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Átirat

Approach of adrenal lesions

Adrenal incidentalomas

*An adrenal mass > 1 cm that is detected on imaging exams not performed for suspected adrenal disease "incidentally discovered"

* They are common and seen in about 3% of abdominal CT's, and 10% in elderly patients

No Follow Up

Typically Benign

A 64-year old patient scanned for analysis of an abdominal aneurysm.

The scan in the arterial phase shows bilateral lesions with a density of 50 HU.

On the non-enhanced CT, the density in both adrenal glands was less than 10HU, proving these to be lipid-rich adenomas.

Myelolipomas:

Benign tumors composed of bone marrow elements, easy to recognize on CT or MR because they contain areas of macroscopic fat.

Calcifications are seen in 24% of cases.

Typically Benign

Cyst:

well-defined lesion of water density that does not enhance.

with a thin wall and may have thin septa.

It may be an endothelial cyst or a pseudocyst (with thick walls), or a true epithelial or parasitic cyst (both rare)

Malignant tumors with cystic degeneration has an irregular thick wall of 5 mm or more and mural, septal or solid enhancement.

Lipid-rich adenoma

Myelolipoma

Cyst

Lesions with benign calcifications

Hemorrhage (appriopriate history, e.g. trauma or severe illness)

Longterm ( > 6 -12 months) unchanged lesions (+ no history of cancer)

Lesions that do not enhance

Benign calcifications:

Coarse rounded, bilateral, peripheral or septal calcifications.

may be seen in:

Adenoma

Myelolipoma

Trauma

Granulomatous infection

Punctate, dystrophic and irregular calcifiations are not typically benign and can be seen in:

Adrenocortical cancer

Adrenal metastases

Indeterminate lesions

Size 1-4 cm

Size >4cm

1-2 cm with no history of cancer>>> Benign

Follow up after 1 year

Indeterminate lesions

Adrenal washout CT or MRI

Adenomas rapidly wash out contrast.

Non-adenomas enhance rapidly, but take longer to washout.

Absolute washout

consists of a non-contrast, a contrast -enhanced scan with a delay of 60-90 sec and a delayed scan at 15 minutes.

Relative washout

Consistent of an enhanced scan and a second scan at 15 minutes after contrast injection

Adrenal washout

Lipid poor adenoma

MRI Out-of-phase imaging

Lipid-poor adenomas can also be diagnosed with out-of-phase imaging.

They contain enough microscopic fat to cause a signal drop on out-of-phase imaging compared to in-phase imaging due to the chemical shift artefact.

atypical adenomas

clinical history

biopsy

Not lipid poor adenoma

with history of cancer

PET biopsy

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