Endo Radiology

ENDOCRINE IMAGING
9/7/2014 Endocrine Imaging 1

Case No: 1
60 yrs old lady
presented to us with:
Gradually increasing
6x4 cm swelling
involving left thyroid
lobe x 1yrs
No compressive
features, no recent
change in voice
No rapid increase in size
No h/o thyroid swelling
in family
No palpable Cervical
lymphadenopathy
No RSE
Investigations
HR-USG neck:
7X3 cm NODULE in Left lobe of thyroid extending to
isthmus with heterogeneous calcification with mild to
significant vascularity. No significant LAP
FNAC Left lobe thyroid and Isthmus: c/w PTC
IDL:
Left VC in para-median position, Rt. VC compensatory
movements

TT with CCLND + Left MRND
(12
th
may 2009)
Per-op Findings:
Hard and calcified nodule
of size 4x3 cm in Left
thyroid lobe infiltrating
overlying deep strap
muscles and with tracheal
invasion (Shin 1) over 2cm
area
Rt. Lobe unremarkable
Large (upto 2cm) cystic
LNs in left Level 2,3,4, and
5
Multiple small sub-
centimetric level 6 LNs

Histopathology
5x4x4 cm size single left lobe nodule: PTC with
strap muscles infiltration
5/10 Level 6 LNs: Metastatic PTC
2/7 Left MRND LNs:Metastatic PTC
FU: Scan negative with rising S.Tg
On TSH suppressive LT4 therapy
20
th
March 2010:
WBRAI Scan: negative,
S.Tg-55.7 ng/mL
23
rd
Oct.2010:
WBRAI Scan: negative,
S.Tg-181 ng/mL
USG Neck: Small LN(1cm) left lower deep cervical
region

17.2
55.7
181
0
50
100
150
200
17.08.09 20.3.10 23.10.10
S.Tg
S
.
T
g

n
g
/
m
L

Radioiodine Remnant ablation
(17
th
Aug 2009)
WBRAI Scan with 5 mCi 131-I (3 months post-
op): Increase tracer uptake in thyroid bed
High dose 40 mCi 131-I: Remnant ablation
18-FDG PET/CT Whole Body Scan
Hypermetabolic LNs noted:
Left level 4 cervical
Pretracheal
Right Tracheobroncheal
Left level 2 Axillary regions





CECT Neck and Chest
Surgical Details (25
th
jan. 2011)
Selective LN excision form Right Tracheobroncheal
and Rt. Pulmonary artery region (via open Anterolateral
Thoracotomy), Left level 4 LNs in neck (via Lower lateral
incision) and Left level 2 Axillary LN (via Axillary crease
incision)
Per-op findings:
3 black colored LNs each at right lower thymic horn, adjacent to
pulmonary vein and along Rt. Pulmonary artery and Rt .main
bronchus found (largest 2x1 cm)
2 LNs in left level 4 region of 2 and 1cm size
Single 2 cm LN in left level 2 Axillary region
Histopathology
Cervical LN: Metastatic PTC
Left Axillary LN: Free of tumor
Mediastinum LNs: Free of tumor with
numerous charcoal laden foamy histiocytes

On TSH suppression and calcium/ vit.D
replacement
follow Tg normalised

Case 2
Known HTN x 15 yrs on single drug antihypertensive
Huge Anterior neck swelling x 12 yrs
Protrusion of both eye balls with redness and pain in
eyes(right>left) x 11 yrs
Palpitations, tremor x 5-6 yrs
Change in voice and difficulty in swallowing food x 4-5
yrs
Dyspnea (NYHA class 3) x 1-1.5 yrs
Watering from both eyes with photophobia x 0.5-1 yr
On NMZ 10 mg TDS 12 yrs
Family h/o:
Younger brother-thyroid nodule
Daughter-hypothyroidism
Endocrine Imaging 38 9/7/2014
O/e:
PR: 96/min irregularly irregular
BP:170/100 mmHg
Examination of neck:
Diffuse asymmetrical (left>right) bosselated thyroid swelling (10x11 cm) with
left lobe RSE
B/L Carotids palpable and displaced laterally
No cervical LNs palpable
Eye examination:
B/L Proptosis (Rt-27 mm,Lt-26 mm), conjunctival congestion, eyelid edema +
(CAS-6/7)-Active Graves ophthalmopathy
Graves dermopathy and acroptchy present
Systemic examination:
Proximal muscle weakness+
Hyperdynamic precordium, apex beat in left 7
th
ICS in anterior axillary line

Investigations:
fT4-11.1 pmol/L (10.3-25.7)
T3-4.88 nmol/L (1.3-2.8)
TSH-0.02 mIU/L (0.3-5)
Thyroid scan:
X-Ray neck:
X-Ray chest PA view:
CECT Neck and superior mediastinum:
Surgery: Total thyroidectomy
Increased vascularity with surface bosselation
No gross adhesions
Endocrine Imaging 49
Gross:
size-
Left lobe-10x8x4 cm
Right lobe-8x7x4 cm
Isthmus-1x1x0.5 cm
Weight-200 gms
9/7/2014
Endocrine Imaging 50
Cut section:
fleshy with pseudo-nodule formation
9/7/2014
Case 3
Apparently normal till 15 years ago

Recurrent episodes of headache/drowsiness/dizziness, progressing to loss of
consciousness

1998 - Pt. realized that his complaints were relieved by intake of sweetened
beverages
2008- Hospitalized and investigated at Kota , Delhi ;
Blood Sugar -30mg%
S. Insulin 57.21( 2.6-24.9)
C. Peptide 7.94( 0.48-5.05 ng/ml)
- Diagnosed as case of Organic Hypoglycemia but lesion could not be localized

9/7/2014 51 Endocrine Imaging
These episodes were increased by prolonged fasting/physical exertion

Gradual increase in weight 10-15 kgs over 12 years

No Diabetics in family

Hypertension was detected in 2008, on treatment

No symptoms suggestive of other components of MEN 1

No previous surgery/addictions / significant family history

Clinical Examination
Ht -175 cm , Wt -81 kg , BMI 26.45

BP 140/90 mm Hg

General Examination WNL

Systemic Examination WNL

Provisional Diagnosis Organic Hypoglycemia

Investigations
Hemogram WNL

Clinical Chemistry WNL

Hypoglycemia on Supervised fasting at 10.5 hours

CECT Abdomen, ASVS, Intra operative USG for discussion

Exploratory Laparotomy with IOUSG And proceed on
23-Jan-2011
2.1x1.4 cm vascular fleshy tumor over anterior surface of body of Pancreas
Main Pancreatic duct atleast 4 mm away from ennucleated margin
No multi focality detected
Blood sugar after enucleation 92mg%

Post operative course
No fluctuations in Blood sugars

Orally allowed on POD 3

Right ( Sub hepatic drain) was removed on POD 8

POD 12, Patient is being discharged with with no specific complaints or residual
complications
Case No 4
Ref SGPGI
h/o bone
pains,proximal
muscle
weakness,mood
swings
h/o Fracture BB
forearm ,trivial
trauma
polydipsia
50 M Industrialist Kolkata
Hypercalcemia on
routine check-up
PHPT
Pulse-90/min
BP-140/100mmHg on
medications
L/E neck-no palpable nodule

Investigations
Hemogram 14.3 mg/dl
S.Creat-1.1
BUN-10
PTH- 133.6 pg/ml (15-65)
25 (OH)Vit D: 56.45 ng/ml (9-47)
S. Inorganic Phosphorus-2.9
S.Calcium- total 13,ionized 6.7mg/dl

USG neck(elsewhere)-normal study
USG neck-heterogenous lesion post-inf aspect
rt lobe thyroid-?parathyroid?LN
MIBI(Kolkata)- rt inf parathyroid adenoma
MRI/SPECT (Kolkata)- Rt submandibular gland
enlargement and Rt inf parathyroid adenoma
MIBI-SPECT-CT(SGPGI)-Lt inf parathyroid adenoma

BMD-L
1
L
4
-1.2,Z=-0.9
Hip T=-1.4, Z= -1.0
Forearm T= -4.5, Z= -4.2

IMAGING FOR DISCUSSION


















Surgery
Equivocal imaging-B/L neck
exploration
Left inf parathyroid
enlarged,firm,maroon
Wt-600mg,1.7x0.7x0.4 cm
IOPTH-curative fall
Post-op Ca
2+

-9.3(total) on
POD1
Post op course-smooth
Follow up-doing well
0
100
200
300
400
PTH
KKV, 44/M, 2010131533
Morbid obesity- 4 years
Snoring and obstructive sleep apnea- 4 years
Hypertension- 3 years
Poorly controlled on single drug
No episodic hypertension, sweating, palpitations
P/R- 80/min, BP- 160/120 mm Hg
No Cushingoid features
USG- Right adrenal mass
Provisional diagnosis- Pheo/ Cuhsings
Work up
24-hour Urinary fractionated metanephrines-
Raised (224 & 70254 miug/24 hours)

Overnight dexamethasone suppression test-
Normally suppressible (35.61 nmol/L)

Serum Potassium- Normal (4.3 mmol/L)
CECT abdomen
For discussion
Diagnosis
Right adrenal pheochromocytoma
Right open trans-peritoneal adrenalectomy
08-Feb-2011
After adequate -blockade and blood pressure
control, patient was taken up for surgery
Abdominal viscera- Normal
No peritoneal deposits, free fluid, retroperitoneal
lymphadenopathy
No gross adhesions, invasion to adjacent structures
Blood pressure fluctuations present-
Max- 130/80 mm Hg
Min- 80/50 mm Hg (after ligation of adrenal vein)
Gross
Well defined highly vascular tumor
8x7x3.5 cm, Weight 280 gm
Cut section- fleshy with areas of hemorrhagic necrosis
9/7/2014
Endocrine Imaging
100
Postoperative course
Uneventful
Gradual oral feeds, tolerated
Discharged on 9
th
post op day on Amlodipine
(BP controlled on single drug)
Histopathology
Right adrenal pheochromocytoma with
capsular invasion and extension into
periadrenal fat
No vascular invasion
No necrosis, increased mitotic activity
Follow up
MIBG scan advised as there was capsular and
periadrenal fat invasion on Histopathology- for
discussion
USG abdomen- Focal fat stranding seen in liver
Post MIBG- CECT abdomen- for discussion
24 hour urinary fractionated metanephrines-
Normal

UP, 38/M, 2004363622
Right STN- 4 x 5 cm
25-Aug 2004 (BHU)-
Right hemithyroidectomy +
berry picking of paratracheal
and level VII LN
HPE-
MTC (4.5 cm)
Lymphatic emboli
Capsular invasion
9/9 LN + for metastases
22-Sep-2004 (BHU)-
Completion thyroidectomy +
right MRND
Sternocleidomastoid muscle
cut to get access to left lobe
Left lobe normal
Right jugular chain multiple
LN
No left jugular LN
HPE-
Resected thyroid normal
7/7 LN + for metastases
Striated muscles show dense
fibrosis
Serum Calcitonin
2510
359
928
983
877.8
662.8
390 390
2000
0
500
1000
1500
2000
2500
3000
N
o
v
'
0
4
D
e
c
'
0
5
M
a
y
'
0
7
O
c
t
'
0
7
F
e
b
'
0
8
A
u
g
'
0
8
A
p
r
'
0
9
N
o
v
'
0
9
F
e
b
'
1
1
9/7/2014
Endocrine Imaging
129
Clinical course
10-Feb-2005 (BHU)-
Small right posterior triangle
cervical LN biopsy (1 cm)
HPE- Reactive
25-Jan-2006 (BHU)-
Cervical LN biopsy (1.5 cm)
HPE- Reactive
Cervical LN with persistent
hypercalcitoninemia, referred to
SGPGI
2007-
FNAC right cervical LN-
+ve for metastases (MTC)
IDL- Right cord paralyzed
Bone scan- Normal
CT neck + thorax-
Bilateral enlarged multiple
jugular LN
Enlarged LN in posterior triangle,
pretracheal, paratracheal,
prevertebral and supraclavicular
space
Thyroid not visualized
Mediastinum and lungs normal
Clinical course (SGPGI)
30-Oct-2007 (SGPGI)-
Diagnostic laparoscopy- No
peritoneal or liver metastases
CCLND with B/L MRND with
transcervical thymectomy
(Multiple bilateral LN in level
3,4,5,6, Maximum- 1.5 x 1 cm)
HPE-
CCLND- 2/4 LN +
Right MRND- 6/21 LN +
Left MRND- 1/6 LN +
Thymus- unremarkable
18-Feb-2008-
Bone scan- Increased tracer
uptake in right supraclavicular
joint (degenerative)
21-Aug-2009-
USG neck-
7-10 mm LN in left jugular chain
17 x 10 mm LN in substernal
location
24-Aug-2009-
Guided FNA Substernal LN- +ve
for metastases (MTC)
For discussion-
CECT neck
68
Ga-DOTANOC PET scan
Surgery, 23-Aug-2011
Excision of thyroid bed
recurrence with
paratracheal LN
resection with right
cervical thymectomy
with intraoperative
neuromonitoring
Size of lesion- 2.5 x 1.5
cm

Post operative period-
Uneventful
Drain removed on day 5
Discharged on day 6

Histopathology-
3/4 LN +ve for
metastatic MTC with
lymphovascular emboli
present
Preop prep
Adequately alpha blocked with
Plenty of fluids & extra salt
BP the day before Surgery
150/90 mm Hg supine
140/80 mm Hg standing
PR : 82 /mt
Weight increased from 49 kg 51
Kg

9/7/2014
Endocrine Imaging
135
Rt paraganglioma situated between IVC & Aorta
With PV antr to mass
Dense vascular adhesions between mass and IVC
Periportal & precaval nodes disssected out
Left adrenal mass minimally adhered to kidney
& surrounding structures, The renal vein was
Strectched over the mass
Rt PGL : 5.5x6x3.5 cm mass, weight :62 gms
Left Adrenal mass : 10x 7x 5.5 cm mass, weight: 185 gms
Max BP : 150/100 mm HG Min BP : 90/50 mm HG
Right Adrenal was normal & left insitu
Cut section
Rt PGL :fleshy with areas of
calcification
Left Adrenal mass : fleshy with
yellow areas
Post op
Stable: monitored for 1 day in ICU
Drain removed on 6
th
POD
BP : 140/ 90 mm HG with T. Amlodipine 10 mg
0 5 mg
Alternate sutures removed on 8
th
POD and all
sutures on 10
th
POD
Stable at the time of discharge
Post op 24 hour Urinary metanephrines
MN : 380 miug/ 24 hrs ( 0 350 )
NMN : 243 miug/ 24 hrs ( 0 600 )
Post op follow up done on 25 th POD : wound
healed well, BP normal with Amlodipine 10 5
mg

Case No 7
vomiting
Fever
weakness
Ref SGPGI
USG-B/L adrenal masses

Pain abdomen
Headache
Palpitations
Increased sweating
BP-120/70 mmHg
supine, 100/50 mmHg
standing, PR-92/min
Plaque over
interscapular area
Rt lobe thyroid-3x3cm
nodule,Lt lobe 1x1 cm
nodule upper pole
No Cushingoid features

T3-1.23nmol/L (1.3-2.8)
T4-23.9 nmol/L (60-160)
TSH- 1.35 mIU/L (0.3-5)
S. Inorganic Phosphorus-
3.5 mg/dl (2.5-4.5)
S. Calcium
Total 8.8 mg/dl (8.5-10.8)
Ionised 4.4 mg/dl (4.6-5.3)

S. Calcitonin-1866 pg/ml
Urine Metanephrine-5847
miug/24hrs (0-350)
Urine Nor-metanephrine-
3929 miug/24hrs (0-600)
S. Cortisol- >1380 nmol/L
(110-520)

USG abd-bilateral supra-renal masses
USG thyroid- multiple hypo-echoic nodules
CECT abd- bilateral adrenal solid cystic masses
Echo-concentric LVH,Grade I diastolic dysfunction

FNAC-s/o medullary thyroid carcinoma

SPOTTERS
Case 1: A 42 YR. OLD FEMALE WITH COMPLAIN OF
LETHARGY AND NECK SWELLING
Case 2:
USG

Hypoechoic area
Tiny punctate hyperechoic area representing
microcalcification
Disorganised hypervascularity with tortous vessels and a-v
shunts
Invasion to adjacent muscles on usg
Cervical LN are enlarged with punctate hyperechogenicity.


Case 3:
ADENOMA
5% -10% of nodular diseases
Females > males
Usually encapsulated solitary nodule with adjacent compression of
adjacent tissues.
No thyroid dysfunction but may be hyperfunctioning
Difficult to d/f from folicular ca
USG
Solid masses that may be hyperechoic,isoechoic or hypoechoic
Peripheral thick and smooth hypoechoic halo is seen
DOPPLER
vessel are seen in the halo
spoke and wheel pattern appearance

ROLE OF USG-

ESTABLISH THE PRECISE ANATOMIC LOCATION OF NODULE
WITHIN THE GLAND OR OUTSIDE

DIFFERENTIATE B/W OTHER CERVICAL MASSES
CYSTIC HYGROMA
THYROGLOSSAL CYST
ENLARGED LYMPH NODES

DETECT OCCULT THYROID NODULES
CLINICAL SOLITARY NODULES
H/O HEAD AND NECK IRRADIATION
H/O MEN TYPE II SYNDROME

BENIGN V/s MALIGNANT NODULE

NODULE
INTERNAL CONSISTENCY
ECHOGENICITY RELATIVE TO ADJACENT THYROID
MARGIN
CALCIFICATION
PERIPHERAL SONOLUCENT HALO
DISTRIBUTION PATTERN OF BLOOD VESSELS

Case 4:
ANAPLASTIC CARCINOMA
Elderly Age Group less than 2% of all cases
Worst Prognosis
Presents As Rapidly Enlarging Mass Infiltrating Adjacent
Structure
Mean survival 6 months and 5 year survival rate 7%
CT-
Heterogenous Mass Invading The Vessels And Neck Muscles
Case 5:
MEDULLARY CARCINOMA
Derived from para follicular cells ,secrets hormone
calcitonin
Related to men type 2 syndrome
usually is multicenteric or bilateral
metastasis is to LN

CT-
Heterogenously enhancing Mass posteriorly displacing The rt. CCA and
IJV with minimal retrotracheal extension.
50 YR MALE
WITH H/O
THYROIDECT
OMT, NOW
COMPLAINS
OF BACK PAIN
Case
6:
Case
7:
42 YE OLD FEMALE WITH CERVICAL PAIN AND NECK
SWELLING; X-RAY C- SPINE
Case
8:
Cervico thoracic sign 9/7/2014 177 Endocrine Imaging
Ant. Sup. Mediastinum

oThyroid / Parathyroid Lesion
oTortuous innominate vessels
oThymoma
oTeratodermoid
oTerrible lymphoma
A 60 YR OLD FEMALE, RESIDENT OF BIHAR CAME WITH
WEAKNESS; CECT NECK
Case
9:
DEGENERATIVE APPEARANCE OF GOITROUS
NODULES

PURE ANECHOIC AREA (SEROUS OR COLLOID FLUID)
ECHOGENIC FLUID WITH F-F LEVEL (HAEMORRHAGE)
BRIGHT ECHOGENIC FOCI WITH COMET TAIL
ARTIFACTS (MICROCRYSTALS)
INTRACYSTIC THIN SEPTATIONS
PERIPHERAL EGG SHELL CALCIFICATION

Case
10:
GRAVES DISEASE
diffuse abnormality of gland characterised by hyperfunction
inhomogenous echotexture d/t presence of large intraparenchymal
vessels.
Doppler
hypervascularity is seen-thyroid inferno
high peak systolic velocity exceeding 70cm/sec
Case
11:
X-RAY
SKULL
Case
12:
48 YR OLD MALE
PRESENTED
WITH RENAL
FAILURE
Case
13:
7
KNOWN C/O HUPERPARATHYROIDISM ON TREATMENT; X-RAY PELVIS SHOWS:
Case
14:
Brown tumors
Radiologically appear as thin walled expansile
lesions and are indistinguishable from bone
malignancies and pagets disease
Commonly seen in long bones but may be
seen in unusual locations like mandible,
maxilla, vertebrae, hard palate, iliac crest and
ribs.
A 35 YR OLD
MALE WITH
COMPLAINS OF
BONE PAIN,
WEIGHT LOSS
AND DISPEPSIA
Case
15:
Case
16
Case
17:
Aetiology
Primary ( PTH, normal or Ca
2+
)
Adenoma 90%
Hyperplasia 10%
Carcinoma < 0.1%

Secondary ( PTH appropriate to low Ca
2+ )

Chronic Renal Failure
Vitamin D Deficiency
Tertiary
Continued excess PTH secretion following prolonged
secondary hyperparathyroidism.
Vascular arc- finding in parathyroid adenoma
envelops 90 to 270 degrees of mass
diff from LN- central hilar flow pattern
Spectrum of adrenal and pancreatic lesions
Coronal reformatted image CT
characteristic inverted Y, V, shape
Case
18:
Although no strict measurements have been
standardized, any area thicker than 10 mm is
abnormal.
A useful rough estimate of normal size is that
the thickness of the gland's limbs should not
exceed the thickness of the ipsilateral
diaphragmatic crus at the same level.
NORMAL
Characterization of an Adrenal
Mass: Is It Benign or Malignant?

Adrenal masses are common, estimated to occur
in 9% of the population. However adrenal gland is
also a common site of metastasis, particularly
from lung carcinoma
In patients with no known primary cancer, an
adrenal mass is almost always a benign adenoma.
in a patient with a known neoplasm, particularly
lung cancer, the finding of an adrenal mass is
problematic.

CT in Differentiating Benign
from Malignant Adrenal Masses
Larger lesions have a greater likelihood of being
malignant. (lesions greater than 4 cm)

Change in lesion size is a useful indicator of
malignancy (adenomas are slow growing and
tend not to change size).

Adenomas tend to have smooth margins and a
homogeneous density, whereas metastases can
be heterogeneous and have an irregular shape

The left adrenal adenoma
(arrow) has smooth margins, is
well defined, and has a
attenuation of 5 HU, all findings
characteristic of an adenoma.
the right adrenal gland
(arrow) is enlarged, has
irregular contours, and has
an attenuation of 36 HU, all
findings characteristic of
metastasis.
Histologically adenomas have abundant
intracytoplasmic fat in the adrenal cortex and
thus have low attenuation at CT
metastases have little intracytoplasmic fat and
thus do not have low attenuation at
nonenhanced CT.
Cushing adenomassolitary well defined,
homogenous , 2-3cm.
Aldosteronism (conns syndrome) adenomas
small mean size 1.6-1.8cm and may have
central low attenuation due to high lipid
content.
Aldosteronoma. Computed tomography image shows
a 1-cm mass in the medial limb of the left adrenal
(arrow). The mass has an attenuation value slightly
lower than that of adjacent normal adrenal tissue.
Case
19:
Well defined hypo-attenuated lesion (-16.7 HU)
Shows homogenous enhancement of contrast (+51 HU)
Size 2.2 x 2.1 x 1.8 cm
Nonenhanced CT

Mean attenuation of adenomas was 2.2 HU and metastasis was 29 HU.
Thresholds to differentiate benign from malignant lesions have ranged
from 0 to 18 HU
Lee et al. Radiology 1991; 179:415418.

Threshold of 10 HU had a 71% sensitivity and 98% specificity for
characterizing adrenal masses. This specificity approached 100% when
other features such as adrenal size, shape, and change in lesion size were
considered
Boland et al AJR Am J Roentgenol1998; 171:201204

Need of Contrast-enhanced CT

30% of adenomas do not contain sufficient
lipid to have low attenuation at CT
Although nonenhanced CT can be used to
identify 70% of adenomas, it does not allow
the 30% that do not contain lipid to be reliably
differentiated from metastases

Physiologic
Differences in perfusion.
Adenomas enhance rapidly with intravenous
contrast media and wash out the agent rapidly
Metastases also enhance vigorously with
contrast material, but the washout of the
agent is more prolonged than with adenomas

A Hounsfield unit of less than approximately 30 at 10
minutes after injection has been shown to be diagnostic of a
lipid-rich adenoma

percentage of washout of contrast material in which the
attenuation of the adrenal gland at delayed CT is compared
with its attenuation at dynamic CT.

Loss of 50% of the attenuation value of the adrenal mass at
delayed CT is specific for an adenoma; less than 50%
washout is indicative of either a metastasis or an atypical
adenoma

(a) NCCT demonstrates enlarged left adrenal gland
with irregular margins and attenuation of 40 HU. (b)
Dynamic enhanced CT scan of the adrenal gland
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 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.

a
c
b
if a lesion in an oncology patient cannot be
definitively called an adenoma after CT
examination, the patient should undergo further
evaluation with MR imaging or an adrenal biopsy
to confirm a benign or malignant adrenal lesion
Chemical shift imaging is an MR imaging
technique used to detect lipid within an organ
and is the most sensitive method for
differentiating adenomas from metastases

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.
Case
20:
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.

Case
21:
.
Addison disease CECT 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.

Adrenal carcinoma .CECT demonstrates
an 11-cm necrotic mass in the left
adrenal gland, which causes inferior
displacement of the left
kidney.
Case
22:
Case
23:
-54HU
Bilateral myelolipomas
Case
24:
Myelolipoma
Case
25:
USG CT T1W MRI
Central necrosis may be so extensive as to simulate a cyst .
Calcification is uncommon; when present, it may have an
eggshell pattern
Pheochromocytoma.
NCCT
CECT
Case
26:
A pheochromocytoma is a neoplasm of the adrenal
medulla.
When such a tumor arises outside the adrenal, it is
properly labeled a paraganglioma
Most are benign, although about 10% are malignant

Sporadic cases are usually unilateral, affecting the right
adrenal slightly more frequently; about 5% are bilateral.
There is an increased likelihood of pheochromocytoma
in patients with neurofibromatosis, von Hippel-Lindau
disease, and multiple endocrine neoplasia (MEN)
syndromes (50% in MEN 2 and 90% in MEN 2b). In such
syndromes, and in children, multiple or bilateral cases
are more likely.
Spontaneous adrenal hemorrhage. Bilateral heterogeneous adrenal
masses with some high-attenuation areas in this patient with severe
heart disease who was recently anticoagulated
Case
27:
Because of their rich vascular supply, islet cell
tumors classically

are hyperattenuating compared
with the surrounding pancreatic

parenchyma on
contrast-enhanced CT.
Capturing the vascular blush

is essential for the
diagnosis of small tumors, which often

do not
distort the contour of the pancreas. Typically, but
not always, intense arterial phase enhancement is
observed.
This is particularly

true in the investigation of
functioning insulinomas because

these are often
small, with 50% measuring less than 1.3 cm
Nonfunctioning islet cell tumors are more easily
detected by

the mass effect they produce
PANCREAS ISLET CELL TUMOR
ARTERIAL
VENOUS
Case
28:
Spiral CT performs poorly in comparison to EUS.
CT can depict metastases as small as 5 mm in
diameter and demonstrate vascular invasion
MRI has demonstrated a higher sensitivity than
CT, offering additional information that may help
characterize islet cell tumors.
Tumors are hypointense on T1-weighted images
and hyperintense on T2-weighted images.
Intense enhancement is seen on administration
of IV gadolinium.

Tumors less than 2 cm in diameter are not
easily identified by transabdominal ultrasound
(TUS). TUS detection sensitivity is 20-75% for
insulinomas and 20-30% for gastrinomas
A recent study has concluded that EUS is the
most accurate preoperative method of
localizing and detecting insulinomas
Highest sensitivity and specificity is of
intraoperative USG + bidigital examination.
BENIGN VS MALIGNANT
SMALL (<2CMINSULINOMA AND <5CM NON
FUNCTIONING) ARE BENIGN
HETEROGENITY FAVOURS MALIGNANCY.
IRREGULAR SHAPE, VASCULAR
INVASION,REGIONAL LYMPHNODES AND
DEFINITIVE IS HEPATIC METS FOR
MALIGNANCY.
ITS METS ARE ALSO HYPERVASCULAR ,
ENHANCING IN ARTERIAL PHASE.
MALIGNANT ISLET
CELL TUMOR
Case
29:
Case
30:
Case
31:
ACC WITH HEPATIC INFILTRATION
Case :4
28/M D.Y Cr No : 2009101189
Headache On & off- 2 yrs
Palpitation +
Increased Sweating +
Loss of weight +
H/o LOC once - 1 year back
H/o Epistaxis 5 mnths back, detected to be
HTN ( BP : 200/120 mmHG) during his
Checkup , Prescribed anti HT
HT not adequately controlled, so u/w USG
abdomen
Detected to have B/L adrenal masses

9/7/2014 Endocrine Imaging
233
No previous Surgery in the past
Family History: Father died at 27 yrs of age d/t
unknown illness
Mother died at 25 yrs of age
GE: Thin Built
No marfanoid habitus
No Neurocutneous markers
BP : 170/110 mmhg supine
160/100 mmhg standing with 4 anti HT
drugs
Neck : Thyroid normally palpable
Fundus : Grade II HTretinopathy, no angiomas

Urinary 24 hour VMA : 56.8 mg/day ( 0.4- 15.44
mg/day)

24 hour urinary creatinine : 1.24 gm/day ( 1.0- 2.0
gm/day)
Hematology : Normal
Serum calcium : T :9.3 mg% ( 8.5- 10.8)
I : 4.8 mg% ( 4.6 -5.3 )
Na: 143 meq K : 3.4 Meq ( both wnl)
24 hour Urinary metanephrines :

MN : 180 miug/24 hrs ( 0 -350 )
NMN : 7333 miug/ 24 hrs ( 0 -600)

CECT FOR
DISCUSSION

Endo Radiology

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