Computed Tomography in Adrenal Tumors

N. REED DUNNICK,’ EVERETT G. SCHANER,1 JOHN L. DOPPMAN,1 CHARLES A. STROTT,2 JOHN R. GILL,3 AND
NASSAR JAVADPOUR4
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Computed tomography (CT) was used to evaluate 26 pa- recently we have taken additional overlapping cuts at 7 mm
tients with a variety of adrenal lesions. Surgical proof was intervals after initially localizing the adrenal glands on routine
available in 22 patients and clinical confirmation with a variety scans.
of other studies in the other four patients. Nine patients had
aldosterone-producing adrenal adenomas and CT correctly Results
identified seven. Four patients had cortisol-producing adeno-
Aldosteronoma
mas and five patients had cortisol-producing carcinomas; CT
identified each of these tumors. Prominent but normal shaped Nine patients had CT scans as part of their evaluation
glands were seen in each of the four patients with adrenal of primary aldosteronism; CT identified the adrenal ade-
hyperplasia. Adrenal metastases from malignant melanoma noma in seven (figs. 1-3). Five had confirmation of the
in two patients were identified. Only one of two pheochromo-
suspected adrenal adenoma by adrenal vein catheteriza-
cytomas in two patients could be seen on CT. CT is a nonin-
tion and all seven had subsequent surgical proof. At
vasive method of localizing adrenal tumors and may be helpful
in distinguishing adenomas from adrenal hyperplasia. surgery, these adrenal adenomas ranged from 1 to 6 cm
in diameter. Of the two CT failures, one patient had an
adrenal adenoma only 0.5 cm in diameter which was
Adrenal venography with samples for laboratory analysis
diagnosed by venous sampling and surgically confirmed.
is a valuable technique for functioning adrenal cortical
The other patient had an adrenal adenoma localized by
lesions [1-3]. However, in addition to being an invasive
venous sampling, but has refused surgery.
procedure with the risk of adrenal infarction, the right
adrenal vein may be difficult to catheterize selectively Cushing’s Syndrome
and sample. Whole body computed tomography (CT) has
Of 13 patients studied for Cushing’s syndrome, five
proved most valuable in the evaluation of retroperitoneal
had adrenal carcinomas, four had adrenal adenomas,
structures difficult to image by conventional means.
and four had bilateral adrenal cortical hyperplasia. Of
Several reports describe the CT manifestations of normal
the four patients with adrenal adenomas, CT correctly
adrenal glands and adrenal tumors [4-6]. Thus, there is
identified all four and each was surgically confirmed.
much interest in the use of CT as a means of detecting
The smallest of these adenomas was 2 cm. The CT
and lateralizing adrenal tumors. We performed CT scans
examination correctly identified the tumor masses in all
on 22 patients with a variety of adrenal tumors, and four
five cases of adrenal carcinoma and each of these cases
patients with bilateral adrenal hyperplasia who were
was surgically confirmed. Adrenal masses were not seen
initially seen for Cushing’s syndrome. The spectrum of
in any of the four cases of adrenal hyperplasia. Instead
CT findings in these adrenal lesions is presented and
the adrenal glands were prominent but maintained a
correlation is made with both catheterization data and
normal configuration (fig. 4).
surgical results.
Metastatic Tumor
Subjects and Methods
A total of 26 patients (14 male, 12 female) ranging in age from Two patients with malignant melanoma were studied
17 to 67 years was examined. Nine patients were studied for for adrenal metastases. CT correctly identified both of
primary aldosteronism, 13 for Cushing’s syndrome, two for these tumors, and both were surgically confirmed
adrenal metastases, and two for biochemical evidence of a (fig. 5).
pheochromocytoma (table 1).
Bilateral adrenal venography with sampling was performed in Pheochromocytoma
12 patients. Arteriography was performed in the two patients
Two patients were studied for suspected pheochro-
with pheochromocytomas and in six patients who had either
mocytoma. CT identified an adrenal mass in one of these
adrenal carcinomas or metastases to the adrenal gland. Surgi-
cases and surgical proof was obtained. The other patient
cal confirmation was obtained in 22 of the 26 patients.
The CT scans were performed on an EMI 5000 whole body had a 3 cm right adrenal pheochromocytoma not identi-
scanner with an 18 sec scan time and a 320 x 320 matrix fied on CT. The paucity of retroperitoneal fat in this
display. Adjacent but not overlapping 13 mm cuts were routinely patient made delineation of retroperitoneal structures
obtained after injection of intravenous contrast material. More impossible on CT.

Received April 13, 1978; accepted after revision October 5, 1978.

I Diagnostic Radiology Department, Clinical Center, National Institutes of Health, Building 10, Room 65211 , Bethesda, Maryland 20014. Address
reprint requests to N. A. Dunnick.
2 Reproductive Research Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
20014.
3 Hypertension Endocrine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland 20014.
4 Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20014.

AJR 132:43-46, January 1979 43 0361-803X/79/1321-0043 $0.00

 44 DUNNICK ET AL. AJR:132, January 1979

TABLE 1
Diagnostic Methods in Patients with Adrenal Tumors

Angiography
Reason Seen and Venous Radionuclide
CT Surgery Pathology and Final Diagnosis
55 0. amp ing Venogram Arteriogram can

Aldosteronism:
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1 + + NP NP + + Adenoma, Aldosteronoma
2 + + NP NP ± + Adenoma, Aldosteronoma
3 + + NP NP + ± Adenoma, Aldosteronoma
4 + - - NP + + Adenoma, Aldosteronoma
5 NP NP NP + + + Adenoma, Aldosteronoma
6 + + NP NP #{247} + Adenoma, Aldosteronoma
7 NP NP NP + + + Adenoma, Aldosteronoma
8 + - NP NP - + Adenoma, Aldosteronoma
9 + - NP NP - NP NP, Aldosteronoma
Cushing’s syndrome:
10 + + + + + + Adenoma
11 NP NP NP + + + Adenoma
12 + #{247} + NP + ± Adenoma
13 NP NP NP + + + Adenoma
14 - - - NP - Hyperplasia
15 - - - NP NP NP, Hyperplasia
16 - - NP NP - NP NP, Hyperplasia
17 NP NP NP - - NP NP, Hyperplasia
18 NP + + NP + + Carcinoma
19 .................... NP NP + NP + + Carcinoma
20 NP NP + NP + + Carcinoma
21 NP + + NP + + Carcinoma
22 NP + + NP + #{247} Carcinoma
Melanoma:
23 NP NP + NP + + Metastasis
24 NP NP NP NP + + Metastasis
Hypertension:
25 NP NP + NP - + Pheochromocytoma
26 NP NP + NP + + Pheochromocytoma
Note. - + = positive for adrenal tumor: - = negative for adrenal tumor: NP = not performed.
. Hyperplasia rather than tumor.

Fig. 1 -Case 5, 47-year-old woman with primary aldosteronism. Right

adrenal mass. Subsequent surgery demonstrated 1 .3 x 1 .0 x 0.5 cm
right adrenal adenoma. Fig. 2.-Case 7, 49-year-old man with primary aldosteronism. Right
adrenal mass. Confirmed by iodocholesterol scan and subsequent sur-
gery.

Discussion

This series of patients demonstrates the value of adre- may not be able to sample successfully both adrenal
nal venography with venous samplings for the evaluation glands in all patients.
of hormone-producing adrenal lesions. However, adre- The normal adrenal glands are commonly identified on
nal venography is an invasive procedure which requires CT scans of the upper abdomen by their characteristic
skilled angiography. Even an experienced angiographer shape and location. The left adrenal gland is routinely
 AJR:132, January 1979 CT OF ADRENAL TUMORS 45

.,
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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.

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 hyper-
plasia. Although both adrenal glands are slightly en-
larged 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 syn-
drome 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 pheochromocyto-
Fig. 4.-Case 16, 26-year-old woman with Cushing’s syndrome. Prom-
inent but normally shaped adrenal glands bilaterally (arrows). Adrenal mas.
vein samples confirmed impression of bilateral adrenal hyperplasia. 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
visualized at the same level, or one cut above the top of diagnosis was confirmed by other studies, usually an-
the left kidney. It is shaped like an inverted V. one arm of giography and surgery. The false negative rate of 1 1 % (3
which may be slightly longer than the other. The right of 26) is a result of a small lesion (0.5 cm) or lack of
adrenal gland is seen medial to the liver and also has an retroperitoneal fat.
inverted V shape. The posterior arm is much longer than In patients with biochemical findings of either Cush-
the lateral arm, and we frequently visualize only the ing’s syndrome or primary aldosteronism, CT may local-
longer posterior arm. It is located immediately behind ize the functioning tumor and thus provide lateralization
the inferior vena cava, slightly above the top of the right for the surgeon. Two other noninvasive methods cur-
kidney, and parallels the right diaphragmatic crus. rently provide similar information: isotopic adrenal scan-
Adrenal tumors appear as discrete masses in the ning with an iodinated cholesterol compound [7-9] and
adrenal gland. If the tumor is small, a portion of normal diagnostic ultrasound [10-11]. Isotopic scanning is a
gland may also be identified. When the tumor is large, prolonged procedure with a rather high radiation dose.
the adrenal etiology may be suspected by the clinical The resolution of gray scale ultrasound is continuing to
presentation, anatomic location, and absence of a nor- improve; however, the adrenal glands are difficult to
mal adrenal gland. As we have stressed in an earlier image, especially in large patients where a lower fre-
 46 DUNNICK ET AL. AJR:132, January 1979
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quency transducer is required. At present, we feel CT 6. Schaner EG, Dunnick NA, Doppman JL, Strott DA, Gill JR
provides the best anatomic information in the presurgi- Jr. Javadpour N: Adrenal cortical tumors with low attenua-
cal evaluation of adrenal lesions. tion coefficients: a pitfall in computed tomography diagno-
sis. J Comput Assist Tomogr 2 : 1 1-15, 1978
7. Moses DC, Schteingart DH, Sturman MF, Beirwaltes WH,
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