adrenal masses: benign or malignant?

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  • 1

    Erica McAuliffeGillian Lieberman, MD

    Adrenal Masses: Benign or Malignant?

    Erica McAuliffe, Harvard Medical School Year IIIGillian Lieberman, MD

    March 2002

  • 2

    Erica McAuliffeGillian Lieberman, MD

    RightAdrenal

    LeftAdrenal

    Normal Adrenal Anatomy

    Netter, Frank. Atlas of Human Anatomy. 2nd edition. Novartis: 1997.

  • 3

    Erica McAuliffeGillian Lieberman, MD

    http://www.vh.org/Providers/Textbooks/LungTumors/CaseStudies/Patient004/Text/CTCompAdrenalMets.html

    Normal Adrenal CT

  • 4

    Erica McAuliffeGillian Lieberman, MD

    Glucocorticoids

    Sex Steroids

    Mineralocorticoids

    Normal Adrenal Histology

    From http://www.vh.org/Providers/Textbooks/MicroscopicAnatomy/Section15/Plate15293.html

    Catecholamines

  • 5

    Erica McAuliffeGillian Lieberman, MD

    Why Look at Adrenals? Endocrine workup in a patient with suspicious

    symptoms or laboratory values ie, hypertension, Cushingoid symptoms, virilism,

    adrenal insufficiency

    Looking for metastases in a patient with known extra-adrenal malignancy

    Post-trauma abdominal survey

    ANY reason for obtaining a scan of the abdomen Incidental adrenal masses are detected in 0.35-4.4%

    of CT scans done for other reasons.

  • 6

    Erica McAuliffeGillian Lieberman, MD

    Menu of Tests for Evaluating Adrenals

    1. Plain Films- Limited role; useful for calcifications

    2. Ultrasound- Cyst vs. solid- Intra-operative use in laparoscopic adrenalectomies

    3. CT- Procedure of choice for patients with known or

    suspected adrenal lesions- Attenuation values useful in differentiating pathology

  • 7

    Erica McAuliffeGillian Lieberman, MD

    Menu of Tests, cont.

    4. MRI- Best test for suspected pheochromocytoma- Chemical shift imaging to determine fat content

    5. Radioisotope Scanning = Functional imaging- 131I labeled cholesterol analog can detect functional adrenocortical tumors- Labeled guanethidine analog (MIBG) can detect functional adrenomedullary tumors

  • 8

    Erica McAuliffeGillian Lieberman, MD

    Differential Diagnosis of Adrenal Enlargement

    BENIGN Adenoma - functional Adenoma - nonfunctional Adrenal hyperplasia Pheochromocytoma (90%) Myelolipoma

    MALIGNANT 1 adrenal carcinoma Metastasis Ganglioneuroma Neuroblastoma

    OTHER Cyst Hematoma/Hemorrhage Infection

  • 9

    Erica McAuliffeGillian Lieberman, MD

    Our Patient W.W. Healthy 61 year old man.

    PMH: gout, appendectomy.

    60 pack-year smoker, quit 13 years ago.

    CXR at outside hospital revealed LUL nodule.

    Referred to BIDMC for further evaluation.

    A chest CT was ordered.

  • 10

    Erica McAuliffeGillian Lieberman, MD

    Our Patient W.W. Chest CT

    Lung Nodule

  • 11

    Erica McAuliffeGillian Lieberman, MD

    Patient W.W. Chest CT Findings

    1.6 x 1.7 cm spiculated nodule in peripheral aspect of LUL.

    Routine chest CT images include the upper abdomen and both adrenal glands.

  • 12

    Erica McAuliffeGillian Lieberman, MD

    Our Patient W.W.: CT Findings

    Renal Mass

  • 13

    Erica McAuliffeGillian Lieberman, MD

    Patient W.W. - CT Findings

    Lung nodule: 1.6 x 1.7 cm spiculated nodule in peripheral aspect of LUL.

    Renal mass: Cystic and solid lesion off upper pole of R kidney, 6.1 x 4.5 cm, consistent with 1 RCC.

  • 14

    Erica McAuliffeGillian Lieberman, MD

    Hemangioma

    L adrenal mass:Focal area of higher intensity

    Our Patient W.W.: CT with contrast

  • 15

    Erica McAuliffeGillian Lieberman, MD

    Patient W.W. - CT Findings Lung nodule: 1.6 x 1.7 cm spiculated

    nodule in peripheral aspect of LUL. Renal mass: Cystic and solid lesion off

    upper pole of R kidney, 6.1 x 4.5 cm, consistent with 1 RCC.

    Liver lesion: 3.2 cm lesion in caudate lobe, consistent with hemangioma.

    L adrenal mass: Well-circumscribed, fat- containing 1.9 x 1.5 cm mass.

  • 16

    Erica McAuliffeGillian Lieberman, MD Our Patient W.W.: CT with contrast - R adrenal gland

    Lobular areas ofdecreased attenuation

  • 17

    Erica McAuliffeGillian Lieberman, MD

    Patient W.W. - CT Findings Lung nodule: 1.6 x 1.7 cm spiculated nodule in

    peripheral aspect of LUL. Renal mass: Cystic and solid lesion off upper

    pole of R kidney, 6.1 x 4.5 cm, consistent with 1 RCC.

    Liver lesion: 3.2 cm lesion in caudate lobe, consistent with hemangioma.

    L adrenal mass: Well-circumscribed, fat- containing 1.9 x 1.5 cm mass.

    R adrenal mass: Lobular areas of decreased attenuation

  • 18

    Erica McAuliffeGillian Lieberman, MD

    Adrenal Metastases

    Common; can alter treatment options. Most common primary sites:

    Lung Breast Kidney Bowel Ovary Melanoma

    90% of adrenal masses found in SC lung cancer patients are mets.

    60% of adrenal masses found in NSC lung cancer patients are mets.

  • 19

    Erica McAuliffeGillian Lieberman, MD

    Benign vs. Malignant?

    Benign Adenoma

    Metastasis 1 Adrenal Carcinoma

    Size Small (< 5cm) Variable, can be bilateral Often >5cm when detected

    CT -Well-defined, -no calcifications, -no hemorrhages < 10 HU

    -Heterogenous, -Indistinct margins

    -Heterogenous, -Necrosis and hemorrage common

    MRI -Low SI -In-phase/out-of-phase shows drop in SI

    -Higher SI than adenoma -No SI drop out on chemical shift MRI

    -Hyperintense

  • 20

    Erica McAuliffeGillian Lieberman, MD

    Cotran: Robbins Pathologic Basis of Disease, 6th ed., Copyright 1999 W. B. Saunders Company

    Adrenal Carcinoma Normal Cortical Tissue

    Intracellular Lipid Content

  • 21

    Erica McAuliffeGillian Lieberman, MD

    Benign vs. Malignant?

    Benign Adenoma

    Metastasis 1 Adrenal Carcinoma

    Size Small (< 5cm) Variable, can be bilateral Often >5cm when detected

    CT -Well-defined, -no calcifications, -no hemorrhages < 10 HU

    -Heterogenous, -Indistinct margins

    -Heterogenous, -Necrosis and hemorrage common

    MRI -Low SI -In-phase/out-of-phase shows drop in SI

    -Higher SI than adenoma -No SI drop out on chemical shift MRI

    -Hyperintense

  • 22

    Erica McAuliffeGillian Lieberman, MD

    MRI Signal Intensity

    Weissleder. Primer of Diagnostic Imaging. Mosby, Inc., 1996.

  • 23

    Erica McAuliffeGillian Lieberman, MD

    Primary Adrenal Carcinoma:Patient #2

    CT Features:- Large size- Calcification- Extension into liver

    - Heterogenous,cystic and solid

    From Kaplan, N. The adrenal incidentaloma. Up to Date 10.1., 2002.

  • 24

    Erica McAuliffeGillian Lieberman, MD

    L ADRENAL MASSHU = -5 to +4

    Patient W.W. CT scan without contrast

  • 25

    Erica McAuliffeGillian Lieberman, MD

    Patient W.W.: CT with contrast

  • 26

    Erica McAuliffeGillian Lieberman, MD

    Chemical Shift MRI

    Fat protons and water protons have different resonance frequencies.

    At a known time interval, the protons are out-of- phase, and their signals cancel out.

    By timing images based upon this interval, we can determine the fat content of a certain tissue.

  • 27

    Erica McAuliffeGillian Lieberman, MD

    P. D. Peppercorn, A. B. Grossman & R. H. Reznek (1998). Clinical Endocrinology 48 (4), 379-388.

    No loss of signal intensity indicates no intracellularfat.

    IN-PHASE

    OUT-OF-PHASE

    Chemical Shift MRI Example of Mets

  • 28

    Erica McAuliffeGillian Lieberman, MD

    IN-PHASE OUT-OF-PHASE

    Loss of signal intensity indicates presence of intracellular lipid.

    Patient W.W.: Chemical Shift MRI of R adrenal mass

  • 29

    Erica McAuliffeGillian Lieberman, MD

    IN-PHASE OUT-OF-PHASE

    Patient W.W.: Chemical Shift MRI of L adrenal mass

    Signal intensity decreases, except for small central focus.

  • 30

    Erica McAuliffeGillian Lieberman, MD

    Our Patient W.W., cont.

    Uncertainty persisted after CT and MRI. Percutaneous biopsy done of L adrenal gland. Pathology revealed benign L adrenal adenoma. Left upper lobectomy performed --> pathology

    revealed adenocarcinoma of lung.

    Right nephrectomy and adrenalectomyperformed --> revealed renal cell carcinoma and R adrenal myelolipoma.

  • 31

    Erica McAuliffeGillian Lieberman, MD

    Benign tumors composed of adipose and hematopoietic tissue.

    Radiographic features: Macroscopic fat (low attenuation) May enhance with contrast administration 20% calcify

    No treatment required.

    Adrenal Myelolipomas: Patient #3

    From Udelsman R. and EK Fishman. Endocrinology and MetabolismClinics of North America. 29(1), March 2000.

  • 32

    Erica McAuliffeGillian Lieberman, MD

    Adrenal mass

    Not hyperfunctioning Biochemistry Functioning

    > 3cm Size Surgery< 3cm

    Biopsyor surgery

    Chemical-Shift MRI

    HU < 10

    Non-contrast CT

    CT attenuation value

    Benign adenoma

    HU > 10

    Chemical-shift MRIor biopsy

    Signal intensity

    Biopsy orsurgery

    No lossLoss

    Benign adenoma

    EITHER

    Algorithm for incidental adrenal mass

    From Sohaib, SAA and RH Reznek. BJU International (2000), 86 Suppl.1, 95-110.

  • 33

    Erica McAuliffeGillian Lieberman, MD

    Differential Diagnosis of Adrenal Enlargement

    BENIGN Adenoma - functional Adenoma - nonfunctional Adrenal hyperplasia Pheochromocytoma (90%) Myelolipoma

    MALIGNANT 1 adrenal carcinoma Metastasis Ganglioneuroma Neuroblastoma

    OTHER Cyst Hematoma/Hemorrhage Infection

  • 34

    Erica McAuliffeGillian Lieberman, MD

    References Bergman, RA, AK Afifi, PM Heidger, University of Iowa, 2001:

    http://www.vh.org/Providers/Textbooks/MicroscopicAnatomy/Section15/Plate15293.html Busick, NP, PC Fretz, JR Galvin, MW Peterson, and CE Platz, Univ. of Iowa, 2000:

    http://www.vh.org/Providers/Textbooks/LungTumors/CaseStudies/Patient004/Text/CTCompAdrenalM ets.html

    Cotran et al., ed.: Robbins Pathologic Basis of Disease, 6th ed., W. B. Saunders Company, 1999.

    Kaplan, NM. The adrenal incidentaloma. UpToDate, online 10.1. 2002. Netter, Frank. Atlas of Human Anatomy. 2nd edition. Novartis: 1997. Pender, SM, GW Boland, and MJ Lee. The incidental nonhyperfunctioning adrenal

    mass: an imaging algorithm for characterization. Clinical Radiology (1998), 53: 796-804 Peppercorn, PD, AB Grossman, and RH Reznek. Imaging of incidentally discovered

    adrenal masses. Clinical Endocrinology (1998), 48: 379-388. Sohaib, SAA and RH Reznek. Adrenal imaging. BJU International (2000), 86 Suppl.1:

    95-110. Udelsman, R. and EK Fishman. Radiology of the adrenal. Endocrinology and

    Metabolism Clinics of North America (2000), 29(1): 27-42. Weissleder. Primer of Diagnostic Imaging. Mosby, Inc., 1996.

    http://www.vh.org/Providers/Textbooks/MicroscopicAnatomy/Section15/Plate15293.html

  • 35

    Erica McAuliffeGillian Lieberman, MD

    Acknowledgments

    Damon Soiero, MD Haldon Bryor, MD Jonathan Kruskal, MD Gillian Lieberman, MD Pamela Lepkowski Webmasters Larry Barbaras and Cara Lyn

    Damour

    Slide Number 1Slide Number 2Slide Number 3Slide Number 4Why Look at Adrenals?Menu of Tests for Evaluating AdrenalsSlide Number 7Differential Diagnosis of Adrenal EnlargementOur Patient W.W.Slide Number 10Patient W.W. Chest CT FindingsSlide Number 12Slide Number 13 Slide Number 15 Slide Number 17Adrenal MetastasesBenign vs. Malignant?Slide Number 20Benign vs. Malignant?Slide Number 22Slide Number 23 Chemical Shift MRISlide Number 27 Our Patient W.W., cont.Slide Number 31Slide Number 32Differential Diagnosis of Adrenal EnlargementReferencesAcknowledgments