Download - Adrenal Masses: Benign or Malignant?
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Erica McAuliffeGillian Lieberman, MD
Adrenal Masses: Benign or Malignant?
Erica McAuliffe, Harvard Medical School Year IIIGillian Lieberman, MD
March 2002
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Erica McAuliffeGillian Lieberman, MD
RightAdrenal
LeftAdrenal
Normal Adrenal Anatomy
Netter, Frank. Atlas of Human Anatomy. 2nd edition. Novartis: 1997.
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Erica McAuliffeGillian Lieberman, MD
http://www.vh.org/Providers/Textbooks/LungTumors/CaseStudies/Patient004/Text/CTCompAdrenalMets.html
Normal Adrenal CT
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Erica McAuliffeGillian Lieberman, MD
Glucocorticoids
Sex Steroids
Mineralocorticoids
Normal Adrenal Histology
From http://www.vh.org/Providers/Textbooks/MicroscopicAnatomy/Section15/Plate15293.html
Catecholamines
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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.
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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
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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
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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
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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.
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Erica McAuliffeGillian Lieberman, MD
Our Patient W.W. Chest CT
Lung Nodule
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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.
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Erica McAuliffeGillian Lieberman, MD
Our Patient W.W.: CT Findings
Renal Mass
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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.
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Erica McAuliffeGillian Lieberman, MD
Hemangioma
L adrenal mass:Focal area of higher intensity
Our Patient W.W.: CT with contrast
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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.
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Erica McAuliffeGillian Lieberman, MD Our Patient W.W.: CT with contrast - R adrenal gland
Lobular areas ofdecreased attenuation
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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
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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.
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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
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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
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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
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Erica McAuliffeGillian Lieberman, MD
MRI Signal Intensity
Weissleder. Primer of Diagnostic Imaging. Mosby, Inc., 1996.
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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.
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Erica McAuliffeGillian Lieberman, MD
L ADRENAL MASSHU = -5 to +4
Patient W.W. –CT scan without contrast
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Erica McAuliffeGillian Lieberman, MD
Patient W.W.: CT with contrast
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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.
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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
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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
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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.
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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.
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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.
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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.
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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
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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.
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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
D’amour