adrenal and other retroperitoneal masses
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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 AND OTHER RETROPERITONEAL MASSES P. Steiger 3
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
no known neoplasmknown neoplasm
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 4
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
no known neoplasmknown neoplasm
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 5
Adrenal Mass
✓ Neoplasm confirmed
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 6
Adrenal Mass
✓ Neoplasm confirmed
Problem: metastasis and adenomas are common
Metastasis yes or no? or something different?
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 7
Adrenal Mass
✓ Neoplasm confirmed
Problem: metastasis and adenomas are common
Metastasis yes or no? or something different?
Most common adrenal metastasis:
Lung, breast, stomach, kidney cancer, melanoma, lymphoma
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 8
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (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 9
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (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)?
Biopsy
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 10
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Metastasis yes or no? or something different?
Biopsy
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 11
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Metastasis yes or no? or something different?
Biopsy
Does it alter treatment? Rule out pheochromocytoma!
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 12
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Metastasis yes or no? or something different?
Biopsy
Does it alter treatment? Rule out pheochromocytoma!
FNA? Core needle biopsy? CT vs. US vs. MR guided
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 13
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 14
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
1
2
3
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 15
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
1 Cyst
2
1. Image due to legal reasons not shown
3
1
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 16
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 17
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
1 Cyst
2 Myelolipoma
3 Lipid rich adenoma (<10 HU)
1
2
1. Image due to legal reasons not shown
2. http://radiopaedia.org/articles/adrenal-myelolipoma Case 3
3. http://radiopaedia.org/cases/ctadenoma
3
1
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 18
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
1 Cyst
2 Myelolipoma
3 Lipid poor adenoma (>10 HU)???
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 19
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
✓ Neoplasm confirmed
Benign imaging characteristics:
1 Cyst
2 Myelolipoma
3 Lipid poor adenoma (>10 HU)???
washout
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 20
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
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
100 x venous HU – delayed 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 21
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
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
100 x venous HU – delayed 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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 22
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 24
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma with MR
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 25
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma with MR
in/out-of-phase
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 26
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 27
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma
MR vs CT
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 28
• 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 29
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma
What else is new?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 30
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma
What else is new?
• Shorter protocols (10min vs. 15min)
• Histogram analysis
• Dixon sequences (quantification of absolute fat
content)
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 31
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 33
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.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 34
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 35
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma
Guidelines recommend:
washout
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 36
Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
no known neoplasmknown neoplasm
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 37
Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
Incidentaloma
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 38
Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
Incidentaloma
Definition: Newly detected adrenal mass > 1cm
(exclude patient with cancer workup and staging)
Incidence: Up to 8.7%, correlates with number in autopsy
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 39
Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
Incidentaloma
- Adenoma 41%
- Metastases 19 %
- Adrenocorctical carcinoma 10%
- Pheochromocytoma 8%
- myelolipoma✓ < -10 HU 9%
- cysts✓ and others 13%
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 41
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 43
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 44
Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
Incidentaloma
Imaging can not distinguish between functioning
and nonfunctioning adrenal mass
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 45
Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
Incidentaloma
Imaging can not distinguish between functioning
and nonfunctioning adrenal mass
Endocrine tests
a) incidental adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 46
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 47
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 48
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 49
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 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 51
Adrenal Mass
a) 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
Clinicians ask you:
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 52
Adrenal Mass
a) 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
Clinicians ask you:
Is there an adrenal mass or extraadrenal mass?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 53
Adrenal Mass
a) 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
Clinicians ask you:
Is there an adrenal mass or extraadrenal mass?
Which imaging modality do we use best?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 54
Adrenal Mass
a) known biochemical abnormality
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 55
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
Primary hyperaldosteronism
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 56
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
Primary hyperaldosteronism ✓ confirmed
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 57
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
Primary hyperaldosteronism ✓ confirmed
Imaging modality?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 58
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
Primary hyperaldosteronism ✓ confirmed
Imaging modality?
MR vs. CT?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 59
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 60
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 61
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 62
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 63
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 64
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
Adrenal mass ✓
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 65
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
• Adrenal mass ✓
problem solved?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 66
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
• Adrenal mass ✓
Clinicians ask you now:
1. Is the nodule on your scan the aldosterone
producing adenoma?
2. Idiopathic primary adrenal hyperplasia?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 67
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
• Adrenal mass ✓
What could you offer?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 68
Adrenal Mass
a) known biochemical abnormality
1) with primary hyperaldosteronism.
Which imaging modality do we use?
• Primary hyperaldosteronism ✓confirmed
• Imaging modality: MR or CT ✓clear
• 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 70
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 71
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
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 Incidentaloma AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15(Suppl 1)
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 72
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
Screening & diagnosis: • Late-night salivary cortisol
• Overnight 1mg dexamethasone suppression test
• 24-hour urine free cortisol
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 73
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
Screening & diagnosis: • Late-night salivary cortisol
• Overnight 1mg dexamethasone suppression test
• 24-hour urine free cortisol
Biochemical 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 AND OTHER RETROPERITONEAL MASSES P. Steiger 74
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
Screening & diagnosis: • Late-night salivary cortisol
• Overnight 1mg dexamethasone suppression test
• 24-hour urine free cortisol
Biochemical diagnosis
Imaging still needed or what clinicians want to know ?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 75
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
Imaging still needed or what clinicians want to know ?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 76
Adrenal Mass
a) known biochemical abnormality
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Which imaging modality do we use?
Imaging still needed or what clinicians want to know ?
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))
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 77
Adrenal Mass
a) known biochemical abnormality
3) with suspicion hyperandrogenism, hyperestrogenism
Which imaging modality do we use?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 78
Adrenal Mass
a) known biochemical abnormality
3) with suspicion hyperandrogenism, hyperestrogenism
Which imaging modality do we use?
Condition which is rarely caused by a primary
adrenal mass
Imaging is not the main diagnostic workup
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 79
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 80
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 81
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 82
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 83
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
Diagnosis
a) 24 hour urine collection
for catecholamines
for total or fractionated metanephrine
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 84
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
Diagnosis
a) 24 hour urine collection
for catecholamines
for total or fractionated metanephrine
b) More recently plasma free metanephrine and normetanephrine
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 85
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
Diagnosis
a) 24 hour urine collection
for catecholamines
for total or fractionated metanephrine
b) More recently plasma free metanephrine and normetanephrine
Why imaging?
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 86
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
Diagnosis
a) 24 hour urine collection
for catecholamines
for total or fractionated metanephrine
b) More recently plasma free metanephrine and normetanephrine
Why imaging?
Localisation DD Paraganglioma
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 AND OTHER RETROPERITONEAL MASSES P. Steiger 87
Adrenal Mass
a) known biochemical abnormality
4) with elevated catecholamines in urine or blood plasma
Which imaging modality do we use?
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.
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 88
Pheochromocytoma
1. http://radiopaedia.org/cases/pheochromocytoma
2. Image due to legal reasons not shown
1
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 89
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 90
Pheochromocytoma
~ 10% extra-adrenal
~ 10% bilateral
~ 10% malignant
~ 10% found in children
~ 10% familial
~ 10 % not associated with hypertension
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 91
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 94
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
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 95
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
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