 24. Addison disease in a 51-year-old man.Contrast-enhanced CT scan shows both adrenalglands, which appear small and with dense calcification.The cause of the calcification was not known butmay have been due to remote hemorrhage or tuberculosis.Figure 25. Adrenal carcinoma in a patient who presentedwith left flank pain. Contrast-enhanced CT scandemonstrates an 11-cm necrotic mass in the left adrenalgland, which causes inferior displacement of the leftkidney. There is stranding of the adjacent retroperitonealfat

-54HUBilateral myelolipomas Case 24: 9/7/2014217Endocrine Imaging

Myelolipoma

Case 25: USG CT T1W MRI9/7/2014218Endocrine Imaging

9/7/2014219Endocrine ImagingCentral necrosis may be so extensive as to simulate a cyst . Calcification is uncommon; when present, it may have an eggshell pattern

Pheochromocytoma.NCCTCECTCase 26: 9/7/2014220Endocrine ImagingA pheochromocytoma is a neoplasm of the adrenal medulla.When such a tumor arises outside the adrenal, it is properly labeled a paragangliomaMost are benign, although about 10% are malignant

Sporadic cases are usually unilateral, affecting the right adrenal slightly more frequently; about 5% are bilateral.There is an increased likelihood of pheochromocytoma in patients with neurofibromatosis, von Hippel-Lindau disease, and multiple endocrine neoplasia (MEN) syndromes (50% in MEN 2 and 90% in MEN 2b). In such syndromes, and in children, multiple or bilateral cases are more likely.9/7/2014221Endocrine Imaging221


Spontaneous adrenal hemorrhage. Bilateral heterogeneous adrenal masses with some high-attenuation areas in this patient with severe heart disease who was recently anticoagulatedCase 27: 9/7/2014223Endocrine ImagingBecause of their rich vascular supply, islet cell tumors classically are hyperattenuating compared with the surrounding pancreatic parenchyma on contrast-enhanced CT. Capturing the vascular blush is essential for the diagnosis of small tumors, which often do not distort the contour of the pancreas. Typically, but not always, intense arterial phase enhancement is observed.This is particularly true in the investigation of functioning insulinomas because these are often small, with 50% measuring less than 1.3 cm Nonfunctioning islet cell tumors are more easily detected by the mass effect they producePANCREAS ISLET CELL TUMOR9/7/2014224Endocrine Imaging

ARTERIALVENOUSCase 28: 9/7/2014225Endocrine Imaging

9/7/2014226Endocrine ImagingSpiral CT performs poorly in comparison to EUS.CT can depict metastases as small as 5 mm in diameter and demonstrate vascular invasionMRI has demonstrated a higher sensitivity than CT, offering additional information that may help characterize islet cell tumors. Tumors are hypointense on T1-weighted images and hyperintense on T2-weighted images. Intense enhancement is seen on administration of IV gadolinium.

9/7/2014227Endocrine ImagingTumors less than 2 cm in diameter are not easily identified by transabdominal ultrasound (TUS). TUS detection sensitivity is 20-75% for insulinomas and 20-30% for gastrinomasA recent study has concluded that EUS is the most accurate preoperative method of localizing and detecting insulinomasHighest sensitivity and specificity is of intraoperative USG + bidigital examination.9/7/2014228Endocrine ImagingBENIGN VS MALIGNANTSMALL (

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