IMAGING OF ADRENAL

TUMOURS
 CT

• Once an adrenal lesion is detected, the important initial

imaging characteristics that are evaluated include

1) lesion size,
2) homogeneity, and
3) presence of fat, hemorrhage or calcifications.
4) Additional characterization includes CT density evaluation on
Both unenhanced and enhanced CT studies.
 NODULE / MASS SIZE

• It is generally considered that the risk of malignancy in an adrenal mass

increases with Increasing size.

• Most masses smaller than 4 cm are likely to be benign;.

• Reviews reported that less than 2% of adrenal adenomas are greater than

4 cm in diameter and less than 0.03% are greater than 6 cm,

• whereas 92% of adrenal cortical carcinomas are greater than 6 cm.

• most studies have shown that size alone cannot be used to exclude

malignancy
 NODULE/MASS HOMOGENEITY
• Most adrenal adenomas are relatively homogeneous, and rarely undergo

Hemorrhagic degeneration, necrosis, or calcifications.

The homogeneous nature of most adrenal adenomas is helpful in

distinguishing them from malignant lesions.

Adrenal adenomas, especially larger ones, may occasionally undergo

intratumoral hemorrhagic degeneration with development of avascular and

cystic internal regions and subsequent fibrosis and ultimate calcification.

• show variable CT attenuation and enhancement pattern and can be
confused with adrenal malignancy
benign right adrenal adenoma (arrow head) on:
a)unenhanced; b )enhanced
Heterogeneous adrenal adenoma mimicking adrenal carcinoma. Pathology
proven adrenal cortical adenoma with organizing hematoma (arrowheads)

heterogeneous right adrenal mass (arrows)

showing several thin peripheral areas of
enhancement on the early enhanced images
with central lower attenuation areas
Demonstrating progressive increased
enhancement on the delayed enhanced
images on CT
• Imaging findings such as presence of fat which suggest a diagnosis

of myelolipoma may be helpful in making a specific diagnosis, but this

is true in only a small percentage of adrenal masses.
• adrenal adenomas may calcify or may undergo myelolipomatous

metaplasia appearing as macroscopic fat.

• heterogeneous appearance of adrenal lesions alone is not helpful in

distinguishing between benign and malignant adrenal masses

 ADRENAL MYELOLIPOMA

Right adrenal myelolipoma (a) with Left adrenal myelolipoma (arrowhead)

predominant fat attenuation and with predominant soft tissue attenuation
minimal soft tissue (arrowheads). and small focus of macroscopic fat (arrow)
Heterogeneous adrenal adenoma with macroscopic fat. Pathology proven
right adrenal cortical adenoma with myelolipomatous metaplasia

Unenhanced (a) and enhanced (b) CT examinations showing a

heterogeneous right adrenal gland mass (arrowhead ) containing low
attenuation areas with areas of fat density (white arrow)
 NODULE/MASS DENSITY
• CT densitometry using unenhanced CT in the differentiation

of benign from malignant adrenal masses.

This is based on that unenhanced CT can detect

intracytoplasmic lipid (composed mainly of cholesterol, fatty
acids, and neutral fat), which is often abundantly present within
most adenomas but rarely present within malignant lesions
• Amount of histologic lipid in many adrenal adenomas

accounts for their low attenuation on the unenhanced CT scans.

• A threshold value of 10HU gave the most optimal overall ratio

of 73% sensitivity and 96% specificity for the diagnosis of

adenoma.
• Adenomas containing relatively small amounts of lipid, or

‘‘lipid poor’’ adenomas, account for 10%–40% of all adenomas.

They have an attenuation value of more than 10HU on
unenhanced CT and therefore cannot be distinguished from non
adenomas (metastases or primary adrenocortical carcinomas )
• several studies performed to evaluate the enhancement features of

adrenal masses that adenomas, in contrast to Malignant masses, tend to

have a rapid loss of attenuation value or rapid washout soon after

enhancement with intravenous contrast (IV) material on delayed scans

• The washout features were also shown to be independent of the lipid

content of an adenoma, as lipid-poor adenomas, demonstrate enhancement

washout features nearly identical to lipid-rich adenomas

Depending on whether an unenhanced scan is obtained or not, two types
of percentage washout, (1) absolute and (2) relative to the initial
enhancement of adrenal masses can be calculated.
• The optimal combination of sensitivity and specificity for the

diagnosis of adrenal adenoma occurred on the 15-min-delayed images,

with sensitivity: specificity ratio of 88% and 96% using absolute

enhancement washout at a threshold of 60%

Using a relative percentage washout threshold of 40% at the 15

min delay, the sensitivity: specificity ratio was 96% and 100%

respectively
UNENHANCED CT (25 HU) POST CONTRAST 60 SEC (90 HU)

DELAYED 15 MIN (45 HU)

Incidental right adrenal lipid-poor
adenoma (arrowhead ) on: a)unenhanced;
b) enhanced; c)15-min-delayed CT.

The attenuation values were 25, 90 and

45HU respectively giving an absolute
contrast washout value of 69%
 MRI OF ADRENAL ADENOMA VS
NONADENOMA

• Majority of adenomas are small (<3–4cm), smooth, round or

oval and Homogenous with signal intensity little different from

that of Liver on both T1 and T2 weighted images,
Whereas malignancies which typically have higher signal on
T2 weighted images.
• Chemical shift imaging (CSI) is the mainstay of MR evaluation
Of solid adrenal lesions
Bilateral adrenal masses seen as
homogeneous intermediate T1 signal
intensity lesions, low T2 signal intensity
and demonstrated rim enhancement
following gadolinium administration.
Chemical shift imaging: (C) in-phase and (D) out-of-phase images. (D),
both drop significant visual signal intensity; all the parameters are in
keeping with typical lipid-rich adenomas.
• MRI identifies intracellular lipid because of the different

precessional frequencies of protons in fat and water in a given

voxel.
This creates in-phase and out-of-phase images with loss of
signal intensity on out-of-phase images when compared with in
phase images
• lipid-rich adenomas -- complete signal intensity loss on out-of

phase images.
malignant lesions which lack intracellular lipid, remain
unchanged.
• Quantitative analysis can be made using
• adrenal-splenic ratio (ASR) and
• signal intensity index (SII)
• To calculate adrenal-lesion-to-spleen ratio (ASR), regions of

Interest (ROIs) are used to acquire the signal intensity (SI) within
the adrenal mass and the spleen from in-phase and out-of-phase
images.
• The ASR reflects the percentage signal drop-off within the

adrenal lesion compared with the spleen.

An ASR ratio of 70 or less has been shown to be 100% specific for
adenomas but only 78% sensitive
Signal intensity index uses the same characteristics of the adrenal
mass on both in- and out-of-phase imaging and can be calculated .

signal intensity index of more than 16.5% both indicate a

lipid-rich adenoma
• Recent studies indicate that CSI is more sensitive in the detection of

intracellular lipid than CT.

Whereas on unenhanced CT, up to 30% of adenomas are lipid poor,
only 8% demonstrate no loss of signal intensity on CSI.
• When CSI was applied to lipid-poor adenomas with non-contrast CT

attenuation values between 10 and 30 HU, CSI detected adenomas

with a sensitivity of 89%.
Therefore in this group of adrenal masses, CSI detects more
adenomas than non-contrastenhanced CT
 ADRENOCORTICAL CARCINOMA

• Adrenal cortical carcinomas (AAC) are very rare, with an

incidence of about 1–2 per million per year worldwide and lead
to 0.1%–0.2% of all cancer Deaths
• There is a bimodal age distribution with disease peaks before

the age of five and in the fourth to fifth decade of life

overall adrenocortical carcinoma is slightly more common in
women than men
• Nonfunctional carcinomas occur in an older age population
(>30 years old) and are more common in men (3:2 male:female
ratio),
functional tumors are more common in women (7:3
female:male ratio) and younger patients.
 Clinical features
• The most frequent presentation of ACC in adults is a rapidly progressive

Cushing’s syndrome combined with evidence of hyperandrogenemia; hirsuitism,

oligomenorrhoea and sometimes Frank virilisation.

Hypercortisolemia in isolation cannot distinguish between an adrenal adenoma

and ACC but the excess secretion of more than one class of hormone is indicative

of ACC.

Children are more likely to present with virilisation alone.

nonfunctioning ACC patients present with a large mass and symptoms related

to mass effect (e.g., abdominal or flank pain or with a palpable mass)

 CT
• The typical appearance of ACC on unenhanced CT is of a large,

inhomogeneous but well-defined suprarenal mass that displaces adjacent

structures as it grows .

• Regions of low attenuation correspond to necrosis

• After the administration of IV contrast material, there is inhomogeneous

enhancement of the tumor, typically with greater enhancement seen

peripherally and relatively little enhancement seen centrally, because of

central necrosis
Unenhanced CT scan shows large low-
Portal venous phase CT scan shows large
attenuation suprarenal mass
heterogeneously enhancing left suprarenal
(arrowheads), with internal areas of high
mass that displaces left kidney inferiorly.
attenuation (arrows) consistent with
Regions of nonenhancing tissue (arrows)
hemorrhage.
are consistent with necrosis.
• ACCs retain IV contrast material and have absolute and relative percentage

washout of less than 60% and less than 40%, respectively, at 15 minutes after

Contrast administration
• Calcification, either microcalcification or coarse calcification, is seen on CT

in approximately 30% of patients with ACC and is usually centrally located

Unenhanced CT image shows that lesion (arrow) has attenuation of 29 HU and therefore
requires further characterization.
B and C, CT images obtained 60 seconds (B) and 15 minutes (C) after administration of IV
contrast material show lesion (arrow) has attenuation values of 54 and 43 HU,
respectively. These attenuation values result in absolute percentage washout of 43% at 15
minutes. Mass was confirmed to be ACC on histology.
• Tumor thrombus extending into the IVC at presentation is not rare and is

more frequently seen in right-sided tumors.

A tumor thrombus within a vein is usually well encapsulated and can often be

withdrawn intact from the vein.

The presence and cephalad extent of tumor thrombus can be identified on

Contrast enhanced CT.

• CT is also of value in showing the local and distant spread of an ACC.
• Preservation of fat planes around the tumor indicates that there is no local

invasion.
• Metastases are frequently found at presentation:
• Regional and paraaortic lymph nodes, lungs , liver ,
and bone are the common sites.
Hepatic metastases tend to be hypervascular and are best
seen on arterial phase imaging after IV contrast administration.
 MRI
• ACC is typically heterogeneous in signal intensity on MRI because of

The Presence of hemorrhage and/or necrosis

• On T1- weighted imaging, ACC is typically isointense or slightly

hypointense to normal liver parenchyma.

High T1 signal intensity is often seen because of the presence of
Hemorrhage
• On T2-weighted imagingACC is usually hyperintense to liver

Parenchyma and has a heterogeneous texture because of the presence

of intratumoral cystic regions and hemorrhage
Axial T1-weighted MR image shows high
signal intensity (arrows) within right Axial T2-weighted MR image shows high signal
adrenal mass (arrowheads) intensity (arrows) consistent with necrosis.
consistent with hemorrhage.
 CHEMICAL SHIFT IMAGING

Chemical shift imaging shows large irregular right-sided lesion (arrow) that
does not show signal loss between in-phase (A) and out-of-phase (B)
images. Tumor was confirmed to be ACC on histology.
 PET
Functional Imaging
• FDG PET can identify some malignant adrenal masses by virtue of their

increased metabolic Activity

• To distinguish between adenomas and non-adenomas, qualitative visual

assessment alone of FDG activity in benign adrenal adenomas is variable,

ranging from mild, moderate to high FDG uptake while malignant masses
have moderate to high uptake.
• the specificity is lower, ranging between 87 and 97%.
• This loss of specificity is attributable to a small number of adenomas and

other benign lesions that mimic the high metabolic activity of malignant
lesions
• The novel PET tracer 11C metomidate, a marker of 11β-hydroxylase,

Is used as tracer for adrenocortical tissue and is taken up by adenomas

and ACCs.

This marker differentiates adrenal cortical lesions from

Pheochromocytomas and metastases, which are uptake-negative

• most valuable aspect of PET is its ability to detect distant

metastases
Axial diagnostic contrast-enhanced CT image (A) and axial (B) fused PET/CT
images show large right adrenal mass (arrow) with avid FDG uptake and
multiple metabolically active hepatic metastases (arrowheads).
 TUMOURS OF ADRENAL MEDULLA

NEOPLASM TISSUE NEOPLASM

NEURAL CREST
Least differentiated

SYMPATHOGONIA
(PRIMITIVE CELL)

SYMPATHOBLAST PHEOCHROMOBLAST

NEUROBLASTOMA NEUROBLASTOMA
SYMPHATHETIC PHEOCHROMOCYT
GANGLION CELL E
Most differentiated
and mature
GANGLIONEUROMA PHEOCHROMOCYTOMA
• These neoplasms are unique in that they apparently have the ability to

change from a clinically and pathologically Malignant tumour to a benign

neoplasm.

This explains the spontaneous regression and cure associated with this

tumour

Neuroblastomas undergo spontaneous regression more commonly than

any other malignant neoplasm by either complete disappearance or

maturation into a benign ganglioneuroma

 NEUROBLASTOMA
• It occurs most frequently in infants and children.
• It is the most common extracranial solid malignant tumour of

childhood
• 8% of total childhood malignancies
• 50-80% arise in the adrenal glands
• 60% of the patients have metastasis to the cortical bone, bone
marrow, lymph nodes, liver
• Neuroblastomas are aggressive tumours; the majority are

irregularly shaped, lobulated and unencapsulated.

They invade adjacent organs or encase adjacent vessels, and
tend to
be inhomogeneous owing to tumour necrosis and haemorrhage.

They contain coarse, amorphous, mottled peripheral

calcification
in approximately 85% of cases
• Neuroblastomas produce abnormally high catecholamine
precursors that
are detected by measurement of urinary catecholamine
metabolites,
• vanillylmandelic acid (VMA) and
• homovanillic acid (HVA).
• Neuroblastomas secrete noradrenaline and gastrointestinal

hormones, particularly, vasoactive intestinal peptide (VIP)

 Plain xray
• Non specific : demonstrate an intrathoracic or intraabdominal

soft tissue mass

• Upto 30% of the cases show calcification in

plain xray
Large soft tissue
density in the left
upper quadrant
displacing bowel
inferiorly
Ultrasonography:

• Mass can be cystic, solid or

of mixed echogenecity

• Calcification : may be seen

CT
• large mass, with calcification, often extending across the midline to engulf

and displace the aorta anteriorly.

• Heterogeneous contrast enhancement is usual.

• Imaging is useful for defining morphological features, precisely assessing

tumour extension to retroperitoneal lymph nodes and liver, around central

vessels, and into the vertebral canal.

Liver metastases may take one of two forms: diffuse infiltration, or focal

hypoenhancing masses.
• Large heterogeneously
enhancing mass
compressing the left
kidney
 MRI
• Axial T2-weighted image

Showing a large hetrogenous mass

(arrow) extending into the

retro-aortic space, encasing and

displacing the aorta anteriorly. These

Features are characteristic of

neuroblastomas
• MRI is the preferred investigation for assessing intraspinal

Extension of primary tumour (the so-called dumbbell tumours,

Seen in 10% of abdominal, 28% of thoracic and occasionally
in cervical neuroblastomas) and
for detection of diffuse hepatic metastases; these metastases
manifest as areas of high signal intensity on T2-weighted images.
DUMBBELL TUMOUR
ACCOMPANYING SYNDROMES
Hutchinson syndrome –bony metastases may present with
skeletal pain or a palpable mass or limping and irritability
Pepper syndrome – hepatomegaly due to extensive liver
Metastasis
Blue berry muffin syndrome - multiple cutaneous metastatic
lesions from a primary adrenal neuroblastoma
Paraneoplastic syndrome - opsomyoclonus (jerky eye
movements with myoclonus and cerebellar ataxia)
 GANGLIONEUROMA

• Most differetiated neoplasm – benign

• It occurs frequently in adults than in children
• Sites : posterior mediastinum , Retroperitoneum , pelvis,

Of the retroperitoneal site, one half will occur in adrenals

• USS- sonolucent ,homogeneous tumour
• CT -- well marginated, lobular in appearance, homogeneous
and relatively low density (less than muscle )
USG
CT
• Contrast enhanced ct – homogeneous with relatively slight

enhancement usually less than muscle

• Punctate calcifications present in 50% of cases

MRI
T1 – homogeneous low signal intensity (less than liver)
T2 – heterogeneous high signal intensity (greater than that of liver)
Gadolinium contrast – moderate enhancement on delayed scan
 PHEOCHROMOCYTOMA
• Phaeochromocytomas, the commonest tumours of the adrenal medulla,

are paragangliomas arising from neural crest cells.

Adrenal phaeochromocytomas constitute 90% of all Paragangliomas.
Ten per cent of adrenal phaeochromocytomas are multiple,
10% are malignant with the incidence increasing in tumours larger
than 6 cm,
10% are associated with neuroectodermal syndromes
(neurofibromatosis, tuberosclerosis, von Hippel–Lindau disease,
multiple neuroendocrine neoplasia types 11a and 11b) and
10% are non-functioning tumours.
• Functioning phaeochromocytomas mainly secrete catecholamines—

adrenaline and nor-adrenaline

• The diagnosis of a phaeochromocytoma is made clinically and

biochemically by detection of elevated plasma and urinary levels of

catecholamines or their metabolites, vanillylmandelic acid (VMA) and

Metanephrine

• Urinary metanephrine or vanillylmandelic acid (VMA) is elevated in >90%

of patients when measured on 24-hour urine collections.

Plasma-free metanephrine levels are elevated in 99% of patients.

• Sporadic adrenal phaeochromocytomas are usually large at

time of diagnosis (90% larger than 2 cm) and readily detected on

imaging.
Phaeochromocytomas occuring in association with
neuroectodermal syndromes (MEN, VHL, neurofibromatosis) are
smaller at the time of detection, as these patients are actively
screened, usually by MRI
 USG
• On ultrasound,

phaeochromocytomas are

welldefined, ovoid or round

suprarenal masses.
• They frequently have an

inhomogeneous internal

Architecture due to haemorrhage

and necrosis
 CT

• On unenhanced CT, the tumours have a soft-tissue density and

speckled calcification is present in up to 12% of tumours.

Phaeochromocytomas characteristically demonstrate intense
contrast enhancement
• In tumours with a large amount of central necrosis, the tumour
may
appear cystic. Even in these tumours a peripheral rim of intensely
enhancing soft tissue can still be demonstrated
 MRI
• On MR imaging, most phaeochromocytomas are iso- or

hypointense to the liver on spin-echo (SE) T1-weighted imaging.

• On spinecho T2-weighted images the typical

Phaeochromocytoma has a very high signal intensity. Larger

tumours tend to be inhomogeneous, containing cystic central
necrosis, calcification or haemorrhage.
• On chemical shift imaging typical phaeochromocytomas do
not show signal intensity loss on opposed-phase images.
Pheochromocytoma. The right adrenal mass shows heterogeneous
enhancement on this MR examination. An incidental hepatic
hemangioma is also seen
A T1-weighted axial spin echo MRI shows majority of 6 cm mass is isointense to liver
(arrow) with a peripheral hyperintense rim (arrowhead). B T2-weighted spin echo
MRI shows majority of mass to be markedly hyperintense (arrow) with peripheral rim
of lower signal intensity (arrowhead). Signal intensities are consistent with
hemorrhage
 MIBG
• Metaiodobenzylguanidine (MIBG) is an aralkyl derivative of guanethidine,

a structural analog of norepinephrine, and is capable of imaging adrenergic

tissue and detecting pheochromocytomas.
Both 131I and 123I are used for imaging, but 123I is preferable due
to its higher sensitivity, lower radiation dose, and better image quality
Pheochromocytomas have increased uptake on MIBG studies

• I-MIBG is especially useful in detecting recurrent or metastatic

pheochromocytoma, tumors with fibrosis, or tumors in unusual locations

Enhanced CT scan shows heterogeneously enhanced adrenal mass
(arrow) with intense enhancement in peripheral portion of mass and
nonenhancing regions mainly in central portion, compatible with cystic
and necrotic degeneration.
B, Metaiodobenzylguanidine-123 scans show focal intense uptake
(arrowheads) at right adrenal mass.
 Lymphoma
• Primary adrenal lymphoma is extremely rare and accounts for 3% of

extranodal lymphomas .

• Secondary adrenal lymphoma is much more common.

• The diffuse large B cell lymphoma subtype accounts for 70% of cases.

• Adrenal lymphoma is bilateral in approximately 50% of cases .

• The presence of bilateral large adrenal masses without extraadrenal

disease should raise suspicion for primary adrenal lymphoma

• Most primary adrenal lymphomas are large well-defined soft tissue

masses that replace the adrenal glands with preservation of the

triangular appearance.
• Adrenal enlargement without shape distortion is also Recognized

• On CT, primary adrenal lymphoma shows an approximately even

distribution of homogeneous and heterogeneous patterns, with most

tumors having a hypoattenuating appearance and slight-to-moderate
enhancement
• Calcifications are rare
• Homogeneously
enhancing masses
(arrows) with low
attenuation are noted in
both adrenal glands on
contrast-enhanced CT
scan
 MRI
• On MRI, primary and secondary lymphomas are hypointense

to isointense on T1-weighted images and hyperintense on T2

weighted images.
• Mild-to-moderate enhancement is commonly seen
 PET/CT
• Adrenal lymphomas
show high uptake on FDG
PET

PET/CT shows both adrenal masses (arrows)

with intense FDG uptake
 Metastasis
• Adrenal metastasis constitutes a small proportion of adrenal

incidentalomas.
Metastases to the adrenal glands are common in patients who have a
history of malignant disease.
• Malignant tumors that originate from the lung, breast, melanoma, kidney,
colon, esophagus, pancreas, liver, and stomach commonly metastasize to the
adrenal gland .
Bilateral involvement of metastasis is more common than unilateral
involvement
• A metastasis is a solid mass and, when <3 cm in diameter, is

usually homogeneous
• Larger Iesions may demonstrate central necrosis or areas of

hemorrhage.
• It is difficult to differentiate metastasis from an adrenal

Adenoma or other adrenal nodule on conventional imaging,

especially when the adrenal lesion is small.
Adrenal metastaaes. Bilateral adrenal masses Adrenal metastases. This right adrenal
are seen with low-density central areas metastasis (arrow) from an underlying
representing tumor neaosis. hepatoma is small. well defined, and
homogeneous.