Imaging of the adrenal glands

CT and Angiography in Adrenocortical Carcinoma

CT and angiography were performed in 15 patients with adrenocortical carcinoma. The tumors had a mean diameter of 11 cm (range 4–20 cm). At CT, the 8 largest tumors were ill-defined, and in these, the organ of tumor origin could not be established. Angiographically the correct organ of tumor origin was established in all but one patient. It is concluded that CT is excellent in showing the extent of an adrenal tumor, but is often unable to predict the organ of origin in large tumors. Angiography is still of great value in the preoperative work-up in patients with large adrenocortical carcinomas for correct identification of tumor origin and for vascular mapping.

Accuracy of Adrenal Biopsy Guided by Ultrasound and CT

We reviewed the results of fine needle biopsy of the adrenal glands guided by ultrasonography or CT in 56 patients. The final diagnoses, obtained at operation, autopsy or follow-up were: metastasis (n = 22), adenoma (n = 21), adrenal cyst (n = 6), hematoma (n = 3), lymphoma (n = 1), pheochromocytoma (n= 1), lymph node (n = 1), and amyloid mass (n= 1). Sufficient cytologic material was obtained in 96.4% (54/56). The overall accuracy to differentiate benign from malignant disease was 85.7% (48/56), 2 were false-negative, one was false-positive. The biopsy was inconclusive (“possibly malignant”) in 3 patients, 2 of whom had an additional cutting needle biopsy yielding a correct positive finding. No complications occurred. We conclude that in disseminated malignant disease with suspected adrenal metastases diagnostic results can be obtained with guided fine needle biopsy. Biopsy in primary adrenal lesions is helpful, especially if the aspirate of the lesion turns out to be composed of something other than adrenal cells.

Pheochromocytoma in children and adolescents: a clinical spectrum

PURPOSE

The purpose of the study was to identify the spectrum of disease characteristics of pheochromocytoma in children.

METHODS

Records of 21 consecutive children diagnosed with pheochromocytoma were reviewed. Patients' age, sex, presentation, associated conditions, diagnostic and imaging modalities used, preoperative preparation, operative details, outcome, and follow-up were recorded.

RESULTS

The study included 21 children. Patients were diagnosed clinically and confirmed by biochemical tests. Tumors were localized by imaging studies and all were confirmed pathologically. Patients included 17 with adrenal and 4 with extra-adrenal tumors including 1 in the urinary bladder. Seventeen had sporadic and 4 had familial pheochromocytoma. Associated manifestations were the predominant features in 1 of the 4 patients with familial pheochromocytoma. The patient with bladder pheochromocytoma presented with gross hematuria. Hypertension and visual disturbances were prominent findings in the other patients with sporadic form. Two patients (1 sporadic and 1 familial) had malignant pheochromocytoma. One patient with benign pheochromocytoma had multiple recurrences in chromaffin-containing sites. All patients were treated surgically. Seventeen patients were treated preoperatively with alpha-adrenergic blockade. Two patients continued to have significant visual disturbances. One patient with malignant pheochromocytoma died of the disease, and 1 with recurrent pheochromocytoma had neurologic consequences.

CONCLUSIONS

Pheochromocytoma in children has unique characteristics. To our knowledge, this series is one of the largest reports of adrenal pheochromocytoma in children. It also reflects the spectrum of pheochromocytoma in this age group.

Diagnosis and management of adrenal cortical carcinoma

Adrenal cortical carcinoma is a relatively uncommon malignancy that represents a significant clinical challenge for the development of optimal treatment strategies. Historically, successful treatment has relied upon rapid identification of the lesion, accurate staging with diagnostic imaging, and complete surgical extirpation. Although the framework of a successful treatment paradigm still relies on these steps, advances in diagnostic imaging have led to increased accuracy in diagnosis, and advances in laparoscopic surgical technique have served to reduce morbidity for patients facing treatment. This review focuses on a discussion of advances in modalities for the diagnosis and treatment of adrenal cortical carcinoma amenable to curative therapy. Patients that present with metastatic or locally advanced disease generally are treated with mitotane-based chemotherapy with or without the addition of cytotoxic drugs. Contemporary results of this treatment approach are presented in this review as well as a discussion of further directions for the treatment of patients with advanced disease.

Hyperaldosteronism and pheochromocytoma: new tricks and tests

Hyperaldosteronism, previously thought to represent only 1% to 2% of cases of hypertension, may cause as much as 25% of hypertension in a primary care setting. The renin/aldosterone ratio is the best test for initial screening, followed by localization if possible. Aldosterone antagonists, such as spironolactone, and surgery are the mainstays of treatment. Pheochromocytomas are rare, but because they are a curable cause of hypertension and potentially fatal if not found, important to diagnose. Clinical presentation is variable; however, if symptoms are present, they usually include hypertension, hyperhydrosis, headaches, or palpitations sometimes occurring in dramatic fashion. Once a diagnosis is entertained, appropriate laboratory confirmation is essential. Positive laboratory confirmation then leads to localization of the tumor for eventual surgical removal. New biochemical tests and imaging procedures are making the difficult job of diagnosing and finding these tumors.

Magnetic resonance imaging of the presumed normal canine adrenal glands

Forty-three dogs without evidence of endocrine disease that underwent spinal or abdominal magnetic resonance imaging (MRI) for clinical reasons were studied. Because the procedures were not optimized for inclusion of the adrenal glands, they were not always visible in all planes. Eighty-five of the 86 adrenal glands were seen and only the left gland in a 6-month-old Irish wolfhound could not be found. The right adrenal gland lay cranial to the left in all of the animals in which both glands were seen. The best landmarks for localization of the glands were vascular; both adrenal glands were always cranial to the ipsilateral renal vessels and in the region of the celiac and cranial mesenteric arteries. Various measurements were made on all the available scan planes. In some dogs the whole adrenal gland was difficult to visualize clearly, and this hindered the measuring process, especially when the right adrenal gland was in close contact with the caudal vena cava. The adrenal glands were mainly linear in shape but also had a variable degree of modification of their poles, especially the cranial pole of the right adrenal gland, which tended to be consistently wider and to present different shapes (rounded, arrowhead, inverted P, hook-shaped, triangular, or dome-shaped). Two main patterns of signal intensity were seen on fast spin echo (FSE) sequences (T2-weighted, T1-weighted, and T1-weighted after administration of a paramagnetic contrast medium): homogeneous and hypointense to surroundings or a corticomedullary type pattern with a hyperintense central area surrounded by a hypointense rim of tissue. The outline of the left adrenal gland was always very clear. The clarity of outline of the right adrenal gland was more variable, especially if it was in contact with the liver or the caudal vena cava. It was felt that the amount of retroperitoneal fat was not as important as stated in the human literature for visualization of the adrenal glands and that with an appropriate selection of scan planes and pulse sequences good assessment of the adrenal glands can be performed with MRI in canine patients.

Magnetic resonance: evaluation of adrenal lesions

Magnetic resonance imaging provides a detailed display of adrenal anatomy. The development of new imaging sequences, especially chemical shift imaging, has vastly enhanced the specificity of magnetic resonance imaging. This review outlines current magnetic resonance imaging strategies for assessing disease affecting the adrenal glands. Particular emphasis is placed on the characterization of adrenal masses.

Secondary hypertension: evaluation and treatment

Most patients with hypertension in the United States have essential (primary) hypertension (95%), the cause of which is unknown. The remaining 5% of adults with hypertension have the secondary form of hypertension, the cause and pathophysiologic process of which are known. Internists and other primary care physicians refer to this as treatable or curable hypertension, because the hypertension can be managed or even controlled with medications. Similarly, the condition is called surgical hypertension by surgeons in the belief that once the cause is determined and identified, surgical intervention will result in cure of hypertension. Secondary causes of hypertension include renal parenchymal disease, renovascular diseases, coarctation of the aorta, Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, hyperthyroidism, and hyperparathyroidism. Occasionally included in this category are alcohol- and oral contraceptive-induced hypertension and hypothyroidism, but these conditions are not discussed herein. The evaluation of secondary hypertension is of interest and can bring together different facets of anatomy, physiology, pharmacology, and radiology in the medical and surgical treatment of these disorders. Despite enthusiasm that can be generated in the evaluation of these conditions, evaluation can be expensive and should not be conducted for all patients with hypertension. Features that aid in the diagnosis of secondary hypertension include the following: 1. Onset of hypertension before the age of 20 or after the age of 50 years. The presence of hypertension at a young age may suggest coarctation of the aorta, fibromuscular dysplasia, or an endocrine disorder. Hypertension found for the first time after the age of 50 years may suggest the presence of renovascular hypertension caused by atherosclerosis. 2. Markedly elevated blood pressure or hypertension with severe end-organ damage, as in grade III or IV retinopathy. These findings suggest the presence of renovascular hypertension or pheochromocytoma. 3. Specific body habitus and ancillary physical findings. For example, truncal obesity and purple striae occur with hypercortisolism, and exophthalmos is associated with hyperthyroidism. 4. Resistant or refractory hypertension (poor response to medical therapy usually necessitating use of more than three antihypertensive medications from three different classes). 5. Specific biochemical test that suggest the existence of certain disorders, such as hypercalcemia in hyperparathyroidism, hyperglycemia in Cushing's syndrome and pheochromocytoma, and unprovoked hypokalemia with renin-producing tumors, primary hyperaldosteronism, or renin-mediated renovascular hypertension. 6. Other characteristics that may suggest secondary hypertension such as abdominal diastolic bruits (renovascular hypertension), decreased femoral pulses (coarctation of the aorta), or bitemporal hemianopias (Cushing's disease). A combination of a good history and physical examination, astute observation, and accurate interpretation of available data usually are helpful in the diagnosis of a specific causation.

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma

OBJECTIVES

Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy.

METHODS

A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery.

RESULTS

Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation.

CONCLUSIONS

In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Diagnostic advances in APUDomas and other endocrine tumors: imaging and localization

The different diagnostic imaging modalities available for determining the location of the various APUDomas are discussed with reference to their advantages and disadvantages. The ability to image these lesions, and to be confident in their role in the underlying pathophysiology, and clinical neuroendocrine syndrome causing symptomatology and illness, has proved to be the key to successful treatment. In many instances it is not the diagnosis that is in question, but it is the extent of disease, the location of the lesion, or whether the anatomical abnormality under study is responsible for the complicating symptoms being considered, that are the crucial questions. The ability to locate APUDomas by a variety of direct and indirect imaging or regionalizing modalities, represent a magnificent advance in the management of these tumors. It should, however, be kept in mind that no one modality or diagnostic method can uniformly be relied upon. It is evident that a multimodal, interactive medical team approach is essential to the successful overall management of patients afflicted with these fascinating tumors.

Mineralocorticoid production of adrenal cortical adenomas

We studied in vitro and in vivo corticosteroid production as well as the presence of symptoms of an increased mineralocorticoid effect in patients with 'silent' adrenal cortical adenomas, and compared these results to those found in patients with classical mineralocorticoid excess syndromes. We found that under in vitro conditions, cells from 'silent' adrenal cortical adenomas (n = 19) produced substantial amounts of both zona glomerulosa and fasciculata steroids, although the production of steroids in these cells was lower compared to that in mineralocorticoid-producing adenoma cells (n = 26). Patients with aldosterone-producing and 'silent' adenomas had significantly increased plasma atrial natriuretic peptide levels, which remained non-suppressible after upright posture and furosemide administration. Of the 25 patients with 'silent' adenomas, 11 had low and non-stimulable plasma renin activity (PRA) before but, in most cases, not after adrenal surgery. When compared to those with normal PRA (n = 14), patients with low PRA 'silent' adenomas (n = 11) had higher blood pressure which was significantly reduced after surgery, and a mild hypokalemia before but not after surgery. Although basal plasma concentrations of aldosterone, 18-hydroxy-corticosterone, corticosterone, deoxycorticosterone, 18-hydroxy-DOC, cortisol,11-deoxycortisol and 17-hydroxy-progesterone (17-OH-P) were not increased in either groups of 'silent' adenomas, ACTH stimulation produced a hyperreactive response for all measured steroids, of which an extremely high 17-OH-P seemed to be one of the most intriguing findings. We consider that these observations in 'silent' adrenal cortical adenomas may justify surgical intervention, irrespective of the size and potential malignancy of these adenomas.

MR imaging of adrenal lymphoma

A case of lymphoma of the adrenal glands is presented. Both computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated large bilateral adrenal masses with no other associated abdominal abnormalities. MR was better able to demonstrate inferior vena caval patency than CT, and effectively exclude pheochromocytoma as a differential diagnostic consideration due to signal characteristics of the masses.

Modern imaging methods in oncology

Modern imaging methods are very important in the management of patients with cancer and of their disease. It is vital that clinicians treating them understand the relevance of different imaging techniques for specific applications, so that the best choice can be made to aid diagnosis and monitor response to treatment. This review briefly covers the development and principles of the diverse imaging methods available, from the discovery of x-rays by Röntgen in 1895 to the recent techniques of magnetic resonance and positron emission tomography. The authors endeavour to point out the strengths and weaknesses of each method, using clinical examples where appropriate. Finally, future developments are discussed. It is hoped that this review will aid clinicians diagnosing and treating cancer patients to choose the most suitable imaging method for their patients from among the vast array available.

MRI of the adrenal gland

Current status of magnetic resonance imaging (MRI) of the adrenal gland is reviewed, and basic techniques and sensitivity of MRI for differentiating histologic lesions are also discussed.

Role of adrenal imaging in surgical management

Adrenal imaging using radiopharmaceuticals is a functional test that can contribute significantly to surgical management and follow-up of patients with either benign or malignant conditions of the adrenal cortex and medulla. Imaging of the cortex is achieved by iodine-131-labeled iodomethyl nor-cholesterol (NP-59), while adrenal medulla imaging can be successfully accomplished by 131I-metaiodobenzylguanidine (MIBG), which localizes in the adrenergic nerve terminal with norepinephrine. Both tests carry high sensitivity and specificity for functional tumors and hyperplasia, and often better than CT scanning. This article reviews the current status and clinical utility of nuclear imaging of the adrenal cortex in congenital hyperplasia, low renin hypertension and aldosteronism, and Cushing's syndrome. Adrenal medulla imaging is reviewed in light of our experience at the University of Texas M.D. Anderson Cancer Center in pheochromocytoma, neuroblastoma, and other neuroectodermal tumors. Investigation of 131I-MIBG therapy of metastatic tumors of neuroectodermal origin potentially offers a means of at least controlling symptoms of hormonal secretion in these patients.

Adrenal venous sampling and adrenal biopsy

The current status of adrenal vein sampling and the role of adrenal gland percutaneous biopsy will be reviewed.