Adrenal Masses: Benign or Malignant?

Erica McAuliffe
Gillian Lieberman, MD

Chemical

• Fat protons and water p
resonance frequencies.

• At a known time interva
phase, and their signals

• By timing images based
can determine the fat co

Shift MRI

protons have different
.
al, the protons are out-of-
s cancel out.
d upon this interval, we
ontent of a certain tissue.

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Erica McAuliffe
Gillian Lieberman, MD

Chemical Shift MRI

IN-PHASE

OUT-OF-PHASE

P. D. Peppercorn, A. B. Grossman & R. H. Reznek (1998). Clini

I – Example of Mets

No loss of signal intensity
indicates no intracellular
fat.

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ical Endocrinology 48 (4), 379-388.

Erica McAuliffe Patient
Gillian Lieberman, MD

Chemical Shift MR

IN-PHASE
Loss of signal intensity indicate

t W.W.:
RI of R adrenal mass

OUT-OF-PHASE
es presence of intracellular lipid.

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Erica McAuliffe
Gillian Lieberman, MD

Patient W

Chemical Shift MRI

IN-PHASE

Signal intensity decreases, ex

W.W.:
of L adrenal mass

OUT-OF-PHASE

xcept for small central focus.

29

Erica McAuliffe
Gillian Lieberman, MD

Our Patient

• Uncertainty persisted af
• Percutaneous biopsy do
• Pathology revealed ben
• Left upper lobectomy pe

revealed adenocarcinom

• Right nephrectomy and
performed --> revealed
and… R adrenal myeloli

W.W., cont.

fter CT and MRI.
one of L adrenal gland.
nign L adrenal adenoma.
erformed --> pathology
ma of lung.

adrenalectomy
renal cell carcinoma
ipoma.

30

Erica McAuliffe
Gillian Lieberman, MD

Adrenal Myelolipo

• Benign tumors composed of
adipose and hematopoietic
tissue.

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

• No treatment required.

omas: Patient #3

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

31

Erica McAuliffe
Gillian Lieberman, MD

Algorithm for incide

Adrenal m

Not hyperfunctioning Biochemi

> 3cm Size < 3cm

Biopsy EITHER
or surgery

Non-contrast CT

CT attenuation value

HU < 10 HU > 10

Benign adenoma Chemical-shift MRI
or biopsy

From Sohaib, SAA and RH Reznek. BJU International (2000),

ental adrenal mass

mass

istry Functioning

Surgery

Chemical-Shift MRI
Signal intensity

Loss No loss

Benign adenoma Biopsy or
surgery
86 Suppl.1, 95-110.
32

Erica McAuliffe
Gillian Lieberman, MD

Differential D
Adrenal En

• BENIGN

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

• MALIGNANT

– 1° adrenal carcinoma
– Metastasis
– Ganglioneuroma
– Neuroblastoma

Diagnosis of
nlargement

• OTHER

– Cyst
– Hematoma/Hemorrhage
– Infection

33

Erica McAuliffe
Gillian Lieberman, MD

Refere

• Bergman, RA, AK Afifi, PM Heidger, Univ

http://www.vh.org/Providers/Textbooks/Microsc

• Busick, NP, PC Fretz, JR Galvin, MW Pe

http://www.vh.org/Providers/Textbooks/LungTu
ets.html

• Cotran et al., ed.: Robbins Pathologic Ba
Company, 1999.

• Kaplan, NM. The adrenal incidentaloma.

• Netter, Frank. Atlas of Human Anatomy. 2

• Pender, SM, GW Boland, and MJ Lee. T
mass: an imaging algorithm for character

• Peppercorn, PD, AB Grossman, and RH
adrenal masses. Clinical Endocrinology (

• Sohaib, SAA and RH Reznek. Adrenal im
95-110.

• Udelsman, R. and EK Fishman. Radiolog
Metabolism Clinics of North America (200

• Weissleder. Primer of Diagnostic Imaging

ences

versity of Iowa, 2001:

copicAnatomy/Section15/Plate15293.html

eterson, and CE Platz, Univ. of Iowa, 2000:

umors/CaseStudies/Patient004/Text/CTCompAdrenalM

asis of Disease, 6th ed., W. B. Saunders

. UpToDate, online 10.1. 2002.
2nd edition. Novartis: 1997.
The incidental nonhyperfunctioning adrenal
rization. Clinical Radiology (1998), 53: 796-804
Reznek. Imaging of incidentally discovered
(1998), 48: 379-388.
maging. BJU International (2000), 86 Suppl.1:

gy of the adrenal. Endocrinology and
00), 29(1): 27-42.
g. Mosby, Inc., 1996.

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Erica McAuliffe
Gillian Lieberman, MD

Acknowle

• Damon Soiero, MD
• Haldon Bryor, MD
• Jonathan Kruskal, M
• Gillian Lieberman, M
• Pamela Lepkowski
• Webmasters Larry B

D’amour

edgments

MD
MD
Barbaras and Cara Lyn

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