adrenal and other retroperitoneal masses

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Modified lecture presented at ESUR fall meeting 2014 in Lisbon

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  • 1. ADRENAL AND OTHERRETROPERITONEAL MASSESModified lecture presented at ESUR fall meeting 2014 in LisbonPhilipp Steiger, Dr. med.OberarztUniversittsinstitut fr Diagnostische, Interventionelle und Pdiatrische RadiologieInselspital Bern, SchweizThis work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

2. Adrenal MassNormal adrenal Adrenal mass1 2Adrenals play a roll in imaging in 2 situationsa) adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound)a) known biochemical abnormality1. http://radiopaedia.org/articles/adrenal-gland2. http://radiopaedia.org/cases/adrenal-massADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 2 3. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound)known neoplasm no known neoplasmADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 3 4. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound)known neoplasm no known neoplasmADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 4 5. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 5 6. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedProblem: metastasis and adenomas are common Metastasis yes or no? or something different?ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 6 7. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedProblem: metastasis and adenomas are common Metastasis yes or no? or something different?Most common adrenal metastasis:Lung, breast, stomach, kidney cancer, melanoma, lymphomaMetastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Lam KY et al. Clin Endocrinol (Oxf). 2002 Jan;56(1):95-101ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 7 8. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmed Metastasis yes or no? or something different?Look carefully: Rule in: Other metastasis? Older images? De novo? PET? Rule out: Benign imaging characteristics (washout,chemical shift)?ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 8 9. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmed Metastasis yes or no? or something different?Look carefully: Rule in: Other metastasis? Older images? De novo? PET? Rule out: Benign imaging characteristics (washout,chemical shift)? BiopsyADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 9 10. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmed Metastasis yes or no? or something different? BiopsyADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 10 11. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmed Metastasis yes or no? or something different? BiopsyDoes it alter treatment? Rule out pheochromocytoma!ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 11 12. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmed Metastasis yes or no? or something different? BiopsyDoes it alter treatment? Rule out pheochromocytoma!FNA? Core needle biopsy? CT vs. US vs. MR guidedADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 12 13. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound)Complications of biopsies: adrenal hematoma abdominal pain hematuria pancreatitis pneumothorax formation of an adrenal abscess tumor recurrence along the needle trackClinical practice. The incidentally discovered adrenal mass. Young WF Jr. N Engl J Med. 2007 Feb 8;356(6):601-10.ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 13 14. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedBenign imaging characteristics:ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 14123 15. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedBenign imaging characteristics:1 CystADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 15121. Image due to legal reasons not shown3 16. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedBenign imaging characteristics:1 Cyst2 MyelolipomaADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 16121. 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 33 17. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedBenign imaging characteristics:1 Cyst2 Myelolipoma3 Lipid rich adenoma (10 HU)???ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 18 19. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound) Neoplasm confirmedBenign imaging characteristics:1 Cyst2 Myelolipoma3 Lipid poor adenoma (>10 HU)???washoutADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 19 20. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenoma (CT washout)Absolute Percentage Washout (APW)100 x venous HU delayed HUvenous HU precontrast HURelative Percentage Washout (RPW)100 x venous HU delayed HUvenous HUAdrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 20 21. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenoma (CT washout)Absolute Percentage Washout (APW)100 x venous HU delayed HUvenous HU precontrast HU > 60% adenomaRelative Percentage Washout (RPW)100 x venous HU delayed HUvenous HU > 40% adenomaAdrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 21 22. Imagesee belowDrawing shows the enhancement pattern of a lipid-poor adenoma.RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.295095027Published in: Pamela T. Johnson; Karen M. Horton; Elliot K. Fishman; RadioGraphics 2009, 29, 1333-1351.DOI: 10.1148/rg.295095027 RSNA, 2009APW: 100%(> 60% adenoma )RPW: 52%(> 40% adenoma )ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 22 23. Google search for Adrenal wash outhttp://www.radiologytutor.com/index.php/cases/endocrine/107-adrenalcalchttp://www-hsc.usc.edu/~phillimc/calc/adrenal_ct.htmlhttp://www.chestx-ray.com/index.php/calculators/adrenal-characterizationhttp://www.radreport.org/template/0000281http://www.braegelmann.com/bernd/scripts/adrenalgland.html 24. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenoma with MRADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 24 25. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenoma with MRin/out-of-phaseADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 25 26. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenoma (MR signal in/opp)Adrenal-to-spleen CSI ratiolesion SIOP / spleen SIOPlesion SIIP / spleen SIIPAdrenal signal intensity index100 x lesion SIIP / lesion SIOPlesion SIIP < 0.71 adenoma > 16.5% adenomaComparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. Israel GM et al. AJR 2004; 183:215-219Characterization of adrenal tumors by chemical shift fast low-angle shot MR imaging: comparison of four methods of quantitative evaluation. Fujiyoshi F. AJR 2002; 180ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 26 27. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenomaMR vs CTADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 27 28. 15-DECT: 478 adrenal masses in 453 patients CSMR: 235 adrenal masses in 217 patientsRPW calculated from 15-DECT showed the highest diagnosticperformance for characterising hyperattenuating adrenal massesregardless 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 incharacterising hyperattenuating adrenal masses regardless ofunderlying 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 28 29. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenomaWhat else is new?ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 29 30. Adrenal Massa) incidental adrenal mass is detected on cross-sectionalimaging (rarely on ultrasound); Neoplasm confirmedDiagnosis of an adenomaWhat else is new? Shorter protocols (10min vs. 15min) Histogram analysis Dixon sequences (quantification of absolute fatcontent)ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 30 31. 10min vs 15min323 adrenal lesions (213 left, 110 right)307 adenom