State-of-the-Art Adrenal Imaging1
William W. Mayo-Smith, MD,
Giles W. Boland, MD,
Richard B. Noto, MD and
Michael J. Lee, MD
1 From the Departments of Radiology of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903 (W.W.M-S., R.B.N.); Harvard University, Massachusetts General Hospital, Boston, Mass (G.W.B.); and Royal College of Surgeons, Beaumont Hospital, Dublin, Ireland (M.J.L.). Received October 25, 2000; revision requested November 15 and received December 28; accepted December 29. Address correspondence to W.W.M-S. (e-mail: william_mayo-smith@brown.edu).
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Figure 1. Normal adrenal gland. Coronal reformatted image from helical CT data shows the triangular shape of the adrenal gland (arrows) and its relationship to the kidneys and diaphragms.
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Figure 2. Normal adrenal gland. T1-weighted breath-hold MR image demonstrates a normal left adrenal gland (arrow).
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Figure 3. Sagittal US scan demonstrates an enlarged right adrenal gland (arrow) lying posterior to the right lobe of the liver. Although US may reveal adrenal masses, CT is the modality of choice for initial adrenal mass characterization.
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Figure 4a. Pheochromocytoma in a 30-year-old man evaluated with CT. (a) Contrast-enhanced axial CT scan demonstrates an enlarged right adrenal gland with internal calcifications (arrow). (b) Coronal reformatted image from the axial data set demonstrates the relationship of the right adrenal pheochromocytoma (arrow) to the upper pole of the right kidney and the liver.
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Figure 4b. Pheochromocytoma in a 30-year-old man evaluated with CT. (a) Contrast-enhanced axial CT scan demonstrates an enlarged right adrenal gland with internal calcifications (arrow). (b) Coronal reformatted image from the axial data set demonstrates the relationship of the right adrenal pheochromocytoma (arrow) to the upper pole of the right kidney and the liver.
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Figure 5a. Pheochromocytoma in a 45-year-old woman evaluated with MR imaging. (a) Axial T2-weighted image with fat saturation demonstrates a bright mass in the right adrenal gland (arrow). (b) Coronal T2-weighted image with fat saturation helps confirm the location of the mass in the adrenal gland (arrow) and that it is separate from the liver and the kidney.
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Figure 5b. Pheochromocytoma in a 45-year-old woman evaluated with MR imaging. (a) Axial T2-weighted image with fat saturation demonstrates a bright mass in the right adrenal gland (arrow). (b) Coronal T2-weighted image with fat saturation helps confirm the location of the mass in the adrenal gland (arrow) and that it is separate from the liver and the kidney.
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Figure 6. Pheochromocytoma in a patient evaluated with nuclear medicine imaging. Posterior image obtained 48 hours after intravenous administration of I-131 MIBG demonstrates increased activity in the right adrenal gland (arrow).
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Figure 7. Adrenal hyperplasia in a woman with Cushing disease. Contrast-enhanced CT scan demonstrates thickening of the limbs of the left adrenal gland but a normal right adrenal gland. The prominent intraabdominal fat and hepatic steatosis seen here are typical findings in this disease.
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Figure 8. Left adrenal aldosteronoma in a 43-year-old woman. Contrast-enhanced helical CT scan shows a 5-mm well-circumscribed left adrenal mass (arrow), which proved at surgery to be an aldosterone-secreting adenoma.
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Figure 9. Functioning right aldosteronoma in a patient with hyperaldosteronism. Posterior image obtained 5 days after intravenous administration of NP-59 shows increased activity in the right adrenal gland (arrow), a finding consistent with a functioning adenoma. Normal activity is seen in the bowel, bladder, and liver.
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Figure 10. Adrenal venous sampling in a 51-year-old man with biochemically proved aldosteronoma. Angiogram shows the catheter, which was placed in the right adrenal vein (arrow) via the inferior vena cava. The adrenal veins were opacified by using gentle hand injection of contrast material, thus confirming correct placement for adrenal venous sampling. Cortrosyn-stimulated aldosterone levels were four times higher on the left than the right. The patient’s symptoms resolved after left adrenalectomy.
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Figure 11. Typical nonenhanced CT findings of an adrenal adenoma in a 64-year-old man with no known malignancy. The left adrenal adenoma (arrow) has smooth margins, is well defined, and has a attenuation of 5 HU, all findings characteristic of an adenoma.
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Figure 12. Typical nonenhanced helical CT findings of metastasis in a 76-year-old man with lung carcinoma. On the CT scan, the right adrenal gland (arrow) is enlarged, has irregular contours, and has an attenuation of 36 HU, all findings characteristic of metastasis. Adrenal masses with attenuation values over 10 HU at nonenhanced CT require further evaluation with either CT contrast material washout, chemical shift MR imaging, or adrenal biopsy.
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Figure 13a. Typical attenuation and washout of intravenous contrast material in a left adrenal adenoma in a 54-year-old woman with a history of breast carcinoma. (a) Nonenhanced CT scan shows a left adrenal adenoma (arrow), which has an attenuation of 4 HU. (b) On the dynamic enhanced phase image, the adrenal gland (arrow) enhances vigorously to 54 HU. (c) On the 10-minute delayed image, the attenuation of the left adrenal gland (arrow) is 23 HU (lower than that of the normal right adrenal gland, kidneys, and liver). There is greater than 50% washout between the dynamic phase of contrast enhancement and the 10-minute delay, which is diagnostic of an adenoma and confirms the finding on the nonenhanced CT scan. Quantitative region-of-interest measurements (in Hounsfield units) are important because degree of enhancement is difficult to quantify with the human eye.
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Figure 13b. Typical attenuation and washout of intravenous contrast material in a left adrenal adenoma in a 54-year-old woman with a history of breast carcinoma. (a) Nonenhanced CT scan shows a left adrenal adenoma (arrow), which has an attenuation of 4 HU. (b) On the dynamic enhanced phase image, the adrenal gland (arrow) enhances vigorously to 54 HU. (c) On the 10-minute delayed image, the attenuation of the left adrenal gland (arrow) is 23 HU (lower than that of the normal right adrenal gland, kidneys, and liver). There is greater than 50% washout between the dynamic phase of contrast enhancement and the 10-minute delay, which is diagnostic of an adenoma and confirms the finding on the nonenhanced CT scan. Quantitative region-of-interest measurements (in Hounsfield units) are important because degree of enhancement is difficult to quantify with the human eye.
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Figure 13c. Typical attenuation and washout of intravenous contrast material in a left adrenal adenoma in a 54-year-old woman with a history of breast carcinoma. (a) Nonenhanced CT scan shows a left adrenal adenoma (arrow), which has an attenuation of 4 HU. (b) On the dynamic enhanced phase image, the adrenal gland (arrow) enhances vigorously to 54 HU. (c) On the 10-minute delayed image, the attenuation of the left adrenal gland (arrow) is 23 HU (lower than that of the normal right adrenal gland, kidneys, and liver). There is greater than 50% washout between the dynamic phase of contrast enhancement and the 10-minute delay, which is diagnostic of an adenoma and confirms the finding on the nonenhanced CT scan. Quantitative region-of-interest measurements (in Hounsfield units) are important because degree of enhancement is difficult to quantify with the human eye.
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Figure 14a. Typical attenuation and washout characteristics of a left adrenal metastasis in a 65-year-old man with lung carcinoma. (a) Nonenhanced CT scan demonstrates an enlarged left adrenal gland (arrow) with irregular margins and attenuation of 40 HU. (b) Dynamic enhanced CT scan of the adrenal gland (arrow) obtained 60 seconds after intravenous administration of contrast material demonstrates an increase in attenuation to 53 HU. (c) Ten-minute delayed image of the left adrenal gland (arrow) demonstrates persistent enhancement of the adrenal gland (56 HU). There is no significant washout of contrast media at 10 minutes, a finding consistent with an adrenal metastasis.
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Figure 14b. Typical attenuation and washout characteristics of a left adrenal metastasis in a 65-year-old man with lung carcinoma. (a) Nonenhanced CT scan demonstrates an enlarged left adrenal gland (arrow) with irregular margins and attenuation of 40 HU. (b) Dynamic enhanced CT scan of the adrenal gland (arrow) obtained 60 seconds after intravenous administration of contrast material demonstrates an increase in attenuation to 53 HU. (c) Ten-minute delayed image of the left adrenal gland (arrow) demonstrates persistent enhancement of the adrenal gland (56 HU). There is no significant washout of contrast media at 10 minutes, a finding consistent with an adrenal metastasis.
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Figure 14c. Typical attenuation and washout characteristics of a left adrenal metastasis in a 65-year-old man with lung carcinoma. (a) Nonenhanced CT scan demonstrates an enlarged left adrenal gland (arrow) with irregular margins and attenuation of 40 HU. (b) Dynamic enhanced CT scan of the adrenal gland (arrow) obtained 60 seconds after intravenous administration of contrast material demonstrates an increase in attenuation to 53 HU. (c) Ten-minute delayed image of the left adrenal gland (arrow) demonstrates persistent enhancement of the adrenal gland (56 HU). There is no significant washout of contrast media at 10 minutes, a finding consistent with an adrenal metastasis.
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Figure 15a. Indeterminate right adrenal mass found at CT in a 45-year-old woman with breast cancer. (a) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows signal drop-off in the adrenal gland (arrow), which is diagnostic of an adenoma.
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Figure 15b. Indeterminate right adrenal mass found at CT in a 45-year-old woman with breast cancer. (a) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows signal drop-off in the adrenal gland (arrow), which is diagnostic of an adenoma.
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Figure 16a. Left adrenal metastases in a 74-year-old man with lung cancer. (a) T1-weighted in-phase MR image demonstrates a left adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows no significant signal loss in the adrenal gland compared with that of the spleen. The mass is either a metastasis or atypical adenoma, and biopsy was recommended.
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Figure 16b. Left adrenal metastases in a 74-year-old man with lung cancer. (a) T1-weighted in-phase MR image demonstrates a left adrenal mass (arrow). (b) T1-weighted out-of-phase MR image shows no significant signal loss in the adrenal gland compared with that of the spleen. The mass is either a metastasis or atypical adenoma, and biopsy was recommended.
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Figure 17a. Right adrenal adenoma in a patient with hepatic steatosis. (a) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow), which is isointense relative to the liver (L) and slightly higher in signal intensity than the spleen (S). (b) T1-weighted out-of-phase MR image shows signal drop-off in both the liver (due to steatosis) and the mass. The adrenal mass has clearly lost signal compared with the spleen on out-of-phase images, a finding that is diagnostic of an adenoma.
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Figure 17b. Right adrenal adenoma in a patient with hepatic steatosis. (a) T1-weighted in-phase MR image demonstrates a right adrenal mass (arrow), which is isointense relative to the liver (L) and slightly higher in signal intensity than the spleen (S). (b) T1-weighted out-of-phase MR image shows signal drop-off in both the liver (due to steatosis) and the mass. The adrenal mass has clearly lost signal compared with the spleen on out-of-phase images, a finding that is diagnostic of an adenoma.
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Figure 18a. Right adrenal adenoma. (a) Contrast-enhanced CT scan demonstrates a smooth-margin, low-attenuation right adrenal mass (arrow). (b) FDG PET scan shows normal activity in the kidneys (arrows) but no increasing activity in the right adrenal gland.
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Figure 18b. Right adrenal adenoma. (a) Contrast-enhanced CT scan demonstrates a smooth-margin, low-attenuation right adrenal mass (arrow). (b) FDG PET scan shows normal activity in the kidneys (arrows) but no increasing activity in the right adrenal gland.
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Figure 19a. Right adrenal metastasis in a patient with lung carcinoma. (a) Nonenhanced CT scan demonstrates a right adrenal mass (arrow). (b) FDG-PET SPECT scan obtained at the same level shows increased activity in the right adrenal gland (arrow), a finding diagnostic of a metastasis.
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Figure 19b. Right adrenal metastasis in a patient with lung carcinoma. (a) Nonenhanced CT scan demonstrates a right adrenal mass (arrow). (b) FDG-PET SPECT scan obtained at the same level shows increased activity in the right adrenal gland (arrow), a finding diagnostic of a metastasis.
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Figure 20. Decubitus position for a right adrenal biopsy in a 76-year-old man with metastatic lung carcinoma. Use of the decubitus position causes decreased ventilation of the dependent lung, allowing a larger window for access to the adrenal gland. As seen on the CT scan, the nondependent lung has markedly increased aeration (large straight arrow) compared with the dependent lung. In addition, use of a coaxial core biopsy system allows access to the adrenal gland (small arrow) while avoiding the adjacent inferior vena cava (curved arrow).
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Figure 21a. Use of an angled gantry for adrenal biopsy in a 64-year-old patient with metastatic lung carcinoma. (a) Nonenhanced diagnostic CT scan obtained with the patient in the supine position demonstrates bilateral adrenal masses. (b) CT scan acquired with the patient in the prone position shows increased aeration of the lung bases (arrows), which makes access to the adrenal glands difficult. (c) With the CT gantry angled 20° and the patient in the prone position, the radiologist has a safer route of access to the left adrenal gland without transgressing a significant amount of pulmonary parenchyma (arrow).
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Figure 21b. Use of an angled gantry for adrenal biopsy in a 64-year-old patient with metastatic lung carcinoma. (a) Nonenhanced diagnostic CT scan obtained with the patient in the supine position demonstrates bilateral adrenal masses. (b) CT scan acquired with the patient in the prone position shows increased aeration of the lung bases (arrows), which makes access to the adrenal glands difficult. (c) With the CT gantry angled 20° and the patient in the prone position, the radiologist has a safer route of access to the left adrenal gland without transgressing a significant amount of pulmonary parenchyma (arrow).
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Figure 21c. Use of an angled gantry for adrenal biopsy in a 64-year-old patient with metastatic lung carcinoma. (a) Nonenhanced diagnostic CT scan obtained with the patient in the supine position demonstrates bilateral adrenal masses. (b) CT scan acquired with the patient in the prone position shows increased aeration of the lung bases (arrows), which makes access to the adrenal glands difficult. (c) With the CT gantry angled 20° and the patient in the prone position, the radiologist has a safer route of access to the left adrenal gland without transgressing a significant amount of pulmonary parenchyma (arrow).
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Figure 22. Transhepatic approach to right adrenal biopsy in a 69-year-old woman with breast cancer. CT scan shows the biopsy needle placed through the liver.
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Figure 23. Algorithm summarizes the work-up used to differentiate benign from malignant adrenal masses in oncology patients.
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Figure 24. Addison disease in a 51-year-old man. Contrast-enhanced CT scan shows both adrenal glands, which appear small and with dense calcification. The cause of the calcification was not known but may have been due to remote hemorrhage or tuberculosis.
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Figure 25. Adrenal carcinoma in a patient who presented with left flank pain. Contrast-enhanced CT scan demonstrates an 11-cm necrotic mass in the left adrenal gland, which causes inferior displacement of the left kidney. There is stranding of the adjacent retroperitoneal fat.
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Figure 26. Bilateral myelolipomas in a 79-year-old man. Nonenhanced CT scan shows an exophytic mass of fat attenuation (straight arrow) in the right adrenal gland. The left adrenal gland has a soft-tissue mass containing calcifications and a central area of fat attenuation (curved arrow). These benign adrenal lesions were stable over 4 years.
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Figure 27. Right adrenal hemorrhage in a 57-year-old woman who sustained pelvic trauma in a motor vehicle accident. Nonenhanced helical CT scan of the abdomen obtained 2 days after the accident demonstrates an enlarged right adrenal mass (arrow). The mass was not present on CT scans acquired at admission (not shown). The attenuation of the right adrenal hemorrhage was 53 HU.
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Figure 28. Adrenal lymphoma in a 74-year-old woman with biopsy-proved non-Hodgkin lymphoma. Contrast-enhanced CT scan demonstrates bilateral adrenal masses (straight arrows). The patient also has a destructive lesion from the lymphoma in the right rib (curved arrow).
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Copyright © 2001 by the Radiological Society of North America.
