The radiological diagnosis of adrenal tumours

Localization of aldosterone-producing tumours in primary aldosteronism by adrenal and renal vein catheterization

Regional venous plasma aldosterone concentrations were determined and assessed against concurrent arterial levels in 16 patients with primary aldosteronism. The results obtained by sampling from the left adrenal vein or the left renal vein allowed correct side prediction of the presupposed adenoma in each patient. The problems caused by intermittent secretion of aldosterone by the tumour and the importance of correct positioning of the catheter are emphasized. Repeated sampling and continuing reference to systemic, arterial aldosterone levels proved valuable.

Magnetic resonance imaging or metaiodobenzylguanidine scintigraphy for the demonstration of paragangliomas? Correlations and disparities

Paragangliomas are tumours arising from paraganglionic tissue dispersed from the base of the skull to the pelvic diaphragm. These tumours produce symptoms by secreting catecholamines (functioning tumours) or by local tumour expansion. They can be part of several hereditary disorders. The introduction of magnetic resonance (MR) imaging and metaiodobenzylguanidine (MIBG) scintigraphy has provided new insights into paragangliomas and has tremendously changed the topographic diagnosis of paragangliomas. Both techniques have proven to be adequate in localising paragangliomas. In this report, the performance of these two noninvasive imaging methods in the examination of paragangliomas is compared and the merits and deficits of the two techniques are discussed. Both techniques produce comparable results in the detection of functioning paragangliomas. MR imaging, however, also demonstrates tumours that do not take up MIBG. MR imaging does not involve the use of ionising radiation and is not hampered by medication. Moreover, MR imaging has a higher spatial resolution. Because of these merits it is concluded that for demonstration of paragangliomas, whole-body MR imaging is the preferred and initial method of investigation. MIBG scintigraphy, on the other hand, continues to be a reliable method for non-invasive detection of functioning paragangliomas. At present it is clearly faster in whole-body imaging than MRI and it is definitely patient-friendly (no claustrophobia). It could be reserved for cases where a strong suspicion of a functioning paraganglioma persists, despite normal MR imaging findings, and for cases where doubt exists about the functional activity of one or more multicentric tumours. MIBG scintigraphy must be used in the evaluation of patients referred for iodine-131 MIBG treatment.

Case report: adrenal haemangioma coexisting with malignant haemangioendothelioma

A 71-year-old man presented with an unusual adrenal tumour. Computed tomography and echography showed a large, necrotic mass with multiple calcifications. Preoperative angiography demonstrated pooling of contrast medium within the mass, strongly suggestive of a diagnosis of haemangioma.

Hemorrhagic necrosis of pheochromocytoma associated with reversible renal artery stenosis

An unusual case of pheochromocytoma associated with renal artery stenosis is described. Despite the removal of bilateral adrenal pheochromocytoma, laboratory findings suggested the presence of residual pheochromocytoma and abdominal aortography revealed more pronounced stenosis of the right renal artery. Two months later, the undetected residual pheochromocytoma underwent hemorrhagic necrosis with acute cessation of catecholamine release. Thereafter, the patient's blood pressure decreased to a normal level with marked improvement in hypertensive symptoms. No remaining stenosis was demonstrated on follow up renal angiography. Our case suggests that constant local secretion of catecholamines may be responsible for the development of renal artery stenosis.

Adreno-cortical carcinoma in infancy and childhood: a radiological report of ten cases

Adreno-cortical carcinoma is a relatively rare neoplasm in infancy and childhood. This review, covering a period of 18 years (1965-83), revealed 10 cases, the study being prompted by three patients in whom the final diagnosis was considerably delayed. There were eight females and two males and their ages ranged from 6 months to 14 years; 50% were below the age of 18 months at the time of the presentation. Seven patients had features of either virilism or precocious puberty and three of these also had stigmas of Cushing's syndrome. In patients where the endocrine disturbance was evident, the clinical diagnosis was made rapidly. However, delay in diagnosis occurred when endocrinopathy was absent. Radiology, including newer methods of imaging, contributed by revealing the tumour and its spread but did not suggest a conclusive diagnosis. At times, clinical features, biochemical findings, radiological investigations and even histological studies mislead, thus delaying the final diagnosis. These cases are illustrated and discussed.

Computed tomography versus angiography in the diagnosis of large right adrenal carcinomas

Adrenal carcinomas are rare. We present four surgically and pathologically proved large right adrenal carcinomas studied by computed tomography, angiography, and other imaging modalities. Computed tomography demonstrated large nonhomogeneous right upper quadrant masses in all four cases, but the adrenal origin of the mass could not be ascertained by computed tomography in three patients due to the transverse display of the anatomy. Ultrasonography provided important additional information in these cases. Arteriography was diagnostic in each case by demonstrating minimal to marked tumor vascularity supplied by adrenal arteries. We also present, for differential diagnostic purposes, a proved benign adrenal hemorrhagic cyst with computed tomography and angiography findings indistinguishable from those of adrenal carcinomas. Computed tomography does not eliminate the need for angiography in patients with large right upper quadrant masses suspected of being an adrenal carcinoma.

Scintigraphic localization of a disseminated malignant pheochromocytoma with the use of 131I-meta-iodobenzylguanidine

Preliminary clinical studies with 131I-meta-iodobenzylguanidine, a newly synthesized radiopharmaceutical and guanethidine analog capable of imaging the adrenal medulla, have led to the identification of a case of disseminated malignant pheochromocytoma with the localization of brain and bone metastases. The result is of particular interest as the symptomatology in this case appeared rather equivocal and various investigations had led to a completely different diagnosis. This new scintigraphic technique has proved to be safe, specific and noninvasive, and it may have a clinical application as a complementary or alternative technique to conventional diagnostic tests.

Role of venous sampling in locating a phaeochromocytoma

Selective venous sampling was performed in 31 patients in whom the diagnosis of phaeochromocytoma was suspected on clinical and biochemical grounds. Data from samples assayed for their adrenaline and noradrenaline content using a radioenzymatic technique were used to confirm or refute the suspected diagnosis. In 19 of the 31 patients a phaeochromocytoma was subsequently removed surgically, and the remaining 12 patients are now thought not to have tumours (mean follow up period: four years). Analysis of the assay data shows that selective venous sampling correctly identified the presence of a tumour in all 19 patients, and correctly excluded the diagnosis in 11 of the 12 remaining patients--an overall success rate of 97%. Success rates of 88% for arteriography and 84% for computed tomography were recorded, though these investigations were not performed in all patients. Ultrasound and intravenous urography were much less accurate. On the basis of this study a sequence of investigation is proposed for patients with a suspected phaeochromocytoma. Computed tomography occupies a central role in this sequence with venous sampling (and occasionally other techniques) being used only as complementary investigations when specific indications for their use exist.

Value of computed tomography of the abdomen and chest in investigation of Cushing's syndrome

Computed tomography (CT) scans were performed on 37 patients with biochemically proved Cushing's syndrome to evaluate the role of CT in the investigation of this condition. CT rapidly and correctly identified all 15 adrenocortical tumours, distinguishing five carcinomas from the 10 adenomas. In ACTH-dependent Cushing's syndrome appreciable bilateral adrenal enlargement was common in patients with an ectopic source (6 of 10 cases), while those with a pituitary source usually had normal sized adrenals (9 of 10). Two patients with a history of over seven years had bilateral adrenal nodules. CT was more accurate in locating a primary ectopic source of ACTH (5 of 12 cases) than any other technique and was particularly valuable in detecting small (less than 1.5 cm) peripheral lung carcinoid tumours which may be undetectable by conventional x-ray techniques. Its speed, accuracy, and simplicity make CT the technique of choice both to show the adrenal anatomy and to locate a suspected ectopic ACTH-secreting tumour in patients with proved Cushing's syndrome.

Clinical experience with 75Se selenomethylcholesterol adrenal imaging

The results of quantitative adrenal imaging using 75Se selenomethylcholesterol in sixty-two subjects are analysed. The adrenal area was localized by a renal scan, lateral views of which enabled adrenal depth to be estimated. The first nineteen cases were scanned with a rectilinear scanner and the remaining forty-three cases imaged with a gamma camera. Quantitation of adrenal uptake was performed on computer-stored static images obtained 7 and 14 days post-injection of 75Se selenomethylcholesterol (3 and 6 days in the first ten cases studied). Normal uptake was found to be 0.07-0.30% of the administered dose. Overall predictive accuracy of the type of adrenal disorder of thirty-two patients with Cushing's syndrome ws 90.6%, this included twelve cases of Cushing's disease (mean uptake 0.58%), seven ectopic ACTH syndromes (mean uptake 0.69%), five unilateral adenomata (mean uptake 0.93%), three post adrenalectomy regrowths (mean uptake 1.37%), three adrenal carcinomas (mean uptake 0.01%), one congenital hyperplasia (mean uptake 3.4%) and one unilateral nodular hyperplasia. Overall predictive accuracy of the cause of Conn's syndrome in twenty-two cases was 86.4%; this included thirteen cases of bilateral hyperplasia (mean uptake 0.34%), eight unilateral adenomata (mean uptake 0.47%) and one patient with mineralocorticoid excess in whom the cause has not been confirmed. The mean uptake in the normal adrenal in cases of unilateral adenoma was 0.19% (range 0.07-0.30%). Causes of unsatisfactory adrenal imaging are examined. The procedure is recommended as the localizing and lateralizing technique of choice in Cushing's syndrome except where due to adrenal carcinoma, and as an important non-invasive technique in Conn's syndrome for the lateralization of adenoma.

Adrenal scintigraphy in primary aldosteronism caused by an aldosterone producing adenoma

Adrenal scintigraphy with 131I-19-iodo-cholesterol was performed in 13 hypertensive patients with biochemical disturbances suggesting an aldosterone-producing adenoma. The actual presence of an adenoma was subsequently confirmed in all cases. An asymmetrical tracer uptake (lateralization) was seen in 7 patients and in 6 of these the adenoma was located in the adrenal with the higher uptake. In one patient a large necrotic tumour was not visualized and a faint contralateral accumulation was wrongly taken to represent a tumour. In 6 patients the scintigram was non-lateralizing. In these highly selected patients a lateralizing scintigram had a high diagnostic specificity and at present adrenal scintigraphy should be the method of first choice in the preoperative side prediction. However, the sensitivity is low: a non-lateralizing scintigram does not exclude the presence of an aldosterone-producing adenoma.

Adrenal angiography in Sipple's syndrome

Adrenal angiography was performed in 8 patients with Sipple's syndrome. Seven patients had pheochromocytomas and one bilateral adrenal medullary hyperplasia. In 4 cases the pheochromocytomas were bilateral. The angiographic findings are discussed and it is concluded that no typical angiographic appearance of pheochromocytoma appears to exist.

Angiographic findings in adrenal masses

The angiographic findings in 34 patients with adrenal lesions were reviewed, including 11 adrenal metastases, 9 adrenal pheochromocytomas, 4 adrenal cortical carcinomas, 4 adrenal cortical adenomas, 3 cases of adrenal hyperplasia and 3 cases of adrenal invasion from carcinoma of the upper pole of the kidney. The results indicate differential diagnostic difficulties in distinguishing among these various entities by angiography.

Selective venous sampling in the diagnosis and localization of phaeochromocytoma

Plasma noradrenaline levels were measured at several sites in the systemic venous system by selective catheterisation in ten hypertensive patients in whom phaeochromocytoma was suspected on clinical or biochemical grounds. Four patients had localized noradrenaline elevation and the diagnosis of phaeochromocytoma was confirmed at operation. The remaining six patients demonstrated no localized elevation of noradrenaline and there has been no evidence of a tumour on follow up. The technique allows the diagnosis and accurate localization of phaeochromocytoma and is useful in excluding the tumour in patients with essential hypertension.

Inferior vena caval involvement by adrenal cortical carcinoma

A case of preoperative demonstration of inferior vena caval extension of tumor thrombus from adrenal cortical carcinoma is presented. Surgery showed that extension had occurred via the adrenal vein rather than by direct invasion. A search of the literature failed to uncover either any mention of preoperative attention to the possibility of caval involvement or of this particular mode of extension. Review of our experience with 17 adrenal cortical carcinomas suggested that carcinoma of the right adrenal gland involves the vena cava more commonly than does carcinoma of the left. We recommend that cavography be performed in the evaluation of adrenal carcinoma.

Paraganglioma of urinary bladder wall

A classic case of pheochromocytoma of the urinary bladder is presented. The history of headaches and palpitations during micturition is the result of sudden release of catecholamines into the general circulation. The diagnosis using selective arteriography as well as the medical and surgical management are described.

Angiography in pheochromocytoma of the urinary bladder. Report of a case

A case of pheochromocytoma of the urinary bladder in a 20-year-old female is reported. This is the 36th reported case in the English language literature. The patient had classical symptoms of vesical pheochromocytoma with sudden onset of headache, palpitations, and blood pressure elevation during voiding. The provisional diagnosis was arrived at on clinical history, laboratory investigations, including the estimation of catecholamines and vanil mandelic acid (VMA). The diagnosis was confirmed and the tumor was exactly localized by means of angiography. The angiographic appearance of pheochromocytoma of the urinary bladder is not pathognomonic and is similar to that previously described for adrenal pheochromocytoma. Angiography is, with adequate precautions, a safe and useful procedure for ruling out synchronous adrenal or extra-adrenal tumors and for exact localization of the bladder tumor.

The pituitary fossa in Cushing's syndrome. A retrospective analysis of 93 patients

A retrospective analysis of the pituitary fossa in 93 patients with Cushing's syndrome is presented. Radiological evidence of a pituitary tumour was found in 20 of 86 patients with pituitary-dependent disease (23%). In 11 of the 20 patients, the diagnosis depended on analysis of lateral tomograms. None of the seven patients with disease which was not pituitary-dependent had evidence of an abnormal sella. One of 20 controls without known endocrine disease had an abnormal sella.

Comparative study of ultrasound, 131I-19-iodocholesterol scintigraphy, and aortography in localising adrenal lesions

Twenty-seven consecutive patients with endocrinological disease necessitating adrenal surgery underwent blind preoperative investigation with ultrasound, renal aortography, and adrenocortical scintigraphy for an adrenal lesion. Nine patients had pituitary-dependent Cushing's syndrome, five had pituitary-independent Cushing's syndrome, four had an adrenocortical androgenic excess, and nine had a preoperative diagnosis of phaeochromocytoma. The predictive value of preoperative ultrasound was 100% for a positive finding and 79% for a negative result. Preoperative aortography had a predictive value of 83% for a positive finding and 64% for a negative result; and the predictive value of adrenocortical scintigraphy was 100% for a positive finding and 85% for a negative finding. In localising biochemically suspected adrenal lesions ultrasound should be the first choice, since it is rapid, noninvasive, cheap, and reasonably accurate. Adrenocortical scintigraphy has a similar diagnostic value, especially in Cushing's syndrome, but it is time consuming. Nevertheless, it may be preferable for diagnosing small glucocorticoid-secreting adenomas. Aortography should be reserved for cases with inconclusive diagnoses and suspected extra-adrenal phaeochromocytomas.