Adrenal Masses: Benign or Malignant?

Erica McAuliffe
Gillian Lieberman, MD

Adrenal Masse
Malign

Erica McAuliffe, Harvard
Gillian Lieb

March 2002

es: Benign or
nant?

d Medical School Year III
berman, MD

1

Erica McAuliffe
Gillian Lieberman, MD

Normal Adre

Right
Adrenal

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

enal Anatomy

Left
Adrenal

2

1997.

Erica McAuliffe
Gillian Lieberman, MD

Normal Ad

http://www.vh.org/Providers/Textbooks/LungTumors/CaseStudie

drenal CT

es/Patient004/Text/CTCompAdrenalMets.html 3

Erica McAuliffe
Gillian Lieberman, MD

Normal Adren

From http://www.vh.org/Providers/Textbooks/MicroscopicAnatom

nal Histology

Mineralocorticoids
Glucocorticoids
Sex Steroids

Catecholamines

4

my/Section15/Plate15293.html

Erica McAuliffe
Gillian Lieberman, MD

Why Look a

• Endocrine workup in a p
symptoms or laboratory

– ie, hypertension, Cushing
adrenal insufficiency

• Looking for metastases
extra-adrenal malignanc

• Post-trauma abdominal

• ANY reason for obtainin

– Incidental adrenal masse
of CT scans done for oth

at Adrenals?

patient with suspicious
y values

goid symptoms, virilism,

s in a patient with known
cy

l survey

ng a scan of the abdomen

es are detected in 0.35-4.4%

her reasons. 5

Erica McAuliffe
Gillian Lieberman, MD

Menu of

Evaluating

1. Plain Films
- Limited role; useful for calc

2. Ultrasound
- Cyst vs. solid
- Intra-operative use in lapa

3. CT
- Procedure of choice for pa
suspected adrenal lesio
- Attenuation values useful i

Tests for
g Adrenals

cifications

aroscopic adrenalectomies

atients with known or
ons

in differentiating pathology

6

Erica McAuliffe
Gillian Lieberman, MD

Menu of Te

4. MRI
- Best test for suspected ph
- Chemical shift imaging to d

5. Radioisotope Scanning = F
- I131 labeled cholesterol ana
adrenocortical tumors
- Labeled guanethidine ana
functional adrenomedullary

ests, cont.

heochromocytoma
determine fat content
Functional imaging
alog can detect functional
alog (MIBG) can detect
tumors

7

Erica McAuliffe
Gillian Lieberman, MD

Differential
Adrenal E

• BENIGN

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

• MALIGNANT

– 1° adrenal carcinoma
– Metastasis
– Ganglioneuroma
– Neuroblastoma

Diagnosis of
Enlargement

• OTHER

– Cyst
– Hematoma/Hemorrhage
– Infection

8

Erica McAuliffe
Gillian Lieberman, MD

Our Patie

• Healthy 61 year old man

• PMH: gout, appendecto

• 60 pack-year smoker, q

• CXR at outside hospital

• Referred to BIDMC for f

• A chest CT was ordered

ent W.W.

n.
omy.
quit 13 years ago.
l revealed LUL nodule.
further evaluation.
d.

9

Erica McAuliffe
Gillian Lieberman, MD

Our Patient W

W.W. Chest CT

Lung Nodule

10

Erica McAuliffe
Gillian Lieberman, MD

Patient W.W. – C

• 1.6 x 1.7 cm spiculated
aspect of LUL.

• Routine chest CT imag
abdomen and both adr

Chest CT Findings

d nodule in peripheral
ges include the upper
renal glands.

11

Erica McAuliffe
Gillian Lieberman, MD

Our Patient W.W

Renal Mass

W.: CT Findings

12

Erica McAuliffe
Gillian Lieberman, MD

Patient W.W.

• Lung nodule: 1.6 x 1
nodule in peripheral a

• Renal mass: Cystic a
upper pole of R kidne
consistent with 1° RC

- CT Findings

1.7 cm spiculated
aspect of LUL.
and solid lesion off
ey, 6.1 x 4.5 cm,
CC.

13

Erica McAuliffe
Gillian Lieberman, MD

Our Patient W.W.

Hemangioma

.: CT with contrast

L adrenal mass:

Focal area of
higher intensity

14

Erica McAuliffe
Gillian Lieberman, MD

Patient W.W.

• Lung nodule: 1.6 x 1
nodule in peripheral a

• Renal mass: Cystic
upper pole of R kidne
consistent with 1° RC

• Liver lesion: 3.2 cm
lobe, consistent with

• L adrenal mass: We
containing 1.9 x 1.5 c

- CT Findings

1.7 cm spiculated
aspect of LUL.
and solid lesion off
ey, 6.1 x 4.5 cm,
CC.
lesion in caudate
hemangioma.
ell-circumscribed, fat-
cm mass.

15

Erica McAuliffe Our Patie
Gillian Lieberman, MD

CT with contrast

Lobular areas of
decreased
attenuation

ent W.W.:
t - R adrenal gland

16

Erica McAuliffe
Gillian Lieberman, MD

Patient W.W.

• Lung nodule: 1.6 x 1.7
peripheral aspect of LU

• Renal mass: Cystic and
pole of R kidney, 6.1 x 4
RCC.

• Liver lesion: 3.2 cm les
consistent with hemang

• L adrenal mass: Well-c
containing 1.9 x 1.5 cm

• R adrenal mass: Lobula
attenuation

- CT Findings

cm spiculated nodule in
UL.

d solid lesion off upper
4.5 cm, consistent with 1°

sion in caudate lobe,
gioma.

circumscribed, fat-
mass.

ar areas of decreased

17

Erica McAuliffe
Gillian Lieberman, MD

Adrenal M

• Common; can alter treatme
• Most common primary sites

– Lung
– Breast
– Kidney
– Bowel
– Ovary
– Melanoma
• 90% of adrenal masses fou
are mets.
• 60% of adrenal masses fou
patients are mets.

Metastases

ent options.
s:

und in SC lung cancer patients
und in NSC lung cancer

18

Erica McAuliffe
Gillian Lieberman, MD

Benign vs.

Benign M
Adenoma
Varia
Size Small (< 5cm) can b

CT -Well-defined, -Hete
-Indi
-no calcifications,
-no hemorrhages -High
< 10 HU aden
-No S
MRI -Low SI chem
-In-phase/out-of-
phase
shows drop in SI

Malignant?

Metastasis 1° Adrenal
Carcinoma
able,
be bilateral Often >5cm when
detected

erogenous, -Heterogenous,
istinct margins -Necrosis and
hemorrage
common

her SI than -Hyperintense
noma
SI drop out on
mical shift MRI

19

Erica McAuliffe
Gillian Lieberman, MD

Intracellular L

Adrenal Carcinoma N

Cotran: Robbins Pathologic Basis of Disease, 6th ed., C

Lipid Content

Normal Cortical Tissue 20

Copyright © 1999 W. B. Saunders Company

Erica McAuliffe
Gillian Lieberman, MD

Benign vs.

Benign M
Adenoma
Varia
Size Small (< 5cm) can b

CT -Well-defined, -Hete
-Indi
-no calcifications,
-no hemorrhages -High
< 10 HU aden
-No S
MRI -Low SI chem
-In-phase/out-of-
phase
shows drop in SI

Malignant?

Metastasis 1° Adrenal
Carcinoma
able,
be bilateral Often >5cm when
detected

erogenous, -Heterogenous,
istinct margins -Necrosis and
hemorrage
common

her SI than -Hyperintense
noma
SI drop out on
mical shift MRI

21

Erica McAuliffe
Gillian Lieberman, MD

MRI Signa

Weissleder. Primer of Diagnostic Imaging. Mosby, Inc

al Intensity

22

c., 1996.

Erica McAuliffe
Gillian Lieberman, MD

Primary Adren
Patie

CT Features:
- Large size

- Calcification
- Extension into

liver
- Heterogenous,

cystic and solid

From Kaplan, N. T

nal Carcinoma:
ent #2

23

The adrenal incidentaloma. Up to Date 10.1., 2002.

Erica McAuliffe
Gillian Lieberman, MD

Patient

CT scan wit

t W.W. –
thout contrast

L ADRENAL MASS

HU = -5 to +4

24

Erica McAuliffe
Gillian Lieberman, MD

Patient W.W.:

CT with contrast

25