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Adrenal: Malignant Adrenal Tumor Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Adrenal ❯ Malignant adrenal tumor
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  • “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
© 1999-2017 Elliot K. Fishman, MD, FACR. All rights reserved.