Computed
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
N. REED
DUNNICK,’
EVERETT
Tomography
G. SCHANER,1
in Adrenal
JOHN L. DOPPMAN,1 NASSAR JAVADPOUR4
Computed tomography (CT) was used to evaluate 26 patients with a variety of adrenal lesions. Surgical proof was available in 22 patients and clinical confirmation with a variety of other studies in the other four patients. Nine patients had aldosterone-producing adrenal adenomas and CT correctly identified seven. Four patients had cortisol-producing adenomas and five patients had cortisol-producing carcinomas; CT identified each of these tumors. Prominent but normal shaped glands were seen in each of the four patients with adrenal hyperplasia. Adrenal metastases from malignant melanoma in two patients were identified. Only one of two pheochromocytomas in two patients could be seen on CT. CT is a noninvasive method of localizing adrenal tumors and may be helpful in distinguishing adenomas from adrenal hyperplasia.
17
and
aldosteronism, metastases,
and
Nine noma
taken
initially
had CT scans as part CT identified
(figs.
adrenal
and
all
1-3).
Five
adenoma
seven
had
1979
had
confirmation
by adrenal
subsequent
vein
adrenal
adenoma
only
0.5
Cushing’s
of the
catheteriza-
surgical
cm
in
proof.
At
from 1 to 6 cm patient had an
diameter
which
diagnosed by venous sampling and surgically The other patient had an adrenal adenoma venous sampling, but has refused surgery.
was
confirmed. localized by
Syndrome
Of 13 patients studied for Cushing’s syndrome, five had adrenal carcinomas, four had adrenal adenomas, and four had bilateral adrenal cortical hyperplasia. Of the
four
patients
identified The
all
smallest
with
four of
adrenal
and
each
these
adenomas,
was
CT
surgically
adenomas
was
correctly
confirmed. 2 cm.
The
CT
examination correctly identified the tumor masses in all five cases of adrenal carcinoma and each of these cases was surgically confirmed. Adrenal masses were not seen in any of the four cases of adrenal hyperplasia. Instead the adrenal glands normal configuration
Metastatic for
were (fig.
prominent 4).
but
maintained
Two patients with malignant melanoma were adrenal metastases. CT correctly identified
these
(fig.
a
Tumor
tumors,
and
both
were
surgically
studied both of
confirmed
5).
Pheochromocytoma Two patients were studied for suspected pheochromocytoma. CT identified an adrenal mass in one of these cases and surgical proof was obtained. The other patient had a 3 cm right adrenal pheochromocytoma not identified on CT. The paucity of retroperitoneal fat in this patient made delineation of retroperitoneal structures impossible on CT.
in 22 of the 26 patients.
of Health,
Building
10, Room
65211
,
Bethesda,
2 Reproductive Research Branch, National Institute of Child Health and Human Development, National Institutes 20014. 3 Hypertension Endocrine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, 4 Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20014.
January
AND
of their evaluation the adrenal ade-
surgery, these adrenal adenomas ranged in diameter. Of the two CT failures, one
display. Adjacent but not overlapping 13 mm cuts were routinely obtained after injection of intravenous contrast material. More
AJR 132:43-46,
R. GILL,3
additional overlapping cuts at 7 mm localizing the adrenal glands on routine
aldosteronism;
in seven
tion
Methods
after revision October 5, 1978. Clinical Center, National Institutes
have
patients
suspected
The CT scans were performed on an EMI 5000 whole body scanner with an 18 sec scan time and a 320 x 320 matrix
Received April 13, 1978; accepted I Diagnostic Radiology Department, reprint requests to N. A. Dunnick.
after
of primary
13 for Cushing’s syndrome, two for two for biochemical evidence of a
was obtained
we
JOHN
Results
pheochromocytoma (table 1). Bilateral adrenal venography with sampling was performed in 12 patients. Arteriography was performed in the two patients with pheochromocytomas and in six patients who had either adrenal carcinomas or metastases to the adrenal gland. Surgical confirmation
recently intervals
A. STROTT,2
Aldosteronoma
A total of 26 patients (14 male, 12 female) ranging in age from to 67 years was examined. Nine patients were studied for
primary adrenal
CHARLES
scans.
Adrenal venography with samples for laboratory analysis is a valuable technique for functioning adrenal cortical lesions [1-3]. However, in addition to being an invasive procedure with the risk of adrenal infarction, the right adrenal vein may be difficult to catheterize selectively and sample. Whole body computed tomography (CT) has proved most valuable in the evaluation of retroperitoneal structures difficult to image by conventional means. Several reports describe the CT manifestations of normal adrenal glands and adrenal tumors [4-6]. Thus, there is much interest in the use of CT as a means of detecting and lateralizing adrenal tumors. We performed CT scans on 22 patients with a variety of adrenal tumors, and four patients with bilateral adrenal hyperplasia who were initially seen for Cushing’s syndrome. The spectrum of CT findings in these adrenal lesions is presented and correlation is made with both catheterization data and surgical results. Subjects
Tumors
43
Maryland
of Health, Maryland
20014. Address
Bethesda,
Maryland
20014.
0361-803X/79/1321-0043
$0.00
DUNNICK
44
ET
TABLE Diagnostic
Reason
Seen
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
55
and
Aldosteronism: 1
Radionuclide can
Arteriogram
CT
Surgery
NP NP
NP NP
+
+
+
±
+
+
+
NP
NP
+
±
+
-
NP
+
+
+
+
+
#{247}
+ +
NP
6
+
7
8 9
January
1979
Tumors
+
NP
-
+
NP NP
NP
NP
NP
NP
+
+
+
-
NP
NP
-
+
+
-
NP
NP
-
NP
Pathology
and
Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma,
Final
Diagnosis
Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma
NP, Aldosteronoma
syndrome:
10
+
11
NP
12 13
NP
+
NP #{247} NP
+
14 15
-
-
-
-
-
-
NP NP NP
16 17 ....................
20 21 22 Melanoma: 23 24 Hypertension: 25
26 Note. - + . Hyperplasia
Adrenal
+
5
18 19
with
+
2 3 4
Cushing’s
=
positive for adrenal rather than tumor.
+
+
+
+
NP
+
±
NP
+
+
+
-
NP NP
-
NP
-
-
+
+
NP
+
NP NP NP NP NP
+
+
+
NP NP
NP NP
NP
NP
NP
+
NP
NP
+
Fig.
1 -Case 5, 47-year-old woman with primary mass. Subsequent surgery demonstrated adrenal adenoma.
NP
-
+
negative
-
NP NP
+
=
tumor:
aldosteronism. 1
NP NP
+
for adrenal
.3
x
1 .0 x
NP, Hyperplasia NP, Hyperplasia
+
+
NP
-
NP NP
+
NP
tumor:
NP
Adenoma Adenoma Adenoma Adenoma Hyperplasia NP, Hyperplasia
+
NP
NP NP
adrenal right
Venogram
AJR:132,
1
in Patients
Angiography
Venous amp ing
0.
Methods
AL.
NP
NP NP =
+
+
Carcinoma Carcinoma Carcinoma
+
+
Carcinoma
+
#{247} Carcinoma
+
+
+
+
Metastasis Metastasis
-
+
Pheochromocytoma
+
+
Pheochromocytoma
+
+
+
+
not performed.
Right 0.5 cm Fig.
adrenal
2.-Case
7, 49-year-old
mass. Confirmed
man
with
by iodocholesterol
primary
aldosteronism.
scan and subsequent
Right
sur-
gery.
Discussion
This series of patients demonstrates the value of adrenal venography with venous samplings for the evaluation of hormone-producing adrenal lesions. However, adrenal venography is an invasive procedure which requires skilled angiography. Even an experienced angiographer
may not be able to sample successfully both adrenal glands in all patients. The normal adrenal glands are commonly identified on CT scans of the upper abdomen by their characteristic shape and location. The left adrenal gland is routinely
CT
AJR:132, January 1979
OF
ADRENAL
TUMORS
45
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
.,
Fig. 3.-Case 3, 55-year-old woman with primary aldosteronism. A, Right adrenal mass (arrow). B, Mass (arrow) confirmed by adrenal venogram and venous sampling. Subsequent surgery removed 1.6 x 1.5 x 1 .2 cm right adrenal adenoma.
Fig. 4.-Case
inent vein
16, 26-year-old
but normally samples
shaped
confirmed
woman
adrenal
impression
with
glands of bilateral
Cushing’s
bilaterally adrenal
syndrome. Prom(arrows). Adrenal hyperplasia.
visualized at the same level, or one cut above the top the left kidney. It is shaped like an inverted V. one arm
which
may be slightly
longer
than
the other.
of of
The right
adrenal gland is seen medial to the liver and also has an inverted V shape. The posterior arm is much longer than the lateral arm, and we frequently visualize only the longer posterior arm. It is located immediately behind the inferior vena cava, slightly above the top of the right kidney,
and
parallels
the
right
diaphragmatic
crus.
Adrenal tumors appear as discrete masses in the adrenal gland. If the tumor is small, a portion of normal gland may also be identified. When the tumor is large, the adrenal etiology may be suspected by the clinical presentation, anatomic location, and absence of a normal adrenal gland. As we have stressed in an earlier
report [6], many adrenal tumors have a low absorption coefficient even after intravenous contrast material. CT correctly identified 11 of the 13 steroid-producing adrenal adenomas, and there were no false positives. The smallest tumor identified was 1 cm in diameter. Two adenomas were missed, one was surgically confirmed (0.5 cm) while the other was diagnosed by venous sampling (of unknown size). CT identified the absence of tumors in the four patients with bilateral adrenal hyperplasia. Although both adrenal glands are slightly enlarged in bilateral adrenal hyperplasia, we have not been able to distinguish these glands from normal glands on CT. However, a normal adrenal scan in Cushing’s syndrome provides reliable, though indirect, evidence of adrenal hyperplasia. CT correctly identified all seven of the malignant tumors involving the adrenal glands, and demonstrated one of the two adrenal pheochromocytomas. Thus, there was an overall accuracy of 89% (23 of 26). However, both of the errors were false negatives. In every case in which CT identified an adrenal lesion, the diagnosis was confirmed by other studies, usually angiography
and
surgery.
The
of 26) is a result of a small retroperitoneal fat.
false
negative
lesion
rate
(0.5 cm)
of 1 1 % (3 or lack
of
In patients with biochemical findings of either Cushing’s syndrome or primary aldosteronism, CT may localize the functioning tumor and thus provide lateralization for the surgeon. Two other noninvasive methods currently provide similar information: isotopic adrenal scanning
with
an
iodinated
cholesterol
compound
[7-9]
and
diagnostic ultrasound [10-11]. Isotopic scanning is a prolonged procedure with a rather high radiation dose. The resolution of gray scale ultrasound is continuing to improve; however, the adrenal glands are difficult to image, especially in large patients where a lower fre-
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
46
DUNNICK
quency transducer is required. At present, we feel CT provides the best anatomic information in the presurgical evaluation of adrenal lesions. REFERENCES 1 . Scoggins
BA, Oddie CJ, Hare WSC, Coghlan JP: Preoperative lateralization of aldosterone-producing tumours in primary aldosteronism. Ann lntein Med 76 :891-897, 1972 2. Mitty HA, Nicolis GL, Gabrilovh JL: Adrenal venography: clinical-roentgenographic 119:564-575,
correlation
in 80 patients.
AiR
AL.
6. Schaner
AJR:132, January 1979
EG, Dunnick
3. Lecky JW, Wolfman NT, Modic CW: Current concepts of adrenal angiography. Radio! Clin North Am 14:309-352, 1976 4. Schaner EG, Head GL, Kalman MA, Dunnick NR, Doppman JL: Whole-body computed tomography in the diagnosis of abdominal and thoracic malignancy: review of 600 cases. tomography of Tomogr 2:1-10,
NA, Doppman
JL, Strott
DA, Gill JR
Jr. Javadpour N: Adrenal cortical tumors with low tion coefficients: a pitfall in computed tomography sis. J Comput Assist Tomogr 2 : 1 1-15, 1978
attenuadiagno-
7. Moses DC, Schteingart DH, Sturman MF, Beirwaltes WH, Ice AD: Efficacy of radiocholesterol imaging of the adrenal glands in Cushing’s syndrome. Surg Gyneco! Obstet 139:201-204, 1974 8. Hogan MJ, McRae J, Schambelan M, Biglieri EG: Localization of aldosterone-producing adenomas with l-131-19-iodocholesterol. N EngI J Med 294 :410-414, 1976 9. Parthasarathy
1973
Cancer Treat Rep 61:1537-1560, 1977 5. Brownlie K, Kreel L: Computer assisted normal suprarenal glands.J Comput Assist 1978
ET
Adrenal
KL, Bakshi
scintigraphy
S. Ackerhalt RE, Villa M, Diae A: I-i 31 -1 9-iodocholesterol. C!in
utilizing
Nuc!Med 1 :150-155, 1976 10. Kehlet H, Blichert-Toft M, Hancke
5, Pedersen
JF, Kristen-
sen JK, Efsen F, Dige-Petersen H, Fogh J, Lockwood K, Hasner E: Comparative study of ultrasound, l-131-19-iodocholesterol scintigraphy, and aortography in localizing adrenal lesions. Br MedJ 2:665-667, 1976 11. Sample WF: A new technique for the evaluation of the adrenal
gland
124:463-470,
with
1977
gray-scale
ultrasonography.
Radiology
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
N. REED
DUNNICK,’
EVERETT
Tomography
G. SCHANER,1
in Adrenal
JOHN L. DOPPMAN,1 NASSAR JAVADPOUR4
Computed tomography (CT) was used to evaluate 26 patients with a variety of adrenal lesions. Surgical proof was available in 22 patients and clinical confirmation with a variety of other studies in the other four patients. Nine patients had aldosterone-producing adrenal adenomas and CT correctly identified seven. Four patients had cortisol-producing adenomas and five patients had cortisol-producing carcinomas; CT identified each of these tumors. Prominent but normal shaped glands were seen in each of the four patients with adrenal hyperplasia. Adrenal metastases from malignant melanoma in two patients were identified. Only one of two pheochromocytomas in two patients could be seen on CT. CT is a noninvasive method of localizing adrenal tumors and may be helpful in distinguishing adenomas from adrenal hyperplasia.
17
and
aldosteronism, metastases,
and
Nine noma
taken
initially
had CT scans as part CT identified
(figs.
adrenal
and
all
1-3).
Five
adenoma
seven
had
1979
had
confirmation
by adrenal
subsequent
vein
adrenal
adenoma
only
0.5
Cushing’s
of the
catheteriza-
surgical
cm
in
proof.
At
from 1 to 6 cm patient had an
diameter
which
diagnosed by venous sampling and surgically The other patient had an adrenal adenoma venous sampling, but has refused surgery.
was
confirmed. localized by
Syndrome
Of 13 patients studied for Cushing’s syndrome, five had adrenal carcinomas, four had adrenal adenomas, and four had bilateral adrenal cortical hyperplasia. Of the
four
patients
identified The
all
smallest
with
four of
adrenal
and
each
these
adenomas,
was
CT
surgically
adenomas
was
correctly
confirmed. 2 cm.
The
CT
examination correctly identified the tumor masses in all five cases of adrenal carcinoma and each of these cases was surgically confirmed. Adrenal masses were not seen in any of the four cases of adrenal hyperplasia. Instead the adrenal glands normal configuration
Metastatic for
were (fig.
prominent 4).
but
maintained
Two patients with malignant melanoma were adrenal metastases. CT correctly identified
these
(fig.
a
Tumor
tumors,
and
both
were
surgically
studied both of
confirmed
5).
Pheochromocytoma Two patients were studied for suspected pheochromocytoma. CT identified an adrenal mass in one of these cases and surgical proof was obtained. The other patient had a 3 cm right adrenal pheochromocytoma not identified on CT. The paucity of retroperitoneal fat in this patient made delineation of retroperitoneal structures impossible on CT.
in 22 of the 26 patients.
of Health,
Building
10, Room
65211
,
Bethesda,
2 Reproductive Research Branch, National Institute of Child Health and Human Development, National Institutes 20014. 3 Hypertension Endocrine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, 4 Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20014.
January
AND
of their evaluation the adrenal ade-
surgery, these adrenal adenomas ranged in diameter. Of the two CT failures, one
display. Adjacent but not overlapping 13 mm cuts were routinely obtained after injection of intravenous contrast material. More
AJR 132:43-46,
R. GILL,3
additional overlapping cuts at 7 mm localizing the adrenal glands on routine
aldosteronism;
in seven
tion
Methods
after revision October 5, 1978. Clinical Center, National Institutes
have
patients
suspected
The CT scans were performed on an EMI 5000 whole body scanner with an 18 sec scan time and a 320 x 320 matrix
Received April 13, 1978; accepted I Diagnostic Radiology Department, reprint requests to N. A. Dunnick.
after
of primary
13 for Cushing’s syndrome, two for two for biochemical evidence of a
was obtained
we
JOHN
Results
pheochromocytoma (table 1). Bilateral adrenal venography with sampling was performed in 12 patients. Arteriography was performed in the two patients with pheochromocytomas and in six patients who had either adrenal carcinomas or metastases to the adrenal gland. Surgical confirmation
recently intervals
A. STROTT,2
Aldosteronoma
A total of 26 patients (14 male, 12 female) ranging in age from to 67 years was examined. Nine patients were studied for
primary adrenal
CHARLES
scans.
Adrenal venography with samples for laboratory analysis is a valuable technique for functioning adrenal cortical lesions [1-3]. However, in addition to being an invasive procedure with the risk of adrenal infarction, the right adrenal vein may be difficult to catheterize selectively and sample. Whole body computed tomography (CT) has proved most valuable in the evaluation of retroperitoneal structures difficult to image by conventional means. Several reports describe the CT manifestations of normal adrenal glands and adrenal tumors [4-6]. Thus, there is much interest in the use of CT as a means of detecting and lateralizing adrenal tumors. We performed CT scans on 22 patients with a variety of adrenal tumors, and four patients with bilateral adrenal hyperplasia who were initially seen for Cushing’s syndrome. The spectrum of CT findings in these adrenal lesions is presented and correlation is made with both catheterization data and surgical results. Subjects
Tumors
43
Maryland
of Health, Maryland
20014. Address
Bethesda,
Maryland
20014.
0361-803X/79/1321-0043
$0.00
DUNNICK
44
ET
TABLE Diagnostic
Reason
Seen
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
55
and
Aldosteronism: 1
Radionuclide can
Arteriogram
CT
Surgery
NP NP
NP NP
+
+
+
±
+
+
+
NP
NP
+
±
+
-
NP
+
+
+
+
+
#{247}
+ +
NP
6
+
7
8 9
January
1979
Tumors
+
NP
-
+
NP NP
NP
NP
NP
NP
+
+
+
-
NP
NP
-
+
+
-
NP
NP
-
NP
Pathology
and
Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma, Adenoma,
Final
Diagnosis
Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma Aldosteronoma
NP, Aldosteronoma
syndrome:
10
+
11
NP
12 13
NP
+
NP #{247} NP
+
14 15
-
-
-
-
-
-
NP NP NP
16 17 ....................
20 21 22 Melanoma: 23 24 Hypertension: 25
26 Note. - + . Hyperplasia
Adrenal
+
5
18 19
with
+
2 3 4
Cushing’s
=
positive for adrenal rather than tumor.
+
+
+
+
NP
+
±
NP
+
+
+
-
NP NP
-
NP
-
-
+
+
NP
+
NP NP NP NP NP
+
+
+
NP NP
NP NP
NP
NP
NP
+
NP
NP
+
Fig.
1 -Case 5, 47-year-old woman with primary mass. Subsequent surgery demonstrated adrenal adenoma.
NP
-
+
negative
-
NP NP
+
=
tumor:
aldosteronism. 1
NP NP
+
for adrenal
.3
x
1 .0 x
NP, Hyperplasia NP, Hyperplasia
+
+
NP
-
NP NP
+
NP
tumor:
NP
Adenoma Adenoma Adenoma Adenoma Hyperplasia NP, Hyperplasia
+
NP
NP NP
adrenal right
Venogram
AJR:132,
1
in Patients
Angiography
Venous amp ing
0.
Methods
AL.
NP
NP NP =
+
+
Carcinoma Carcinoma Carcinoma
+
+
Carcinoma
+
#{247} Carcinoma
+
+
+
+
Metastasis Metastasis
-
+
Pheochromocytoma
+
+
Pheochromocytoma
+
+
+
+
not performed.
Right 0.5 cm Fig.
adrenal
2.-Case
7, 49-year-old
mass. Confirmed
man
with
by iodocholesterol
primary
aldosteronism.
scan and subsequent
Right
sur-
gery.
Discussion
This series of patients demonstrates the value of adrenal venography with venous samplings for the evaluation of hormone-producing adrenal lesions. However, adrenal venography is an invasive procedure which requires skilled angiography. Even an experienced angiographer
may not be able to sample successfully both adrenal glands in all patients. The normal adrenal glands are commonly identified on CT scans of the upper abdomen by their characteristic shape and location. The left adrenal gland is routinely
CT
AJR:132, January 1979
OF
ADRENAL
TUMORS
45
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
.,
Fig. 3.-Case 3, 55-year-old woman with primary aldosteronism. A, Right adrenal mass (arrow). B, Mass (arrow) confirmed by adrenal venogram and venous sampling. Subsequent surgery removed 1.6 x 1.5 x 1 .2 cm right adrenal adenoma.
Fig. 4.-Case
inent vein
16, 26-year-old
but normally samples
shaped
confirmed
woman
adrenal
impression
with
glands of bilateral
Cushing’s
bilaterally adrenal
syndrome. Prom(arrows). Adrenal hyperplasia.
visualized at the same level, or one cut above the top the left kidney. It is shaped like an inverted V. one arm
which
may be slightly
longer
than
the other.
of of
The right
adrenal gland is seen medial to the liver and also has an inverted V shape. The posterior arm is much longer than the lateral arm, and we frequently visualize only the longer posterior arm. It is located immediately behind the inferior vena cava, slightly above the top of the right kidney,
and
parallels
the
right
diaphragmatic
crus.
Adrenal tumors appear as discrete masses in the adrenal gland. If the tumor is small, a portion of normal gland may also be identified. When the tumor is large, the adrenal etiology may be suspected by the clinical presentation, anatomic location, and absence of a normal adrenal gland. As we have stressed in an earlier
report [6], many adrenal tumors have a low absorption coefficient even after intravenous contrast material. CT correctly identified 11 of the 13 steroid-producing adrenal adenomas, and there were no false positives. The smallest tumor identified was 1 cm in diameter. Two adenomas were missed, one was surgically confirmed (0.5 cm) while the other was diagnosed by venous sampling (of unknown size). CT identified the absence of tumors in the four patients with bilateral adrenal hyperplasia. Although both adrenal glands are slightly enlarged in bilateral adrenal hyperplasia, we have not been able to distinguish these glands from normal glands on CT. However, a normal adrenal scan in Cushing’s syndrome provides reliable, though indirect, evidence of adrenal hyperplasia. CT correctly identified all seven of the malignant tumors involving the adrenal glands, and demonstrated one of the two adrenal pheochromocytomas. Thus, there was an overall accuracy of 89% (23 of 26). However, both of the errors were false negatives. In every case in which CT identified an adrenal lesion, the diagnosis was confirmed by other studies, usually angiography
and
surgery.
The
of 26) is a result of a small retroperitoneal fat.
false
negative
lesion
rate
(0.5 cm)
of 1 1 % (3 or lack
of
In patients with biochemical findings of either Cushing’s syndrome or primary aldosteronism, CT may localize the functioning tumor and thus provide lateralization for the surgeon. Two other noninvasive methods currently provide similar information: isotopic adrenal scanning
with
an
iodinated
cholesterol
compound
[7-9]
and
diagnostic ultrasound [10-11]. Isotopic scanning is a prolonged procedure with a rather high radiation dose. The resolution of gray scale ultrasound is continuing to improve; however, the adrenal glands are difficult to image, especially in large patients where a lower fre-
Downloaded from www.ajronline.org by 109.161.204.3 on 10/16/15 from IP address 109.161.204.3. Copyright ARRS. For personal use only; all rights reserved
46
DUNNICK
quency transducer is required. At present, we feel CT provides the best anatomic information in the presurgical evaluation of adrenal lesions. REFERENCES 1 . Scoggins
BA, Oddie CJ, Hare WSC, Coghlan JP: Preoperative lateralization of aldosterone-producing tumours in primary aldosteronism. Ann lntein Med 76 :891-897, 1972 2. Mitty HA, Nicolis GL, Gabrilovh JL: Adrenal venography: clinical-roentgenographic 119:564-575,
correlation
in 80 patients.
AiR
AL.
6. Schaner
AJR:132, January 1979
EG, Dunnick
3. Lecky JW, Wolfman NT, Modic CW: Current concepts of adrenal angiography. Radio! Clin North Am 14:309-352, 1976 4. Schaner EG, Head GL, Kalman MA, Dunnick NR, Doppman JL: Whole-body computed tomography in the diagnosis of abdominal and thoracic malignancy: review of 600 cases. tomography of Tomogr 2:1-10,
NA, Doppman
JL, Strott
DA, Gill JR
Jr. Javadpour N: Adrenal cortical tumors with low tion coefficients: a pitfall in computed tomography sis. J Comput Assist Tomogr 2 : 1 1-15, 1978
attenuadiagno-
7. Moses DC, Schteingart DH, Sturman MF, Beirwaltes WH, Ice AD: Efficacy of radiocholesterol imaging of the adrenal glands in Cushing’s syndrome. Surg Gyneco! Obstet 139:201-204, 1974 8. Hogan MJ, McRae J, Schambelan M, Biglieri EG: Localization of aldosterone-producing adenomas with l-131-19-iodocholesterol. N EngI J Med 294 :410-414, 1976 9. Parthasarathy
1973
Cancer Treat Rep 61:1537-1560, 1977 5. Brownlie K, Kreel L: Computer assisted normal suprarenal glands.J Comput Assist 1978
ET
Adrenal
KL, Bakshi
scintigraphy
S. Ackerhalt RE, Villa M, Diae A: I-i 31 -1 9-iodocholesterol. C!in
utilizing
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Radiology
