4. What is radiology?
It is a medical specialty that employs the use of
imaging to both diagnose and treat disease within
the human body.
What is the Adrenal glands?
The adrenal glands (also known as suprarenal
glands) are endocrine glands that produce a variety
of hormones including adrenaline and the
steroids aldostrone and cortisol. They are found
above the kidney.
5.
6.
7. Objective
To know:
Normal Anatomy of Adrenal Gland.
Imaging Modalities of Adrenal gland.
D.D of Adrenal Masses.
Imaging Appearance of adrenal masses.
Imaging Work UP of adrenal incidentaloma.
Questions.
8.
9.
10. Normal Anatomy
The adrenal glands are two small, retroperitoneal
yellowish organs located in the perirenal space,
immediately anterosuperior to the upper pole of
the kidneys.
Yellow appearance because of their high lipid
content.
Gerota’s fascia connect the gland to upper pole of
the kidney
11. Right adrenal is triangular, related to upper
pole Right kidney.
Left adrenal is crescent shaped, related to
upper and medial part Left kidney.
Average size is 3-5 cm long, 2-3 cm wide
and 5 mm in thickness.
Average weight is 3-5 g of which 90 % is
contributed by cortex.
Normal Anatomy
12.
13. Vascular Supply
Receive arterial blood from branches of the
inferior phrenic artery, aorta, and renal arteries.
The right adrenal vein is short and exits the gland
medially to enter the vena cava.
The left adrenal vein exits anteriorly and usually
drains into the left renal vein.
As a result, adrenal venous catheterization is
accomplished more easily on the left than the
right.
14.
15. The adrenal gland is
composed of an outer cortex
and thinner inner medulla.
The cortex is further
subdivided into three zones:
outer zona glomerulosa-site
for aldosterone synthesis,
middle zona fasciculata, and
inner zona reticularis
produce both cortisol and
androgens.
16.
17. RT ADRENAL
Anteriorly: IVC and Liver
Posteriorly: Diaphragm
LT ADRENAL
Anteriorly: Pancreas and Stomach
Posteriorly: Diaphragm
Relations
18.
19. Axial CT scan demonstrating normal right and
left adrenal glands with inverted ‘ Y’’ shapes
above both kidneys.
20.
21. Coronal CT scan demonstrating normal right
and left adrenal glands with inverted ‘ Y’’
and ‘ V’’ shapes respectively located above
both kidneys.
22. Coronal T1-weighted MR image shows
the normal inverted Y shape of the right
adrenal gland (arrow).
28. Imaging Modalities
The use of CT, MR imaging, and PET exploit
three fundamentally different physiologic
principles:
1.The intracellular lipid concentration of
the mass.
2.The perfusion differences between
benign and malignant masses.
3.The metabolic activity of the mass.
29. Plain Films
Limited role.
Demonstrate a soft tissue mass or
tumefaction possibly displacing the kidney
Demonstrate calcifications (idiopathic,
neoplasm, granuloma, cyst, old
hemorrhage and Wolman’s disease)
30. Left: Plain film showing bilateral stippled adrenal
calcification.
Right: Large left supra renal mass (M) with low fat
density, mass effect on the upper pole of the left kidney is
noted in this case of left adrenal myelolipoma
31. IVU
The mass may cause lateral and downward
displacement and flattening of the
corresponding renal pelvi-calyceal system
causing the drooping–lily sign.
Intravenous urogram (IVU) shows a
classic drooping-lily sign involving
the right kidney. This patient had a
known right adrenal neuroblastoma
32.
33. Ultrasound
Often adrenal masses are incidentally
detected with abdominal ultrasound.
Ultrasound can differentiate solid from
cystic masses.
The location, size, echopattern and
vascularity of masses are assessed using
color Doppler imaging.
34.
35. CT
Is the most effective technique for examining the adrenal
glands.
The imaging procedure of choice for most patients with
known or suspected adrenal lesions.
Perinephric fat allows the gland to be displayed clearly.
Sensitivity up to 100% in identifying tumors as small as 10
mm.
CT can demonstrate the adrenal glands in all patients and
can usually identify the size, location, appearance, and
presence of local or vascular invasion, lymph node
involvement, and presence of distant metastases.
36. 5 mm collimated slices and even narrower
collimation may be used to clarify equivocal
findings.
Start by performing an unenhanced CT.
If the attenuation value is <10HU, then the
mass is characterized as lipid rich adenoma
and no further workup is done.
Inverse linear relationship between lipid
concentration and attenuation
value on unenhanced CT.
CT Protocol
37. If the attenuation value is >10 HU, then intravenous
contrast is administered (125 cc of Ultravist, administered
at a rate of 3 cc/s) and images obtained during the portal
venous phase with a 65-80 sec scan delay, and then 15 min
delayed images are acquired.
When oral contrast material is being used, administer 1000
mL of water at the time of the study.
Typically the ROI should be placed over one-half to two-
thirds of the lesion surface and avoiding necrotic or
hemorrhagic areas.
CT Protocol
38. CT Protocol
Lastly, the absolute and relative enhancement
washout calculations are performed.
Absolute enhancement washout (APW)=
Enhanced attenuation value-Delayed enhanced value
Enhanced attenuation value-Unenhanced attenuation value
Relative enhancement washout (RPW)=
Enhanced attenuation value-Delayed enhanced value
Enhanced attenuation value
39. CT Protocol
Most investigators use a 40% threshold on a 15-
minute delayed scan for RPW or 60% for APW.
Therefore, any lesion that demonstrates RPW > 40%
or APW > 60% at this time is consistent with an
adenoma, with sensitivity and specificity both close
to 100%.
Lesions that demonstrate RPW < 40% or APW < 60%
on a 15-minute delayed scan are almost always
malignant.
40. CT
The washout CT technique have some
limitations:
Most standard CT scans are now obtained after
IV contrast, and therefore the unenhanced
attenuation value cannot be obtained, and to
reschedule the patient for a dedicated CT
adrenal protocol is burden to the patients.
The possibility exists that an adrenal carcinoma
contains foci of intracytoplasmic lipids, as well
as exceptionally metastatic from clear cell renal
carcinoma and hepatocellular carcinoma.
41. MRI
A typical MRI protocol for adrenal imaging
includes three plane localizer to make proper
coverage.
High quality axial T1 and T2 weighted images (3–5
mm) sections preferably with suspended
respiration are standard.
Chemical shift imaging is now standard.
42. MRI
Typically a standard dose of intravenous
gadolinium contrast is also given and
breath-hold T1 weighted images repeated.
Fat-abundant lesions will be bright on T1WI
Fluid-abundant lesions will be bright on T2
(mets, pheo)
43. MRI-Chemical Shift
Principle:
Based on the differences in resonance frequencies
between fat protons and water protons when
subjected to magnetic field.
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.
Used to differentiate adenomas from non-adenomas.
44. MRI-Chemical Shift
In phase: water and lipid are aligned so signal intensity
high.
Opposed phase: opposite from each other so signal
intensity low.
Interpretation: loss of SI within adrenal mass on an
opposed phase image when compared with in-phase image
indicates presence of intracellular lipids.
India Ink Artifact: dark line indicative of fat-fluid interface
when macroscopic fat is present
45.
46.
47. MRI-Chemical Shift
The chemical shift phenomenon can be measured
either qualitatively (visual) or quantitatively.
Quantitative measurement is done by calculating
the adrenal-to-spleen (ASR) chemical shift ratio
and signal intensity index (SII).
ASR= (SIAO/SISO)/ (SIAI/SISI)
ASR of less than 0.71 indicates a lipid-rich
adenoma.
48. MRI-Chemical Shift
SII= [(SIAI-SIAO)/ SIAI] X100
SII of more than 16.5% is also consistent with a
lipid-rich adenoma.
However, most radiologists evaluate any chemical
shift change visually or qualitatively, and this has
been reported to be as effective as quantitative
methods.
49. MRI-Chemical Shift (C.S)
Chemical shift MR imaging has some limitations:
It is difficult to obtain images of adequate quality with a
section thickness of less than 5 mm in a single breath
hold with two-dimensional pulse sequences.
Volume averaging with the SI artifact on out-of-phase
MR images along the adrenal margins has the potential
to artificially reduce SI, thus giving spurious high
measurements of SI decrease.
To avoid this:
Excluded all nodules smaller than 8 mm from CS.
Be careful when performing measurements to avoid
adrenal margins.
50. Radio-isotope Scanning
Based on the uptake and accumulation of radiotracers
(radio-cholesterol) in functioning adrenal tissue.
Anatomical localization and functional characterization.
The widespread application of adrenal scintigraphy is
limited by the lack of experienced nuclear medicine center.
I131 labeled cholesterol analog can detect functional
adrenocortical tumors.
Labeled guanethidine analog (MIBG) can detect functional
adrenomedullary tumors.
51. Radio-isotope Scanning
Adenomas (hypersecreting or nonhypersecreting)
show radiocholesterol uptake and so appear as
“hot” nodules.
Malignant tumors (primary or secondary) appear
as “cold” nodules.
Therefore, adrenal masses can show different
patterns of uptake depending on nature.
52. Radio-isotope Scanning
Limitations:
Masses less than 1.5 to 2 cm in diameter and
large tumors with extensive tumoral necrosis
and/or hemorrhage may not show sufficient
MIBG uptake for visualization.
False negative results also may be due to drugs
that interfere with uptake.
53. PET and PET-CT
Positron emission tomography (PET) is a promising
imaging modality in oncology to measure noninvasively
biochemical and/or physiological processes in vivo.
Combining PET and computed tomography (CT) providing
useful structural and functional information for the
detection and characterization of a variety of conditions
affecting the adrenalgland.
The most common radiopharmaceutical is 18-fluoro-deoxy-
glucose (FDG).
54. PET and PET-CT
Tracers are injected intravenously and
incorporated into the organ of interest
through the metabolism.
For FDG, which is an analog of glucose, the
metabolic process is glycolysis.
Malignant lesions are known to be associated
with enhanced glycolysis, and therefore
accumulate FDG
55. PET and PET-CT
Advantages:
High sensitivity for detecting
malignancy.
Disadvantages:
16% of benign adrenal lesions may
be positive on PET.
Cost and insufficient data to support
their routine use (not recommend ).
56. Schlamp A et al. (2007) Recurrent adrenocortical carcinoma after laparoscopic resection
Nat Clin Pract Endocrinol Metab 3: 191–195 doi:10.1038/ncpendmet0391
CT and fluorodeoxyglucose (FDG)-PET scans of the tumor before and after
primary surgery
57. Angiography
Arteriography and venography: used in
the preoperative evaluation of large
adrenal lesions.
However, due to the unique sensitivity
of spiral CT and MRI scans, these
invasive techniques have become
obsolete.
58. Adrenal Venous Sampling
Venous sampling may have a place when
bilateral adrenal masses associated with
endocrine hyperfunction……..to localize site
of hypersecretion
An experienced interventional radiologist is
required because the right adrenal vein can
be difficult to catheterize.
59. Adrenal Biopsy
is a reliable technique and is the standard for
diagnosis of adrenal pathologic conditions that
cannot be accurately characterized with CT, MR
imaging, or PET and in whom accurate staging is
mandatory.
Safe procedures with a high degree of accuracy
and a low complication rate.
CT is the modality of choice for guiding adrenal
biopsies.
Axial technique with a cutting core needle is
useful.
60. Adrenal Biopsy
Fine-Needle Aspiration Biopsy (FNAB):
Using either CT or ultrasound guidance.
Cannot differentiate between an adrenal cortical
carcinoma and an adrenal adenoma.
It can distinguish between an adrenal tumor and a
metastatic tumor so used when there is a suspicion of
cancer outside the adrenal gland.
Invasive produces causing significant morbidity.
Complications such as pneumothorax, septicemia, and
hemorrhage have been reported in 8% to 13% of cases.
Pheochromocytoma should always be excluded before
attempting FNA biopsy of an adrenal mass.
67. Fat-containing Adrenal Masses
Fat-containing adrenal masses can be
classified into two main types:
1. those that contain intracellular fat
(eg, adenoma)
2. and those with macroscopic fat
(eg, myelolipoma).
68. Mass Discovery
Adrenal masses are discovered by the following methods:
1) Adrenal masses were found incidentally )Incidentalomas) on
abdominal sonography, CT or MRI done for non-related
complaints such as abdominal pain, mass, vomiting and loss
of weight.
2) Adrenal masses were found during examination for an extra
adrenal 1ry malignant tumor.
3) Adrenal masses were found during the work up for endocrine
and clinical manifestations raising the suspicion of adrenal
affection such as hypertension, headache, muscle weakness,
hypokalemia, elevated plasma aldosterone, suppressed plasma
renin activity, paroxysmal attacks of hypertension and elevated
urinary 24 hour VMA.
69.
70.
71.
72.
73. Adenoma
Most common adrenal tumor.
Arise from the adrenal cortex
Characterised by the presence of
intracellular lipid.
Lipid rich 70% and Lipid poor 30%.
80% are non-functioning.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83. Adenoma
CT:
Small < 4 cm.
Well-defined margin.
Ovoid or rounded in shape.
Homogenous density
Calcification and hemorrhage are rare.
Lipid rich adenoma>10 HU.
Unenhanced CT is unable to characterize lipid-
poor adenomas<10 HU.
Enhanced and delayed CT with APW and RPW has
high sensitivity and specificity in distinguishing lipid
poor adenomas.
84. Adenoma
MRI:
Isointensity with liver on both T1 and T2W.
Chemical shift imaging is the most reliable
technique for diagnosing adrenal adenoma with
loss of signal intensity on out-of-phase images.
Uniform enhancement with contrast enhanced
images is typical of adenomas.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102. Myelolipoma
Benign neoplasms that composed of mature
adipose cells and hemopoietic tissue in varying
proportions.
Most tumors are hormonally inactive.
Mostly discovered accidentally.
The most common symptom is pain.
Usually found in the adrenal gland.
Extra-adrenal sites especially presacral but also
retroperitoneal or pelvic
Vary considerably in size from 1 cm to 30 cm
103. Myelolipoma
Usually easy to recognize by large amount of
mature fat
Calcification in 20%
The fatty component is evident and characterized
on CT scans by low-density and inhomogeneous.
On MRI, the fat appears hyperintense on T1WI and
intermediate on T2WI.
Loss of signal intensity of the fatty component on
Fat-Suppressed Technique
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114. Axial T1 MRI Axial T1 with Fat
Suppressed Technique
125. Pseudocysts
Pseudocysts typically arise after an episode of adrenal
hemorrhage and do not have an epithelial lining.
Have a complicated appearance on MR images,
manifesting with septations, blood products, or a soft-
tissue component secondary to hemorrhage or
hyalinized thrombus.
Peripheral curvilinear calcification may be present.
132. Adrenal Hemorrhage
It may occur spontaneously or may be the result of
anticoagulation or trauma.
Adrenal hemorrhage can be bilateral or unilateral.
When adrenal hemorrhage is bilateral, the cause is usually
associated with anticoagulation therapy or a blood
dyscrasia; less commonly, it is associated with the stress
of surgery, sepsis, or hypotension; and rarely, it is caused
by trauma.
Unilateral adrenal hemorrhage is usually caused by blunt
abdominal trauma, adrenal vein thrombosis. It may occur
into a preexisting neoplasm, necessitating surgical
exploration if follow-up imaging does not show a nearly
normal adrenal gland.
133. Adrenal Hemorrhage
CT:
Acute or subacute adrenal hemorrhage typically has an
unenhanced attenuation value of 50-90 H.
Follow-up studies show diminution in size of the adrenal
mass with a gradual decrease in the attenuation value.
The high attenuation value of a recent adrenal
hemorrhage is usually readily apparent on unenhanced
CT, but is indistinguishable from a solid adrenal
neoplasm on contrast enhanced CT.
Detection of an adrenal mass on contrast-enhanced CT
after trauma is usually assumed to result from a
hematoma, but an unrelated adrenal neoplasm can be
excluded only by unenhanced CT or serial follow-up CT.
134. Adrenal Hemorrhage
MR imaging:
In the acute phase, a signal loss is observed on
T1 and T2 images due to the presence of
deoxyhemoglobin.
In the subacute phase, hemorrhage have a high
signal intensity, which reflects the presence of
methemoglobin, on T1-weighted images.
In chronic phases, the intensity on both T1 and
T2 images is increased due to calcification and
hemosiderin deposition.
135.
136.
137.
138.
139.
140. Adrenal Hemangioma
A rare benign tumor.
Composed of closely adjacent vascular
channels lined with a single layer of
endothelium.
Does not produce adrenal hormones.
The most are large when found as an
incidental finding.
Hemangiosarcomas occur but are even less
common.
141. Adrenal Hemangioma
CT:
Large well-defined masses.
Soft tissue density on unenhanced images and
exhibit inhomogeneous enhancement.
Most hemangiomas are calcified, either from
phleboliths in the tumor or from previous
hemorrhage.
142. Adrenal Hemangioma
MRI:
A hypointense appearance relative to the liver on T1-
weighted sequences.
Central hyperintensity may be seen because of
hemorrhage.
On T2-weighted images, they are hyperintense.
Peripheral enhancement that persists on delayed
images is characteristic.
143.
144.
145.
146. Granulomatous Disease
Tuberculosis, histoplasmosis, and other
granulomatous diseases are usually bilateral
but often asymmetric.
Uncommon.
Should be considered in the differential
diagnosis of incidental bilateral adrenal
masses in the absence of a primary
neoplasm or coagulation abnormality.
147. Granulomatous Disease
CT findings are nonspecific and can include
soft-tissue masses, cystic changes,
calcifications, or a combination of these
findings.
Biopsy is needed to confirm the diagnosis
and identify the responsible organism.
148.
149.
150.
151. Adrenal Abscess
Typically encountered in the newborn as a
complication of neonatal adrenal hemorrhage.
They are exceptional in adults and are secondary
to hematogeneous spread or infection of adrenal
hematoma.
Diagnosis is suggested by an abnormal mass
projected in the anatomical location of the adrenal
gland, usually associated with a septic condition.
152. Adrenal Abscess
Ultrasound, CT scan and MRI are all helpful in
describing the lesion.
Early images can be misleading as the abscess
can mimic a renal or adrenal tumor, but imaging
follow-up will demonstrate a rapid growth and
liquefaction of the mass.
Percutaneous aspiration may be useful in
establishing an accurate diagnosis and is essential
for a conservative approach.
153.
154.
155.
156.
157. Adrenal Hyperplasia
Often seen in patients with Cushing syndrome and less
commonly in Conn’s disease.
The hyperplasia may be diffuse or nodular and typically is
bilateral.
On CT and MRI, the attenuation and signal intensity of
hyperplastic adrenal glands are usually similar to that of
the normal adrenal gland, although non-contrast
attenuation could be lower in some cases.
158. Adrenal Hyperplasia
The signal intensity may also decrease on out-of-
phase pulse sequences compared to in-phase
pulse sequences, especially in patients with
adenomatous cortical nodules.
Bilateral cortical hyperplasia is seen in 45% of
patients with Cushing syndrome, whereas nodular
cortical hyperplasia is seen in only 3% of these
patients.
164. Adrenocortical Carcinoma
Rare malignancy.
Women: men 5:1
Age: 30 – 70 and may occur in childeren.
Large size
Can manifest as a hyperfunctioning mass
causing Cushing or Conn syndrome.
Other manifestations include an abdominal mass
and abdominal pain.
165. Adrenocortical Carcinoma
CT:
Irregular shape
Inhomogeneous density (central necrosis)
>4 cm, unilateral and calcify
High unenhanced CT (>20HU)
Delayed contrast washout
Absolute contrast washout < 60 %
Evidence of local invasion or metastasis.
171. Pheochromocytoma
Catecholamine-secreting tumor arising from chromaffin
cells of adrenal medulla or extraadrenal ectopic tissue
(paraganglioma).
The cause of hypertension in less than 1% of the
hypertensive population.
Clinical symptoms: Headache, Sweating, Tachycardia
Part of syndromes: MEN II, NF, VHL, Sturge Weber.
Rule of 10’s: extra-adrenal, malignant, bilateral, extra-
abdominal, familial, pediatric, no BP elevation.
172.
173. Pheochromocytoma
The diagnosis of pheochromocytoma is clinical and
laboratory by measurement of 24 hours urine
catecholamin level or plasma free metanephrine level.
Most commonly benign, being malignant in 10% of patient.
Benign lesions can be locally invasive into the IVC and
renal vein
It is difficult to differentiate benign from malignant
pheohromocytoma histologically
Malignancy is usually established by local invasion or
metastases.
The most common site of metastasis include bone, liver,
lungs and nodes.
174.
175. Pheochromocytoma
CT:
A well-defined, rounded or oval hypervascular soft-tissue
density masses frequently with central necrosis.
2 to 5 cm in diameter.
Homogeneous or heterogeneous density.
Solid or cystic.
Calcification
Increased attenuation value on unenhanced CT (more
than 20 HU).
Marked enhancement after intravenous contrast material.
Injection of ionic contrast medium can precipitate
hypertensive crisis in some patients.
Delayed contrast washout.
Absolute contrast washout <60 %.
176.
177.
178.
179. Pheochromocytoma
MRI:
The imaging procedure of choice.
Hypointense on T1WIs.
Characteristically hyperintense on T2-WIs (light bulb
sign).
Often have a heterogeneous appearance due to the
presence of cystic regions, necrosis, and fibrosis.
No signal loss on out-of-phase chemical shift images.
MR angiography useful to delineate the anatomic
relationships between adrenal tumors and vascular
structures.
180. Light Bulb Sign
The light bulb sign of an adrenal
pheochromocytoma is MRI feature of this tumour. This
refers to marked hyperintensity seen on T2 weighted sequences
however this finding is neither sensitive nor specific and
pheochromocytomas are more often heterogeneous with
intermediate or high T2 signal intensity.
The light bulb sign of a hepatic haemangioma is a
feature than can be seen on MRI imaging with a classic hepatic
haemangioma. This refers to marked hyperintensity seen on
heavily T2 weighted sequences that has been likened to a
glowing light bulb.
The light bulb sign in posterior shoulder dislocation: refers to the
abnormal AP radiograph appearance of the humeral head. When the humerus
dislocates it also internally rotates such that the head contour projects like a
light bulb when viewed from the front.
181.
182.
183.
184.
185.
186.
187. Axial T1 in Phase MRI
Axial T1 out of Phase MRI
Contrast-enhanced Image
193. Axial 18-FDG PET-CT image shows focal,
marked uptake in right adrenal
pheochromocytoma.
194.
195. Adrenal Metastasis
The adrenal glands are a common site of
metastatic disease.
The most common neoplasms with adrenal
metastases are carcinomas of the lung and breast
, melanoma and renal cell carcinoma.
In general, the adrenal lesion is part of the clinical
picture of diffuse metastatic disease.
Usually bilateral but may also be unilateral.
196. Adrenal Metastasis
The CT and MR imaging features are
nonspecific.
Small metastases are often homogeneous on
contrast-enhanced CT or MR imaging,
whereas large metastases often have local
regions that appear heterogeneous as a
result of necrosis, hemorrhage, or both.
Calcification is rare in adrenal metastases.
197.
198.
199.
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211. Adrenal Lymphoma
Primary lymphoma of the adrenal glands is rare
Secondary involvement when other
retroperitoneal lymphoma is present is seen
more commonly among patients with non-
Hodgkin's lymphoma than Hodgkin's disease.
Involvement is often bilateral and other
retroperitoneal disease is usually present.
212. Adrenal Lymphoma
CT appearance:
Discrete masses or diffuse involvement of the
gland in which the shape of the gland may be
maintained.
There may be extensive retroperitoneal tumor
that engulfs the adrenal glands, making them
difficult to identify.
Mild post-contrast enhancement.
214. Adrenal lymphoma in a 67-year-old man with an adrenal mass. Imaging was
performed for diagnosis and staging. Axial arterial phase (a) and coronal arterial
phase volume-rendered (b) CT images show an 11-cm mass in the left adrenal bed.
The mass invades the left hemidiaphragm, encases the celiac and renal arteries, and
displaces the aorta. The mild degree of organ displacement despite the size of the
mass and the infiltrative appearance are suggestive of lymphoma; the diagnosis was
confirmed at core biopsy.
215.
216.
217.
218.
219. Neuroblastoma
The 2nd most common pediatric abdominal mass
(after Wilms tumor).
5%–15% of all malignant tumors in children
Arises from the neural crest in the adrenal
medulla or along the sympathetic chain.
Calcification is present in 85% of the lesions.
220. Neuroblastoma
CT:
Large mass, often extending across the midline
to engulf and displace the aorta anteriorly.
Irregularly shaped, lobulated and
unencapsulated.
Invade adjacent organs or encase adjacent
vessels.
Inhomogeneous owing to tumor necrosis and
hemorrhage.
Coarse amorphous mottled peripheral
calcification in about 85% of cases at CT.
Heterogeneous contrast enhancement is usual.
221. Neuroblastoma
MRI:
Heterogeneous low signal intensity on T1WIs.
High signal intensity on T2WIs.
Heterogeneous enhancement.
Areas of intratumoral hemorrhage typically have
high signal intensity on T1WIs.
Cystic changes have high signal intensity on
T2WIs.
Is the preferred modality for investigating
intraspinal extension of primary tumor (the so-
called dumbbell neuroblastoma)
222. Dumbbell appearance of spinal tumors
Refers to a tumor which has both a
component within the canal and a
component in the paravertebral
space linked by tumor traversing the
neural exit foramen.
The appearance can be seen in:
Spinal nerve sheath tumours
spinal schwannoma
spinal neurofibroma
spinal ganglioneuroma
Neuroblastoma
Spinal meningioma
223. Contrast-enhanced CT shows a large retroperitoneal neuroblastoma
with a very irregular lobulated border that surrounds vessels and has
displaced the right kidney. The interface with the left renal cortex is
indistinct and there is tumor invasion into the left renal hilum.
224. Coronal unenhanced T1-weighted MR image (a) and axial T2-weighted MR image
obtained with inversion recovery (b) show a right adrenal tumor. The tumor is
predominantly hypointense on the T1-weighted image and has areas of high-
signal-intensity hemorrhage (arrow in a). The tumor is hyperintense on the T2-
weighted image.
227. Ganglioneuroblastoma
Intermediate in malignancy between that of
neuroblastoma and ganglioneuroma
Arise from the neural crest.
Are smaller and more well defined than
neuroblastoma
Demonstrates Intermediate signal intensity on
T1WI and heterogeneously high signal intensity
on T2WI, with heterogeneous enhancement after
administration of contrast material.
228. -Right: Coronal T2-weighted image showing a large lobulated right adrenal mass
with heterogeneous signal intensity in a 14-year-old child with elevated urinary
catecholamines.
-Left: Coronal T1-weighted image with contrast enhancement and fat saturation.
The mass is poorly enhancing and separate from the right kidney.
-Histologically this was a ganglioneuroblastoma.
229. T1-WI shows a heterogeneous mass with
intermediate signal intensity
230. Neurogenic Tumor
Neurogenic tumors: are the cause of approximately
90% of posterior mediastinal masses. They can be
subdivided into three groups by their location and
involvement of peripheral nerves or sympathetic chain.
Peripheral nerve sheath tumor
Sympathetic ganglia tumor
Paraganglioma
Peripheral nerve sheath tumors and paragangliomas are
far more common in adults while the sympathetic ganglia
tumors are more common in children.
231. Neurogenic Tumor
Peripheral nerve sheath tumours
These tumors manifest as round paravertebral masses
that span one or two vertebral bodies.
They are homogenous, soft-tissue attenuation masses
at CT and the commonest cause of posterior
mediastinal and paravertebral masses.
They may cause widening of the neural foramen and
thickening of the adjacent posterior rib.
Schwannoma
Neurofibroma
Malignant peripheral nerve sheath tumour
232. Neurogenic Tumor
Sympathetic ganglia tumors
These tumors tend to present as elongated
paraspinal masses that span multiple vertebral
levels. Intra-tumoral calcification is common.
Neuroblastoma - young children
Ganglioneuroblastoma - older children
Ganglioneuroma - children and adults
Neuroblastoma and ganglioneuroblastoma are
most commonly seen in children and in a child they
comprise the most common neurogenic tumour.
234. Collision Tumors
Are formed by coexisting lesions of different pathologic
origins.
Manifest with atypical imaging appearances.
Represent a pitfall in anatomic staging as with CT alone,
differentiation of benign from malignant tissue in an
adrenal gland is difficult,
One of the principal advantages of PET-CT is its precise
coregistration, which improves the detection of subtle
disease.
235. (Top left): Contrast-enhanced CT
scan shows a regular, ovoid mass
of the right adrenal gland with a
fatty component (-84 HU).
(Top right): Coronal FLASH two-
dimensional gradient-echo T1-
weighted MR image shows a
heterogeneous mass with some
well-limited hyperintense areas
(arrow).
(Bottom left): T2-weighted MR
image shows that these areas
(arrow) have the same high signal
intensity as retroperitoneal fat.
(Bottom right): T1-weighted MR
image obtained with fat
suppression shows heterogeneous
enhancement and the lipidic nature
of the corresponding areas (arrow).
Collision tumor with associated
myelolipoma and adenoma.
236.
237.
238.
239.
240.
241.
242.
243.
244.
245.
246.
247.
248.
249.
250.
251.
252.
253.
254.
255.
256.
257.
258.
259.
260.
261.
262.
263.
264. Adenoma Adrenocortical
Carcinoma
Pheochromocytoma Metastasis
Size < 3 cm diameter >4 cm diameter >3 cm diameter Usually <3 cm
Shape Round, smooth
Margins
Irregular, no clear
margins
Round/oval, clear
margins
Oval/irregular,
unclear margins
Texture Homogenous Heterogenous,
mixed densities
Heterogenous, cystic Heterogenous,
mixed densities
Lateralize Solitary, unilateral Solitary, unilateral Solitary, unilateraly Bilateral
CT Attenuation <10 HU >25 HU >25 HU >25 HU
CT Washout at
10 minutes
>50% <50% <50% <50%
T2 MRI
Appearance
(compare to
liver)
= + +++ +
Necrosis, Ca,
hemorrhage
Rare Common Common Occasional
Growth rate Slow Rapid Slow Variable
265.
266.
267.
268.
269.
270.
271.
272.
273.
274.
275.
276.
277.
278.
279.
280.
281.
282.
283.
284.
285.
286.
287.
288.
289.
290.
291.
292.
293.
294. Long Case
43 year-old male
Three months history of episodic palpitations and chest burning, radiating to
his back
Past medical history: hypertension, dyslipidemia
Social history: Alcohol abuse, non-smoker
Review of system: No fever, no chills, no changes in his weight, no
temperature intolerance, no visual difficulties, no headaches, no difficulty
swallowing, no cough, no shortness of breath, no leg edema, no GI or GU
symptoms, no skin rashes.
Physical Exam: Regular apical pulse of 110
A portable AP chest radiograph was obtained in the ED to rule out any acute
cardiopulmonary processes.
295. •Cardiomediastinal and
hilar contours are
normal.
•Lungs are clear with out
consolidation or
pulmonary edema.
•No pleural effusion.
•Osseous structures are
unremarkable.
Heavy metal/calcific
opacity superimposed
the RUQ
•What are the findings?
296. Patient Presentation: 5 Months Later
More frequent palpitations with chest pain
Episodic hypertension
Complaint of night sweats and headache
EKG unchanged
Due to complaints of upper abdominal/lower chest
pain, chest radiographs were obtained to rule out any
acute cardiopulmonary processes.
297. Unchanged amorphous
calcific density
Where is this lesion?
5-month Follow-up Chest Radiograph
• In the liver?
• In the gallbladder?
• In the bowel?
• In the kidney?
• In the adrenal?
• In the connective
tissue?
• Let’s look at the lateral
chest radiograph.
298. The lesion is posterior,
possibly retroperitoneal.
It does not seem to involve
the liver or gallbladder
The lesion may be in the
right adrenal, right kidney,
bowel, or connective
tissue
299. Differential Diagnoses for the Patient’s Posterior Calcific Lesion
Based on Organs:
• Right Adrenal gland
– Pheochromocytoma
– Adrenocortical carcinoma
– Myelolipoma
– Prior hemorrhage, trauma, infection
– Metastases (calcifications rare)
• Right Kidney
– Renal cell carcinoma
– Hemorrhagic cyst
– Prior infarction, laceration
• Bowel
– Gastrointestinal stromal tumor
Not Organ-related: Liposarcoma
300.
301.
302. The patient’s history of episodic
tachycardia, diaphoresis, headache and
hypertension combined with findings on
chest radiographs and ultrasound suggest
pheochromocytoma and further workup is
indicated.
Preliminary Diagnosis
303.
304.
305. Both lesions demonstrate avid peripheral enhancement.
Both appear heterogeneous. The larger mass (left)
shows central calcifications.
Our Patient: Contrast-enhanced Axial CT Images
306.
307.
308. T1 weighted, pre-contrast
T1 hypointense relative to
skeletal muscle
The periphery avidly enhances.
The central area of necrosis
demonstrates no uptake.
T1 weighted, post-contrast, arterial phase
309.
310.
311.
312.
313.
314. A 45 years old female patient with history of ovarian
carcinoma under follow up.
CT Examination
315. CT Examination:
Axial and coronal non-enhanced CT images showed a well-
defined hypodense left adrenal mass with attenuation value (5
HU).
Axial and coronal contrast- enhanced CT images acquired after
1 minute showed diffuse homogeneous enhancement of the
left adrenal mass with increased attenuation value reaching (56
HU).
Axial and coronal delayed contrast-enhanced CT images
acquired 15 minutes later showed significant washout of
contrast with reduction of attenuation value reaching (20 HU).
The non-contrast CT attenuation value was (5 HU), the APW
was (71%) and RPW was (64%). These values were
consistent with lipid-rich adenoma.
317. MRI Examination:
Axial T1, axial and coronal T2-weighted MR images
showed a well-defined left adrenal mass, displaying
isointense signal relative to spleen on T1 and T2WIs.
Axial and coronal gradient-echo in-phase& K, M) Axial
and coronal out of-phase MR images showed
significant visual signal loss between in-phase and out
of-phase images (qualitative assessment).
By quantitative assessment of chemical shift images, the
ASR was (0.31) and SII was (42%).
MRI findings were consistent with adenoma
318.
319. CT examination
A 62 years old male patient presented to the orthopedic
clinic by pathological fracture of RT femur
320. CT Examination:
Axial non-enhanced CT image showed a well-
defined hypodense right adrenal mass with
attenuation value (48 HU).
Axial and coronal contrast enhanced-CT images
obtained after 1 minute showed diffuse
heterogeneous enhancement of the mass with
increased attenuation value (74 HU).
Axial delayed contrast enhanced-CT image obtained
after 15 minutes showed no significant washout of
contrast with attenuation value (62 HU).
The APW was (46%) and the RPW was (16%).
Based on the CT study, these values matching with
322. MRI Examination: done after 6 month
Axial T1, axial and coronal T2-weighted MR images showed
the right adrenal mass with central area of necrosis.
Axial gradient-echo in-phase and out of-phase MR images
showed no significant visual signal loss between in-phase
and out of-phase images. (Qualitative assessment).
By Quantitative assessment of chemical shift images, the
ASR was (1.08) and SII was (15.8%).
These MRI findings were matching with non-adenoma
Biopsy was done and Histopathology revealed Adrenocortical
Carcinoma.
