Adrenal Tumors

What a Coincidence!

Gill Bates (45) is being worked up by his general practitioner for persistent decreased appetite and a slightly elevated erythrocyte sedimentation rate. Today he is booked for an abdominal CT. He is a little nervous, but Paul reassures him, while giving him a big cup of dilute oral contrast that will fill the lumen of the stomach and the small and large intestine. An intravenous cannula is inserted before the investigation. Contrast is injected after an initial unenhanced CT scan to better evaluate blood vessels and parenchymal organs of the abdomen. Paul looks through the CT images and discovers an abnormal-appearing adrenal gland (Fig. 10.19).

f The adrenal glands have a "Y" or "V" configuration with a i thickness of5-8 mm. As a rule of thumb, the width should not exceed that of the adjacent crus of the diaphragm.

• What is Your Diagnosis?

Adrenal adenoma: An adrenal adenoma is a frequent incidental finding in the absence ofsymptoms, which is why

I The Case of Gill Bates

Fatty Tumor Adrenal Gland
Fig. 10.19 This is the relevant CT image of Gill Bates. What is your diagnosis?

I Adrenal Tumors a Adenoma a Adenoma

Fatty Tumor Adrenal Gland

Fig.10.20a The arrow points to a homogeneous well-circumscribed adrenal mass of about 2 cm in diameter and of low density. This is a textbook case of an adenoma. b In this patient with bronchogenic carcinoma, both adrenal glands (arrows) are enormously enlarged and accumulate contrast in the periphery, a typical picture of adrenal metastasis. c This fat-containing capsulated mass (arrow) of the adrenal gland is well demarcated from the surrounding fatty tissue. This is the characteristic appearance of a myelolipoma.

Fig.10.20a The arrow points to a homogeneous well-circumscribed adrenal mass of about 2 cm in diameter and of low density. This is a textbook case of an adenoma. b In this patient with bronchogenic carcinoma, both adrenal glands (arrows) are enormously enlarged and accumulate contrast in the periphery, a typical picture of adrenal metastasis. c This fat-containing capsulated mass (arrow) of the adrenal gland is well demarcated from the surrounding fatty tissue. This is the characteristic appearance of a myelolipoma.

it is also often called an "incidentaloma" (Fig. 10.20a). Any adrenal mass <3.5 cm maximum diameter with a density less than 10 Hounsfield Units on unenhanced CT and smooth in outline is most likely to be an adenoma. Follow-up CT should be performed as clinically indicated. If the mass is >3.5 cm in diameter, if it shows a tendency to grow, or if the patient is symptomatic because the tumor secretes adrenal hormone, surgical removal needs to be considered.

I The Case of Gill Bates

Adrenal metastases: Adrenal metastases are common in bronchogenic carcinoma, but certainly also occur with other primary malignancies (Fig. 10.20b). When performing a thoracic CT for staging of a bronchogenic carcinoma, the adrenal glands should always be included. Normally, heterogeneous enhancement, irregular outline, and rapid growth can suggest the diagnosis of adrenal metastases.

Myelolipoma: An adrenal myelolipoma is a benign mass with—as the name implies—a high fat content (Fig. 10.20c). It does not require follow-up.

Other tumors: All other adrenal lesions such as cysts or carcinomas are fairly rare. On CT, cysts have the same density as water and do not take up contrast; on US, they do not produce echoes but do give posterior acoustic enhancement. Endocrinologically active adrenal tumors (e.g., pheochromocytomas) are usually diagnosed clinically and biochemically. Imaging helps to localize the tumor and for surgical planning.

• Diagnosis: Of course Paul spotted the fat in the tumor right away. This is confirmed by comparing densities of tumor and subcutaneous fat. This lesion is a myelolipoma. Good news for Mr. Bates, because it is of no clinical significance and needs no further work-up or therapy.

Further investigation of his low appetite is unsuccessful. Three months later Paul runs into him in the street and has a chat with him. After some candid conversations with his wife and a wonderful holiday together, Mr. Bates has started to enjoy his food again.

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Responses

  • gilberto beneventi
    Can a heterogenous adrenal mass be an adenoma?
    5 years ago

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