Imaging Pearls ❯ Adrenal ❯ Malignant Adrenal Tumor
|
-- OR -- |
|
4cm is the number- “A 4-cm size threshold demonstrates the highest combined sensitivity and specificity, with a preserved specificity compared with higher size thresholds, but with a trend toward improved sensitivity. Future research reevaluating 4-5 cm size thresholds while excluding characteristically benign lesions by imaging may help redefine a size threshold that has improved specificity but preserved sensitivity, compared with the existing 4-cm threshold.”
Impact of Size Thresholds on the Diagnosis of Incidental Adrenal Lesions: A Systematic Review and Meta-Analysis
Mitchell P. Wilson, et al.
J Am Coll Radiol 2024;21:107-117. - “The ACR currently recommends consideration of surgical resection for incidental adrenal lesions measuring 4 cm in patients without diagnostically benign features, with no prior history of cancer, and with no biochemical features of pheochromocytoma . However, some European guidelines do not use a size threshold as a guide for management, recognizing the lack of underlying evidence supporting this size-threshold recommendation.”
Impact of Size Thresholds on the Diagnosis of Incidental Adrenal Lesions: A Systematic Review and Meta-Analysis
Mitchell P. Wilson, et al.
J Am Coll Radiol 2024;21:107-117. - TAKE-HOME POINTS
- Pooled weighted sensitivity and specificity values for detecting malignancy in patients with incidental adrenal lesions identified on imaging using a 4-cm size threshold are 85% (CI 78%-90%) and 75% (62%- 85%), respectively.
- A 4-cm size threshold demonstrates relatively preserved specificity with a trend toward improved sensitivity, compared with 5-cm and 6-cm thresholds.
- Most studies did not exclude characteristically benign lesions from size-threshold analysis, and future research reevaluating the 4-5-cm thresholds with exclusion of imaging of benign lesions may identify a higher size threshold that has improved specificity, but preserved sensitivity, compared with the 4-cm threshold.
Impact of Size Thresholds on the Diagnosis of Incidental Adrenal Lesions: A Systematic Review and Meta-Analysis
Mitchell P. Wilson, et al.
J Am Coll Radiol 2024;21:107-117. - OBJECTIVE. The purpose of our study was to evaluate the diagnostic utility of adrenal mass biopsy in patients without known or suspected extraadrenal primary malignancy.
CONCLUSION. Adrenal mass biopsy had low diagnostic yield, with low sensitivity and low specificity for malignancy. A biopsy result of adrenocortical neoplasm did not reliably differentiate benign and malignant adrenal masses.
CLINICAL IMPACT. Biopsy appears to have limited utility for the evaluation of incidental adrenal masses in patients without primary extraadrenal malignancy.
Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study
Satheesh Krishna et al.
AJR 2024; 222:e2329826 - Key Finding
- In patients without primary extraadrenal malignancy, adrenal mass biopsy had a diagnostic yield of 64% (44/69; 95% CI, 51–75%), concordance with the diagnosis from subsequent surgical resection of 100% (12/12), and sensitivity and specificity for detection of malignancy (by subsequent resection or imaging follow-up) of 73% (22/30) and 54% (21/39), respectively.
Importance
- Adrenal mass biopsy has limited diagnostic utility for theevaluation of incidental adrenal masses in patients without primary extraadrenal malignancy.
Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study
Satheesh Krishna et al.
AJR 2024; 222:e2329826 - “Incidental adrenal masses with macroscopic fat on imaging were historically considered to unequivocally represent myelolipomas. However, it has recently been recognized that adrenal adenomas can contain small amounts of macroscopic fat due to myelolipomatous degeneration and that ACC may also rarely contain small amounts of macroscopic fat. In the present study, among the 18 adrenal masses with macroscopic fat, only four were malignant; biopsy had a sensitivity of 50% for these malignancies.”
Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study
Satheesh Krishna et al.
AJR 2024; 222:e2329826 - “In conclusion, this study identified that biopsy of adrenal masses in patients without a known or suspected primary extraadrenal malignancy was safe, without any significant immediate postprocedural complications. When diagnostic, adrenal mass biopsy had high sensitivity and specificity for malignancy. However, adrenal mass biopsy had a high nondiagnostic rate, and, when classifying nondiagnostic biopsies as false results, had low sensitivity and specificity for malignancy. In particular, adrenal mass biopsies were commonly reported as adrenocortical neoplasm, a result that could not reliably differentiate benign and malignant adrenal masses.”
Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study
Satheesh Krishna et al.
AJR 2024; 222:e2329826
- “Primary adrenal leiomyosarcoma is an extremely rare mesenchymal tumor that arises from smooth muscle cells that reside in the wall of the central adrenal vein or its branches. A recent review of case reports found less than 50 cases have been reported in the English medical literature. Risk factors include acquired immunodeficiency syndrome (AIDS) and Epstein-Barr virus infection. The most common symptoms are abdominal/flank pain and anorexia and/or weight loss. Typical imaging findings are a heterogeneous adrenal mass with irregular margins that may have areas of necrosis. There may also be venous invasion and infiltration of adjacent organs.”
Primary adrenal leiomyosarcoma
Andrew Waack et al.
Radiology Case Reports,Volume 18, Issue 3,2023,Pages 741-744 - “The median age at diagnosis is 60 years. There is no sex or side predilection. Metastasis usually occurs to the lungs, liver, pancreas and bones. Surgical resection is the standard of care. Chemotherapy and radiation therapy are of uncertain benefit. There is limited information describing the imaging characteristics of primary adrenal leiomyosarcoma because it is such a rare tumor and it has been reported only relatively recently.”
Primary adrenal leiomyosarcoma
Andrew Waack et al.
Radiology Case Reports,Volume 18, Issue 3,2023,Pages 741-744
- “(GN) typically occur along with the dis- tribution of the sympathetic chain in the posterior mediasti- num (41.5%), retroperitoneum (37.5%), or adrenal medulla (21.0%). Adrenal GNs are uncommon tumors that constitute 20–30% of all ganglioneuromas. The tumor itself is composed of Schwann cells and ganglion cells. In contrast to other GNs, which more commonly affect the pediatric population, adrenal GNs are typically seen in adults in their fourth and fifth decades of life. As adrenal GNs are endocrinologically inactive, they are often clinically silent even they are large in size.”
Cross‐sectional imaging features of unusual adrenal lesions: a radiopathological correlation
Karaosmanoglu AD et al.
Abdominal Radiology (2021) 46:3974–3994 - “On CT, they appear as a mostly homogenous mass that may encircle adjacent blood vessels without luminal obstruction or invasion. The tumor borders are well-defined, and the post-contrast enhancement is characteristically not intense. Calcifications are also common and are observed in 42–60% of all GNs. Linear septal enhancement in the early stages of contrast enhancement has also been described in some patients.”
Cross‐sectional imaging features of unusual adrenal lesions: a radiopathological correlation
Karaosmanoglu AD et al.
Abdominal Radiology (2021) 46:3974–3994 - “Collision tumors are infrequently described entities and, by definition, refer to independently coexisting neoplasms that have different biological and genetic features. These coexisting neoplasms are sharply demarcated, and they do not show any tissue admixture. Although they are rare, collision tumors may also be encountered in the adrenal glands. Several adrenal collision tumors (ACT) have been reported, including adenoma or pheochromocytoma, adenoma and metastasis, myelolipoma and lymphoma, adrenocortical carcinoma and metastases, or myelolipoma have all been reported.”
Cross‐sectional imaging features of unusual adrenal lesions: a radiopathological correlation
Karaosmanoglu AD et al.
Abdominal Radiology (2021) 46:3974–3994 - “Teratomas (AT) are extremely rare tumors, with only around slightly more than 30 cases have ever been reported. Pathologically, ATs may be solid, unilocular, or multilocular cystic and may contain sebum, hair, teeth, and cal- cification. Patients are mostly asymptomatic; however, abdominal pain, low back pain, and palpable abdominal mass may be presenting symptoms.”
Cross‐sectional imaging features of unusual adrenal lesions: a radiopathological correlation
Karaosmanoglu AD et al.
Abdominal Radiology (2021) 46:3974–3994
- “We found the highest interobserver agreement in the assessment of precontrast attenuation (Κ = 0.81) as well as substantial agreement in determining the shape and the presence of calcifications (Κ = 0.69 and 0.74, respectively). Readers agreed less often regarding the presence of fat (Κ = 0.48), as well as regarding the presence of necrosis, heterogeneity, and the overall impression (Κ = 0.15, 0.24, and 0.26, respectively). CT characteristics correlated with benignity included round shape (p = 0.02), an overall radiologic impression of a benign lesion (p < 0.0001), the presence of fat (p = 0.01), and a precontrast attenuation of less than 10 Hounsfield units (p < 0.0001). The latter two of these characteristics were highly specific for benign pathology (93% and 100%, respectively).”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - “In patients without prior malignancy, size alone was a highly sensitive indicator of adrenocortical carcinoma in one study, with 90% sensitivity but only 24% specificity in one series using a 4-cm cutoff. The likelihood of adrenocortical carcinoma increases as the size increases. Approximately 6% of all adrenal tumors that have a size range of 4–6 cm are malignant, and the probability of malignancy increases to 25% for lesions larger than 6 cm.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - “Morphologic features can also be useful for characterizing these lesions. Necrosis, irregular margins, heterogeneous appearance, and the absence of fat have all been associated with malignancy. Adrenocortical carcinomas also calcify in approximately 30% of cases. Tumor morphology may more reliably indicate adrenocortical carcinoma than contrast washout, owing to the heterogeneity within a given lesion. Nonetheless, adrenocortical carcinomas usually display a washout pattern similar to that of other malignant adrenal processes.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - “In contrast to adrenocortical carcinomas, adrenal adenomas are the most common adrenal tumors, and they are usually small and not hormonally active . When smaller than 4 cm, approximately 70% of adenomas contain intracytoplasmic lipids and measure less than 10 HU on noncontract CT. Thus, they can confidently be considered benign. In the lipid-poor minority, a benign washout pattern can also be diagnostic of a benign lesion. Unfortunately, atypical adenomas can be large and heterogeneous, with areas of hemorrhage, calcification, and cystic degeneration, and in these cases, there can be significant imaging overlap with adrenocortical carcinomas.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - "The most predictive characteristic was precontrast attenuation. Lesions that were classified as < 10 HU in attenuation by the readers were all benign, and the lowest precontrast attenuation for an adrenocortical carcinoma was measured at 18.6 HU. Low precontrast attenuation has been demonstrated to be specific for benign adenomas due to the fact that adrenal adenomas often display abundant intracytoplasmic lipid. The presence of fat on CT was correlated to a benign pathologic diagnosis in our study with a specificity of 93%, and there was moderate interobserver agreement regarding its presence or absence.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - "In conclusion, our study identified morphologic CT characteristics that correlate with the pathologic diagnosis for large adenomas and adrenocortical carcinomas, including precontrast attenuation, shape, and the presence of fat, which can be determined by different radiologists with moderate or greater consistency. Two of these, attenuation and the presence of fat were both highly specific for benign pathology, although the sensitivity for each was low, and many lesions therefore remain indeterminate by CT. Attenuation was both more specific and had higher interobserver agreement, indicating it may be the best indicator of the underlying pathology. Further study is needed to uncover additional imaging findings that can confidently and consistently predict a benign diagnosis, potentially allowing patients to undergo conservative management and avoid the cost and potential complications of surgery.”
Interobserver agreement in distinguishing large adrenal adenomas and adrenocortical carcinomas on computed tomography.
Thomas AJ et al.
Abdom Radiol (NY). 2018 Nov;43(11):3101-3108. - “Angiosarcomas make up less than 1% of soft-tissue sarcomas; they are malignant tumors that arise from the endothelium of blood vessels and, in addition to soft tissue, commonly occur in the breast, skin, spleen, bone, and liver. The survival rate at 5 years is 24% to 31%.Twenty-two cases of adrenal angiosarcomas in the medical literature (English language alone) have been reported.”
Primary Adrenal Angiosarcoma: A Rare and Potentially Misdiagnosed Tumor.
Grajales-Cruz A et al.
Cancer Control. 2017;24(2):198-201. - “The etiology of adrenal angiosarcoma is unknown, but it has been associated with exposure to arsenic-containing insecticides. Another report concerns a person aged 68 years who was employed at a factory and had been exposed to vinyl chloride for 15 years No case, including ours, had a history of multiple endocrine neoplasia syndrome.Our patient also had no known history of toxic exposure. Adrenal angiosarcoma occurs more frequently in men in the sixth and seventh decades of life than in younger men or women of any age.The most commonly reported symptom is pain combined with the finding of an abdominal mass.”
Primary Adrenal Angiosarcoma: A Rare and Potentially Misdiagnosed Tumor.
Grajales-Cruz A et al.
Cancer Control. 2017;24(2):198-201. - "Diagnosing primary angiosarcomas of the adrenal gland is made difficult for pathologists and other health care professionals for several reasons. Necrosis and hemorrhage associated with cystic changes make it challenging to identify the primary focus.In addition, other neoplasias, including pheochromocytomas and cortical adenomas, have been associated with cystic components.Thus, an experienced clinician must pay detailed attention to the gross specimen and take into account identification of the solid component of the angiosarcoma.By contrast to most angiosarcomas with a histological vasoformative pattern, most primary adrenal gland angiosarcomas have a solid epithelioid pattern.”
Primary Adrenal Angiosarcoma: A Rare and Potentially Misdiagnosed Tumor.
Grajales-Cruz A et al.
Cancer Control. 2017;24(2):198-201.
- “Neuroblastoma (NB) is a tumor derived from the neural crest that usually originates in the adrenal medulla, but it may arise anywhere within the sympathetic nervous system. NB is a common malignancy in children but rarely occurs in adults; less than 10% of all cases are diagnosed after the age of 10 years. The incidence for patients between 30 and 39 years of age is approximately 0.2 cases per million person-years. NB has different biological features in adolescents and adults, and a longer course in both of these groups than in children. However, the outcome is poor regardless of stage .”
Long-Term Survival in Adult Neuroblastoma with Multiple Recurrences.
Vénat-Bouvet L, et al.
Case Rep Oncol. 2010 Feb 24;3(1):45-48. - “The computed tomographic (CT) findings in five adult patients with neuroblastoma and in one with ganglioneuroblastoma are presented. Four patients had abdominal and thoracic disease, one had abdominal disease only, and one had isolated chest involvement. The CT findings are nonspecific and may be confused with lymphoma. Nevertheless, multifocal presentation, particularly if it includes the posterior mediastinum and association with diffuse or focal bone involvement, when present, should suggest the diagnosis and lead to appropriate laboratory and histopathologic workup.”
Computed tomography of adult neuroblastoma.
Feinstein RS, Gatewood OM, Fishman EK, Goldman SM, Siegelman SS.
J Comput Assist Tomogr. 1984 Aug;8(4):720-6
- "Non-traumatic adrenal hemorrhage is uncommon but potentially fatal. Listed etiologies for non-traumatic adrenal hemorrhage include stress (from recent surgery, organ failure, burns, hypotension, sepsis, and pregnancy), post- procedural (adrenal venous sampling and adrenal biopsy), hemorrhagic diathesis or coagulopathy, neonatal stress and intratumoral hemorrhage.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology https://doi.org/10.1007/s00261-020-02580-w - “Although rare, intratumoral adrenal hemorrhage is the fourth most common cause of spontaneous retroperitoneal hemorrhage after renal cell carcinoma, renal angiomyolipoma and renal artery aneurysm. The most common adrenal tumors associated with hemorrhage include pseu- docyst, myelolipoma, adrenal hemangioma, pheochromo- cytoma, adrenocortical carcinomas, hemorrhagic adrenal metastases (most commonly from bronchogenic carcinoma and malignant melanoma) and rarely adrenal adenoma. Benign tumors more commonly hemorrhage com- pared to malignant tumors and pheochromocytoma is the most common benign tumor which may bleed.”
CT and MR imaging of acute adrenal disorders
Amar Udare et al.
Abdominal Radiology https://doi.org/10.1007/s00261-020-02580-w
- “A laparoscopic approach to adrenal tumor excision is the preferred surgical method, due to associated shorter recovery time and lower risk of operative complications, relative to the open approach. Laparoscopic adrenalectomy involves the transabdominal insertion of a small video chip camera, and other surgical instruments, into the peritoneal space through specially designed ports, allowing the surgeon to resect an adrenal tumor through 5–12 mm incisions. Relative to an open approach, this technique provides lower perioperative morbidity and mortality, shorter hospitalization time, better cosmetic results, reduced postoperative narcotic analgesic requirements, and improvement in the post- operative interval to normal dietary intake.”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe,Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - However, controversy persists as to the appropriateness of the laparoscopic approach under some circumstances, particularly for large adrenal tumors and for suspected ACC. For ACC in particular, open adrenalectomy has been associated with improved oncologic outcomes, secondary to lower rates of intraoperative tumor capsule violation and to lower risk of tumor margin positivity, despite the more significant short-term morbidity inherent to this invasive technique (relative to its laparoscopic counterpart).
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - “Adrenal CT scanning provides information that determines the potential for successful laparoscopic adrenal resection, including lesion size, characteristics of surrounding anatomy, and tumor features suggestive of malignancy (including degree of tissue heterogeneity, lesion vascularity, presence of calcifications, necrosis, and local invasion).”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - “Scenarios in which image-guided biopsy may provide useful information are limited to cases of suspected metastasis to an adrenal gland, for which biopsy material can facilitate identification of the originating site for an otherwise unknown primary tumor, and to cases of adrenal infection, for which the causative organism is unknown.”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - “Feo and colleagues reported that experienced surgeons could resect adrenal tumors 5 cm laparoscopically, with surgical outcomes similar to those associated with smaller tumors, although tumors >8 cm were associated with longer operative times.”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - “Given a generally accepted increase tumor recurrence risk associated with laparoscopic ACC resection, open adrenalectomy, during which direct tumor palpation is used to assess disease extent and preserve the tumor capsule, is the preferred approach for ACC. In light of this preference, preoperative identification of adrenal malignancy becomes critically important to the surgeon.”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - Under such circumstances, laparoscopic adrenalectomy may be considered, as metastatic disease to the adrenal gland, unlike ACC, has not generally been associated with increased risk of peritoneal carcinomatosis. Nonetheless, tumor imaging features in these cases, including metastasis size and evidence for associated local invasion, drive selection of operative approach, just as in cases of ACC.”
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - Adrenalectomy is the standard of care when treatment is indicated for an adrenal tumor. Though dissertation of the various modalities available for adrenal imaging is beyond the scope of this manuscript, assessment of imaging characteristics that inform selection of adrenalectomy operative approach is effectively achieved by multi-phase CT scanning (including tumor size, probability of malignant character, identification of local tumor invasion and assessment for local/distant metastatic disease).
What the radiologist needs to know: the role of preoperative computed tomography in selection of operative approach for adrenalectomy and review of operative techniques
Steven P. Rowe, Carolina Lugo-Fagundo, Hannah Ahn, Elliot K. Fishman, and Jason D. Prescott
Abdom Radiol (2019) 44:140–153 - Laparoscopic left adrenalectomy
- Laparoscopic right adrenalectomy
- Bilateral Adrenal Masses: Malignant
- Metastases (renal cell carcinoma, melanoma, hepatoma)
- Lymphoma
- Neuroblastoma
- Pheochromocytoma
- “Imaging characteristics of adrenal tumors on CT scan predict benign pathology 100% of the time. Regardless of size, when interpreted as benign on CT scan, laparoscopic adrenalectomy, if technically feasible, should be the technique used when surgery is offered, or close surveillance may be a safe alternative.”
Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter? Azoury SC, Nagarajan N, Young A, Mathur A, Prescott JD, Fishman EK, Zeiger MA. J Comput Assist Tomogr. 2017 Jan 20. (in press) - ”Pathology was benign in 88.4%, indeterminate in 2.3%, and malignant in 9.3%, with a median tumor diameter of 2.7 cm (interquartile range, 1.7-4.1 cm) and 9.5 cm (interquartile range, 7.1-12 cm) in the benign and malignant groups, respectively (P < 0.001). Of the tumors with benign features on CT, 100% (143/143) had benign final pathology.
Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter? Azoury SC, Nagarajan N, Young A, Mathur A, Prescott JD, Fishman EK, Zeiger MA. J Comput Assist Tomogr. 2017 Jan 20. (in press) - “In resected adrenal tumors, the presence of nonbenign ImF is more sensitive for malignancy than mass size (100 vs. 55 %) with equivalent specificity. Regardless of mass size, adrenalectomy should be strongly considered when non-benign ImF are present.”
Adrenal Imaging Features Predict Malignancy Better than Tumor Size. Yoo JY et al. Ann Surg Oncology 2015 Dec;22 Suppl 3:S721-7. - “If size ≥4 cm had been used as the sole criterion for surgery, 45 % of malignancies (9/20) would have been missed including 8 metastases and an ACC.”
Adrenal Imaging Features Predict Malignancy Better than Tumor Size. Yoo JY et al. Ann Surg Oncology 2015 Dec;22 Suppl 3:S721-7.
- “Differentiation between benign and metastatic adrenal masses in patients with RCC can be achieved accurately by combining multiple imaging features on contrast-enhanced CT.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “Adrenal metastasis is reported to occur in 1.2–10% of patients with renal cell carcinoma (RCC). On the other hand, adrenal incidentalomas, which are discovered at radiologic examinations conducted for indications other than adrenal disease, are relatively common, occurring in approximately 3–7% of the adult population, and most are benign. Given the frequency of adrenal metastasis in patients with RCC and the frequency of incidentaloma in the general population, it is expected that approximately half of adrenal masses in patients with RCC are metastases.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “Choi et al. reported that adrenal metastases from hypervascular primary extraadrenal malignancies, such as RCC or hepatocellular carcinoma, showed a wash- out pattern similar to that of adrenal adenoma.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “The size of the adrenal mass is an important variable in predicting malignancy .If an adrenal mass is larger than 4 cm, it is usually thought to be malignant. The adrenal masses larger than 4 cm in our population also had high predictive value for metastasis. On the contrary, smaller adrenal mass tended to be benign. However, there was substantial overlap between benign and metastatic adrenal masses with small size.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “The CT attenuation values of metastatic adrenal masses were statistically significantly higher than those of benign masses in both the corticomedullary phase and nephrographic phase. According to Choi et al., the attenuation values of metastases from RCCs (n = 16) and hepatocellular carcinomas (n = 3) on 1-minute contrast-enhanced CT were significantly higher than those of adenomas. They also reported that attenuation values of greater than 140 HU included 37% (7/19) or 32% (6/19) of metastases, whereas no cases of adenomas were included. Our observation was similar to their result; attenuation values greater than 130 HU in the corticomedullary phase had high predictive values of metastasis (100% [11/11]), although only 26.2% (11/42) of metastatic adrenal masses met the criteria.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “We calculated the attenuation difference between renal and adrenal masses on the hypothesis that the difference would be smaller in metastases than other adrenal masses because the metastatic site usually follows the characteristics of the primary tumor. As we speculated, the attenuation difference was statistically significantly smaller in metastatic adrenal masses than in benign adrenal masses in both the corticomedullary phase and nephrographic phase.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038 - “In the univariate analysis, the attenuation difference was useful for the prediction of benignity when the difference was large; the attenuation difference larger than 40 HU in the corticomedullary phase had high predictive values of benignity. In addition, the absolute values of the attenuation difference were statistically significant variables in the multivariate logistic regression models of both the corticomedullary phase and nephrographic phase. On the other hand, the attenuation difference was less useful in the prediction of metastasis when the difference was small because of large overlap with benign adrenal masses.”
Differentiation of Benign From Metastatic Adrenal Masses in Patients With Renal Cell Carcinoma on Contrast-Enhanced CT Sasaguri K et al. AJR 2016; 207:1031–1038
- Lymphoma
- Usually secondary adrenal involvement
- 4% of patients with non-Hodgkin lymphoma have adrenal involvement
- Nearly half will be bilateral
- CT:
- Discrete mass
- Infiltrative and ill-defined
- Encases vessels without obstruction - Adrenal Insufficiency
- Bilateral hemorrhage adrenal insufficiency
- Nonspecific symptoms
- Fatigue, weakness, muscle/joint pain
- Abdominal pain, vomiting, diarrhea
- Depression, behavioral changes
- Hypotension - Collision Tumor
- Coexisting lesions of different pathology
- CT and clinical findings inconsistent with one type of lesion
- Example: mass with macroscopic fat in a patient with Cushing’s disease - Adrenal Masses
- Adenoma
- Myelolipoma
- Metastases
- Pheochromocytoma
- Adrenal Cortical Carcinoma
- Lymphoma - Adrenocortical Carcinoma
- 1st and 4th decades of life
- 55% are functional
- Cushing syndrome
- Feminization
- Virilization
- Mixed Cushing/virilization
- Hypertension common with functional - Adrenocortical Carcinoma
- Mean 10 cm…up to 25 cm
- Larger less likely to be functional
- Compression of adjacent organs
- Heterogeneous enhancement
- Presence of necrosis
- Calcification in minority
- IVC invasion
- Adrenocortical carcinoma
- Renal cell carcinoma
- Hepatocellular carcinoma - Mimics of Adrenocortical Carcinoma
- Hepatocellular carcinoma
- Retroperitoneal sarcoma
- Large, necrotic pheochromocytoma
- Large hematoma
- Lymphoma
- Usually secondary adrenal involvement
- 4% of patients with non-Hodgkin lymphoma have adrenal involvement
- Nearly half will be bilateral - Lymphoma: CT
- Discrete mass
- Infiltrative and ill-defined
- Encases vessels without obstruction - Mimics of Adrenal Carcinoma
- Hepatocellular carcinoma
- Retroperitoneal sarcoma
- Large, necrotic pheochromocytoma
- Large hematoma
- Adrenal Metastases: Common Sites of Origin
- Renal cell carcinoma
- Melanoma
- Lung cancer
- Colorectal cancer
- Breast cancer
- Lymphoma