Adrenal Masses: MR Imaging Features with Pathologic Correlation

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Adrenal Masses MR Imaging Features with
Pathologic Correlation

• By
• Nour Eldin Mohammed
• Ref Khaled M. Elsayes, et al , 2004,
  Radiographics

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Normal Anatomy

• The adrenal glands are two small, yellowish
  bodies located in the perirenal space,
  immediately anterosuperior to the upper pole of
  the kidneys.
• They are very vascular and receive blood supply
  from the superior, middle, and inferior
  suprarenal arteries

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• The adrenal gland is composed of an outer cortex
  and thinner inner medulla.
• The cortex is further subdivided into three
  zones outer zona glomerulosa, middle zona
  fasciculata, and inner zona reticularis

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Normal MRI Appearance

• The right adrenal gland is located posterior to
  the inferior vena cava and superior to the upper
  pole of the right kidney.
• The left adrenal gland is anteromedial to the
  upper pole of the kidney and posterior to the
  pancreas
• Normal adrenal glands range from 2 to 6 mm in
  thickness and from 2 to 4 cm in length

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Fat-containing Adrenal Masses

• Fat-containing adrenal masses can be classified
  into two main types
• those that contain intracellular fat (eg,
  adenoma)
• and those with macroscopic fat (eg, myelolipoma).
  

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Adrenal Adenoma

• The most common adrenal lesions.
• Characterised by the presence of intracellular
  lipid.
• Chemical shift imaging is the most reliable
  technique for diagnosing adrenal adenoma with
  loss of signal intensity on out-of-phase images.
• Uniform enhancement with contrast enhanced images
  is typical of adenomas.
• Cystic changes, hemorrhage, or variation in
  vascularity lead to small, rounded foci of
  altered signal intensity.

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Axial in Phase MRI
Axial out of phase MRI
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Myelolipoma

• The myelolipoma is an uncommon benign tumor
  composed of mature adipose tissue and
  hematopoietic tissue.
• Mostly discovered accidentally.
• The fatty component of this tumor is hyperintense
  on T1-weighted images.
• With loss of signal intensity of the fatty
  component on Fat-Suppressed Technique.

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Axial T1 with Fat Suppressed Technique
Axial T1 MRI
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Cystic Masses

• These include
• Simple Cysts
• Pseudocysts
• Lymphangioma

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Simple Cysts
T1 Coronal MRI
T2 Coronal MRI
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Pseudocysts

• Pseudocysts typically arise after an episode of
  adrenal hemorrhage and do not have an epithelial
  lining.
• Have a complicated appearance on MR images,
  manifesting with septations, blood products, or a
  soft-tissue component secondary to hemorrhage or
  hyalinized thrombus.
• Peripheral curvilinear calcification may be
  present.

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Coronal T2 MRI
Axial T1 with Contrast
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Lymphangioma
Low signal intensity at T1-weighted imaging and
high signal intensity at T2-weighted
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Hypervascular Lesions (Pheochromocytoma)

• It arises from the adrenal medulla.
• 10 of pheochromocytomas are bilateral,10 are
  extraadrenal,10 occur in children, and 10 are
  malignant
• Pheochromocytomas do not contain a substantial
  amount of cytoplasmic lipid, So they maintain
  their signal intensity on out-of-phase GRE
  chemical shift images.
• Most pheochromocytomas demonstrate high signal
  intensity on T2-weighted images (light bulb sign).

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Axial T1 in Phase MRI
Axial T1 out of Phase MRI
Contrast-enhanced Image
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Malignant Neoplasms

• Adrenocortical Carcinoma
• Adrenal Lymphoma
• Metastases

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Adrenocortical Carcinoma

• a rare tumor.
• Age 30 - 70
• Large size
• Can manifest as a hyperfunctioning mass causing
  Cushing syndrome or Conn syndrome.
• Other manifestations include an abdominal mass
  and abdominal pain.

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Sagittal 3D contrast-enhanced MRI
Coronal T2-weighted MRI
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Adrenal Lymphoma

• More with non-Hodgkin lymphoma
• Bilateral involvement occurs in 50 of patients .
• Characterized by low signal intensity on T1 WI
  and heterogeneous high signal intensity on T2 WI
  , with minimal progressive enhancement after
  administration of contrast material.

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Axial T1-weighted MRI
Axial T2-weighted MRI
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Metastases

• The most common malignant lesions involving the
  adrenal gland.
• Found in up to 27 of patients with Carcinomas at
  autopsy.
• Common primary sites of tumors that metastasize
  to the adrenal glands include the lung, bowel,
  breast, and pancreas.
• Usually bilateral but may also be unilateral.

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Contrast Enhanced T1 Image Of Metastatic Deposit
From Renal Cell Carcinoma
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Pediatric Neoplasms

• Neuroblastoma
• Ganglioneuroblastoma

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Neuroblastoma

• The 2nd most common pediatric abdominal mass
  (after Wilms tumor).
• Representing 515 of all malignant tumors in
  children .
• Arises from the neural crest in the adrenal
  medulla or along the sympathetic chain.
• Usually demonstrates heterogeneous low signal
  intensity on T1-weighted images, high signal
  intensity on T2-weighted images , and enhancement
  after administration of contrast material.
• Calcification is present in 8090 of the lesions

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Coronal unenhanced T1 MRI
Axial T2 MRI
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Ganglioneuroblastoma

• Intermediate in malignancy between that of
  neuroblastoma and ganglioneuroma
• arise from the neural crest.
• Ganglioneuroblastoma are smaller and more well
  defined than neuroblastoma
• Demonstrates Intermediate signal intensity on T1
  WI and heterogeneously high signal intensity on
  T2 WI, with heterogeneous enhancement after
  administration of contrast material.

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T1-WI shows a heterogeneous mass with
intermediate signal intensity
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Thank you