Adrenal metastases of malignant melanoma: Characteristic computed tomography appearances

Malignant melanoma is an extremely aggressive form of cancer. Adrenal metastases are found in 50% of cases of malignant melanoma, and are most often clinically and biochemically silent. Clinical presentation varies, and the diagnosis of adrenal metastases is often made incidentally, and frequently years after treatment of the primary lesion. An adrenal mass lesion seen on a CT scan, greater than 5 cm in diameter, with central or irregular areas of necrosis/haemorrhage (and no lipomatous component) is characteristic of a metastasis from malignant melanoma, in the setting of normal gland function. If these features are bilateral, they are pathognomonic. Oval, low‐attenuation (on CT) adrenal masses less than 3 cm in diameter should not be considered benign in a patient with any prior history of melanoma. Careful imaging review of the adrenal glands should be undertaken in all patients with malignant melanoma. Early diagnosis of these distant metastases has important prognostic and therapeutic implications. The four cases presented illustrate the spectrum of presentations and clinical course of adrenal metastases from malignant melanoma. The accompanying CT images show the characteristic appearances of adrenal metastases.     

High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology

AIMS AND BACKGROUND: The incidental finding of nonfunctioning adrenal masses (incidentalomas) is common, but no reliable criteria in differentiating between benign and malignant adrenal masses have been defined. The aim of this preliminary study was to assess the usefulness of adrenal imaging and image-guided fine-needle aspiration cytology in patients with nonfunctioning adrenal incidentalomas with the aim of excluding or confirming malignancy before surgery. METHODS: Forty-two consecutive patients (18 men and 24 women; median age, 54 years; range, 25-75 years) with incidentally discovered adrenal masses of 3 cm or more in the greatest diameter were prospectively enrolled in the study. All patients underwent helical computerized tomography scan and image-guided fine-needle aspiration cytology, 33 (78.6%) underwent magnetic resonance imaging, and 26 (61.9%) underwent norcholesterol scintigraphy before adrenalectomy. RESULTS: The revised final pathology showed 30 (71.4%) benign (26 adrenocortical adenomas, of which 3 were atypical, 2 ganglioneuromas, and 2 nonfunctioning benign pheochromocytomas) and 12 (28.6%, 95% CI = 15-42) adrenal malignancies (8 adrenocortical carcinomas and 4 unsuspected adrenal metastases). The definitive diagnosis of adrenocortical carcinoma was made according to Weiss criteria and confirmed on the basis of local invasion at surgery or metastases. The sensitivity, specificity and accuracy were 75%, 67% and 83% for computerized tomography scan, 92%, 95% and 94% for magnetic resonance imaging, 89%, 94% and 92% for norcholesterol scintigraphy, and 92%, 100% and 98% for fine-needle aspiration cytology. The sensitivity and accuracy of image-guided fine-needle aspiration cytology and magnetic resonance imaging together reached 100%. Immediate periprocedural complications of fine-needle aspiration cytology occurred in 2 (4.7%) patients: self-limited pneumothorax (n = 1), and severe pain (n = 1) requiring analgesic therapy. No postprocedural or late complications were observed. CONCLUSIONS: With the aim of selecting for surgery patients with a non-functioning adrenal incidentaloma of 3 cm or more in diameter, the combination of magnetic resonance imaging and fine-needle aspiration cytology should be considered the strategy of choice.     

肾上腺神经鞘瘤的诊断及临床特点并文献复习（附8例报告）

背景与目的：肾上腺神经鞘瘤非常少见,多为良性,缺乏特异性的临床及影像学表现。该研究通过对肾上腺神经鞘瘤的CT和MRI表现与病理对照分析,提高对肾上腺神经鞘瘤的诊断水平。方法：回顾性分析经病理证实的8例肾上腺神经鞘瘤患者的CT和MRI影像特征,其中4例患者仅行CT扫描,3例患者仅行MR扫描,1例患者行CT和MR扫描。并将影像学诊断结果与病理诊断结果进行对比分析。结果：5例肿瘤位于左侧肾上腺,3例位于右侧肾上腺;所有患者均未出现内分泌症状。所有8例肿瘤表现为边界清楚的类圆形、分叶状肿块,2例肿瘤见钙化,5例肿瘤伴囊变,2例肿瘤伴出血;7例肿瘤CT或MRI的强化表现为中度不均匀、延迟强化,并可见强化的包膜,4例肿瘤增强可见兔尾征。结论：肾上腺神经鞘瘤的影像及病理有一定的特征性,完整包膜、囊变、兔尾征、钙化及渐进强化等影像征象有助于提高肾上腺神经鞘瘤的诊断准确率。     

12例肾上腺淋巴瘤的影像学表现分析

目的探讨肾上腺淋巴瘤的影像学特点。方法回顾性分析12例初诊未治、有完整影像学资料及病理结果的肾上腺淋巴瘤患者的临床表现、病理类型及影像学表现。结果 12例均为非霍奇金淋巴瘤（2例原发性,10例继发性）。10例继发性病例中8例为双侧肾上腺受侵,2例为单侧受侵;8例表现为肾上腺肿物,2例为肾上腺增厚。8例边界清楚。4例伴有坏死或囊变。无伴有出血、钙化、脂肪者。增强扫描强化程度低于静脉期肝实质。8例伴多脏器受侵。9例伴淋巴结肿大,受侵淋巴结主要分布于腹腔及腹膜后。其中3例行PET-CT检查,肾上腺病变均伴有明显摄取增高,中位SUVmax为24.5。2例原发病例均为双侧肾上腺受侵,肿物密度混杂,内见囊变、坏死,增强扫描静脉期强化程度均低于肝实质。结论肾上腺淋巴瘤CT表现具有一定特征,以双侧受侵、边界清楚的低血供肿物为多见。继发病例常伴有多脏器、多组淋巴结受累。PET-CT有助于肿瘤定性诊断和观察有无淋巴结及其他脏器受累。     

Adrenal incidentaloma

Adrenal incidentalomas are incidentally discovered adrenal masses greater than 1 cm in diameter that appear to be clinically nonfunctioning. They are detected during imaging procedures of the abdomen and chest (CT, MRI, and ultrasonography) for an unrelated condition or symptom complex. With the widespread escalation in the use of these imaging modalities and marked improvements in image resolution, the probability of finding an incidentaloma on cross-section imaging is rapidly approaching the 6% prevalence of previously reported autopsy studies. All incidentalomas greater than 1 cm should be evaluated for hormonal activity, including a 1-mg overnight dexamethasone suppression test, total 24-hour urinary metanephrines and fractionated catecholamines, and, in the hypertensive patient, a serum potassium level and plasma aldosterone concentration to plasma renin activity ratio. All hormonally active tumors should be removed. Hormonally inactive tumors are resected based on size, imaging phenotype, and interval growth. Percutaneous biopsies are generally unwarranted and are potentially dangerous. Laparoscopic adrenalectomy has become the surgical procedure of choice for most benign functioning and nonfunctioning tumors of the adrenal gland. Subclinical metabolic abnormalities associated with adrenal incidentalomas remain an area of intense clinical research.     

667例肾上腺偶发瘤的临床分析

  目的  分析肾上腺偶发瘤的临床特点,探讨其诊治经验。  方法  回顾性分析2001年1月至2013年1月667例中山大学附属肿瘤医院和附属第一医院肾上腺肿瘤患者的临床资料。  结果  667例患者中病理确诊的肾上腺偶发瘤为511例。最常见的病理类型为皮质腺瘤240例,占47%（240/511）;嗜铬细胞瘤90例,占18%（90/511）;皮质腺癌41例,占8%（41/511）。511例患者中肿瘤直径≤4 cm为266例,良性占98%（260/266）,183例行腹腔镜下肾上腺肿瘤切除术;肿瘤直径>6 cm为245例,恶性占37%（91/ 245）,162例行开放性肾上腺肿瘤切除术。  结论  诊断肾上腺偶发瘤时肿瘤直径4 cm为参考临界值。腹腔镜肾上腺切除术是直径≤4 cm的肾上腺偶发瘤患者的首选治疗。      

Fine-needle aspiration cytology of adrenal masses in noncancer patients: clinicoradiologic and histologic correlations in functioning and nonfunctioning tumors.

BACKGROUND: Image-guided, fine-needle aspiration (FNA) cytology is performed currently in patients with malignant disease who have suspected adrenal metastases. The objective of this study was to evaluate the usefulness and safety of FNA cytology in patients with incidental adrenal masses and functioning tumors. METHODS: Computed tomography (CT)-guided or ultrasound-guided aspirates using 21-23-gauge needles were performed successfully in 70 patients with functioning (n = 38 patients) and nonfunctioning (n = 32 patients) adrenal masses (median size, 4 cm; range, 3-12 cm) that were detected previously by CT scans. RESULTS: Definitive histology was available in 68 patients (97.1%), showing 53 benign tumors (77.9%), 11 primitive malignant tumors (16.2%), and 4 unsuspected adrenal metastases (5.9%) in patients with unknown primary tumors. In two patients with aspirate reports that ruled out malignancy, the mass was unchanged on CT scan follow-up; thus, they were considered benign lesions. The benign masses were significantly smaller (P < 0.01), although seven malignant tumors (46.7%) measured 3-4 cm in greatest dimension, and eight benign lesions (14.5%) measured 5-6 cm in greatest dimension. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 96.4%, 83.3%, 91.4%, and 90.0%, respectively, for CT scan and 93.3%, 100%, 100%, 98.2%, and 98.6%, respectively, for FNA cytology. The morbidity rate of image-guided FNA cytology was 4.3% (two patients with self-limited, asymptomatic pneumothorax and one patient with spontaneously resolved adrenal hematoma). CONCLUSIONS: Adrenal FNA cytology represents a safe and specific procedure for evaluating patients with adrenal masses measuring > 2 cm in greatest dimension. FNA is able to reveal malignancies and unsuspected pheochromocytomas and should be performed in all patients with adrenal tumors whenever requested for surgical planning.     

CT-scan, MRI and image-guided FNA cytology of incidental adrenal masses.

AIM: The aim of this study was to compare the usefulness of computed tomography (CT)-scan, magnetic resonance imaging (MRI), and fine-needle aspiration (FNA) cytology in patients with incidentally discovered adrenal masses. PATIENTS AND METHODS: Thirty-four consecutive patients (six men and 28 women, median age of 47 years, range 26-80) with non-functioning adrenal masses of 2 cm or more (median 3.5 cm, range 2-9) were studied. All patients underwent CT-scan, MRI, and image-guided FNA cytology using spinal-type narrow-gauge needles prior to further procedures. Nineteen patients underwent adrenalectomy. RESULTS: Final pathology showed 13 benign adrenal lesions, four adrenocortical carcinomas, and two unsuspected adrenal metastases. Fifteen patients who did not have surgery were considered definitively as having benign adrenal lesions since the mass was unchanged on CT-scans performed during follow-up. The sensitivity, specificity, and positive predictive value were 66.7, 85.7, and 50.0%, for CT-scan, 83.3, 92.9, and 71.4% for MRI, and 83.3, 100, and 100% (p<0.05) for FNA cytology, respectively. CONCLUSIONS: Image-guided FNA cytology is a safe and sensitive procedure that may reveal unsuspected adrenal malignancies, and should be performed in all patients with incidentally discovered adrenal masses of more than 2 cm in size.     

An unusual case of adrenal metastasis from colorectal cancer: computed tomography and fluorine 18-fluoro-deoxy-glucose positron emission tomography-computed tomography features and literature review

Incidentally discovered adrenal masses are a common diagnostic problem. While computed tomography (CT) and magnetic resonance (MR) imaging can adequately characterize most benign or malignant adrenal masses, in some cases the results are indeterminate. We report and discuss a case of an adrenal metastasis with misleading clinical and CT features, in which an abnormal metabolic uptake detected through fluorine 18-fluoro-deoxy-glucose positron emission tomography ((18)F-FDG PET)-CT raised the suspicion of adrenal metastasis relatively early compared with apparently normal results on repeated follow-up CT examinations.     

Surgical treatment of adrenal diseases at Nara Medical University and affiliated hospitals.

The effect of advanced diagnostic imaging on the surgical treatment of adrenal diseases was examined in 86 cases of adrenal disease surgically treated at the Department of Urology, Nara Medical University, and affiliated hospitals from August, 1962, to July, 1991. The number of cases included in the present study was 16 for the period before the introduction of CT (from 1962 to 1978), and 70, including 13 cases of adrenal incidental tumor, after the introduction of CT in 1979. There were no malignant tumors histopathologically, among the 13 cases of incidental tumor. Accurate localization of functioning adrenal disease was possible at a rate of 100% with angiography, including selective venous blood sampling, 98.6% with CT and 84.5% with ultrasonography. The rate was 100% with magnetic resonance imaging which was carried out on 19 cases (20 adrenal glands). Signs of malignancy were observed in the removed tissue of three cases from the pheochromocytoma group. As the diagnostic imaging technique has improved, the use of a flank approach has increased in the surgery for adrenal disease.     

Imaging diagnosis of genitourinary tract tumors

Recent advance of imaging technique have brought great advantages for management of genitourinary tract tumors. We described few examples of changes in this field from our experience. Many asymptomatic masses are discovered in the kidney and adrenal gland associated with wide clinical application of CT and US. In the kidney, the greater part of incidental masses are renal cell carcinomas (RCC) and the rate of such cases has been increasing. When small RCC is diagnosed without any clinical symptoms, better survival would be expected. Many adrenal incidental mass are also discovered by routine use of CT for abdominal workup. Since greater part of these masses are benign nonfunctioning adenomas, correct diagnosis should be made in order to avoid inappropriate surgery. Rapid development of MR also resulted in some changes in the diagnosis of urinary tract tumors. However, MR cannot be used as a screening method. For staging of RCC, intravascular or adjacent organ invasion was well determined with MR compared with CT. Differentiation of adrenal carcinomas from nonfunctioning adenomas is suggested by the difference of signal intensity on T2 weighted images. Fast spin echo scan with GD-DTPA enhancement is new MRI technique separating bladder mucosal layer from muscle layer as hyper-intensity area. Using this method, diagnostic accuracy of deep muscle invasion for bladder tumor would be improved.     

肾上腺偶发瘤的临床对策

目的:探讨肾上腺偶发瘤的临床对策.方法:回顾总结2002年1月～2004年5月收治的50例肾上腺偶发瘤病例资料.结果:50例经腰切除31例,经腹切除10例,腹腔镜切除9例,效果满意.病理检查皮质腺瘤31例,皮质增生3例,皮质腺癌2例,嗜铬细胞瘤8例,肾上腺囊肿3例,髓质脂肪瘤l例,节细胞瘤1例,肾上腺转移癌1例.结论:所有肾上腺偶发瘤均应行内分泌功能检查,肾上腺B超、CT、MRI对确诊肾上腺占位病变有较高价值.除诊断明确的＜3.0cm的肾上腺囊肿和肾上腺髓样脂肪瘤外均应早期手术治疗.腹腔镜手术创伤小,恢复快,为首选术式,肿瘤较大或与周围脏器有粘连者宜经腹手术.     

B超和CT对上腹部大肿物的定位诊断

目的 准确定位上腹部大的实体肿物,方法 将同期Ｂ超和ＣＴ扫描对肾上腺,肝,脾,肾的肿物定位准确率进行比较,结果 超声定位肝肿物准确率为３３．３％（３／９）,ＣＴ为２２．２％（２／９）,超声定位肾上腺肿物准确率为７６．２％（１６／２１）,ＣＴ为２２．２％（４／１８）,超声及ＣＴ定位脾肿物准确率均为０（０／４）超声定位肾肿物准确率为５０％（２／４）,ＣＴ为０（０／１）,结论 超声定位肾上腺肿物的准确性     

肾上腺髓质脂肪瘤的诊断和治疗(附16例病例报告并文献复习)

目的:探讨肾上腺髓质脂肪瘤的诊断和治疗方法.方法:回顾性分析2010年1月至2015年5月我科收治的16例肾上腺髓质脂肪瘤患者的临床特点、影像学表现、手术方式以及预后情况,并复习相关文献.结果:16例肾上腺髓质脂肪瘤患者男5例,女11例,平均年龄46.2岁(29～ 70岁).病变位于右侧14例,左侧2例.术前无症状者9例,单纯性后腰背部疼痛5例,腰痛伴周身浮肿1例,高血压、心悸心慌、头晕等1例.16例患者均经超声或CT检查确诊,行开放或腹腔镜肾上腺及肿瘤切除术.手术均顺利,术后均有病理证实为髓质脂肪瘤.出院后随访3～36个月,原有症状消失,肿瘤无复发.结论:肾上腺髓质脂肪瘤可依靠影像学检查诊断,治疗手段以手术切除为主,安全有效,手术方式以腹腔镜为首选.     

Diagnostic approach to incidental adrenal nodules in the cancer patient. Results of a clinical, radiologic, and fine-needle aspiration study

Twenty-three nonfunctioning adrenal nodules were discovered during computed tomographic (CT) evaluation of the abdomen in 16 patients with a variety of primary extra-adrenal malignant neoplasms. In seven cases the adrenal masses were bilateral. Following percutaneous fine-needle aspiration biopsy, pathologic diagnosis was consistent with benign adenoma in seven patients, and with adrenal metastasis in nine. There was no significant difference in age, sex, or incidence of bilateral distribution among these two groups. Three of the adenomas were calcified, and the size of the benign nodules in all patients was less than 3 cm. No calcification was seen in metastatic adrenal nodules, and their sizes ranged between 2 and 20 cm. The clinical and radiologic features of these two groups of patients are evaluated, and a rational approach for the management of adrenal masses is described. The CT images of adrenal adenoma and adrenal metastasis, along with their corresponding cytopathologic features, are illustrated.     

Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer.

Although adrenal metastases are frequently noted with non-small-cell lung cancer (NSCLC) at autopsy, their incidence in patients with operable NSCLC is unclear. We prospectively assessed consecutive patients with otherwise operable NSCLC for the incidence and histology of unilateral adrenal masses. Assessment included blood chemistries, lung function tests, bronchoscopy, chest x-ray, bone scan, and computed tomography (CT) of the head, chest, and upper abdomen. Of 246 patients with otherwise operable NSCLC, 10 (4.1%) had a unilateral adrenal mass. Unilateral adrenal masses were needle-aspirated under CT control. If cytology was nondiagnostic, adrenalectomy was performed. Four (40%) of 10 patients had adrenal metastases proven by needle aspiration. Of the six (60%) patients with benign unilateral adrenal masses, one was demonstrated by needle aspiration. In the other five patients, a nondiagnostic needle aspiration led to adrenalectomy, which yielded two adenomas, two hyperplastic nodules, and one hemorrhagic cyst. There was no significant difference between the patients with benign and metastatic unilateral adrenal masses with respect to patient age or stage and size of adrenal mass. Patients with benign unilateral adrenal masses underwent curative resection of their NSCLC and had significantly prolonged survival compared with patients with metastatic unilateral adrenal masses treated with chemotherapy (P = .037). Median survival of patients with benign and metastatic unilateral adrenal masses was greater than 30 months and 9 months, respectively. In conclusion, the presence of unilateral adrenal masses in patients with otherwise operable NSCLC should not preclude thoracotomy without pathologic proof of metastatic disease.     

多层螺旋CT灌注成像诊断周围型肺癌及其微血管密度对照研究

Objective： To investigate the clinical diagnostic value of peripheral lung cancer using multi-slice CT （MSCT） perfusion imaging and the relationship with microvessel density （MVD）. Methods： 38 patients with pulmonary masses proved by pathology including 25 cases of peripheral lung cancer and 13 cases of benign masses were studied prospectively with GE Lightspeed Qx/I plus 16-slice helical CT perfusion imaging, and 25 patients with lung cancer were comparative studied with its MVD calculated using LSAB. With the CT perfusion 2-body tumor software, the parameters of CT perfusion including blood value （BV）, blood flow （BF）, mean transit time （MTT） and permeability surface （PS） were analyzed. Results： The four parameter values in lung cancer were all higher than that in pulmonary benign masses, and there were significant differences among BV, MTT and PS （P〈0.05）, especially in BV （P〈0.01）. The MVD value of lung cancer was higher than that of pulmonary benign masses （P〈0.05）, and the MVD of adenocarcinoma was higher than that of squamous cell carcinoma （P〈0.05）. In 25 cases with lung cancer, there was positive correlation only between BV and MVD value （r=0.852, P〈0.01）. Conclusion： It is helpful to diagnose the peripheral lung cancer with MSCT perfusion imaging and to differentiate from pulmonary benign masses, its bases are MVD pathologically.     

肝脏血管平滑肌脂肪瘤的CT、MR表现与手术病理对照研究

目的:研究肝脏血管平滑肌脂肪瘤(HAML)的CT、MR表现及其病理基础,提高对该病的认识.方法:回顾性分析了10例经手术病理证实为HAML的CT、MR表现,并与病理组织学对照.结果:CT平扫呈不均匀低密度,内见斑点状、务状及片状更低密度区,边界清楚.MR中,3例T1WI表现为以低信号为主,内见斑点状、细条状高信号,T2WI为不均匀高信号.1例呈"靶"征,CT平扫中心密度与肝实质相仿,周围被更低密度环绕,对应MR在T1WI呈中心低信号,周围环绕高信号.CT、MR增强扫描均表现动脉期明显强化,门脉期和(或)延迟期中度和轻度强化.1例瘤内伴假性动脉瘤,2例有假包膜,表现在门脉期和(或)延迟期病变边缘环形强化.结论:CT、MR表现可反映其病理组织学基础,对微小脂肪灶的检出及病变增强扫描特点有助于HAML的诊断.     

肾占位性病变的CT定性诊断

目的分析肾占位性病变的CT表现,探讨CT对该类疾病的定性诊断价值。方法对手术/病例证实的28例肾占位性病变进行回顾性分析,所有病例均行平扫和增强扫描。结果肾恶性肿瘤21例(75%),其中肾癌(RCC)16例,CT表现为肾实质内形态不规则的低密度软组织肿块,增强后不强化或轻度强化;肾盂癌2例,CT表现为肾盂内软组织肿块影,增强后不强化或轻度强化。肾母细胞瘤(Wilms瘤)3例,CT表现为较大不规则的分叶肿块,增强后不强化;肾良性肿瘤3例(11%),均为肾血管平滑肌脂肪瘤(ALL),两例CT表现为多种不同成分的混杂密度肿块,一例表现为均匀等密度肿块,增强后软组织部分强化,而脂肪成分不强化。其它4例(14%),3例肾囊肿,CT表现为典型的边界清楚的囊性病灶,增强后未见强化;1例肾脓肿,CT表现为实质性与囊性混杂密度的肿块,增强后实质性部分有轻度强化,囊性部分不强化。结论CT平扫及增强扫描,以及诊断过程中密切结合病史,对肾占位性病变有重要的鉴别诊断价值。     

18F]FDG positron emission tomography/computed tomography and multidetector computed tomography roles in thymic lesion treatment planning

RATIONALE: Thymic masses may represent an unsolved diagnostic problem which often require surgical procedures for an accurate staging. A non-invasive way to determine the nature of thymic lesions would help identify the patients which are true candidates for surgery. Our retrospective study aims to assess multidetector computed tomography and 2-[(18)F]fluoro-2-deoxyglucose positron emission tomography/computed tomography ([(18)F]FDG-PET/CT) capacity to distinguish benign from malignant thymic lesions. METHODS: Helical multidetector CT (MDCT) and [(18)F]FDG-PET/CT of twenty consecutive patients presenting with a thymic mass at our Institute were retrospectively analyzed. MDCT scans were focused on morphologic features and invasiveness characteristics. Qualitative and semi-quantitative analyses by maximum standardized uptake value corrected for body weight (SUVbw max) were performed on [(18)F]FDG-PET/CT. In all cases, readers were blinded to pathology findings. Both imaging techniques were correlated to final pathology. Student's t-test was performed on SUVbw max stratified for thymic epithelial tumors. RESULTS: In the group of benign lesions MDCT correctly identified well-defined margins of masses in 8 out of 8 patients whereas [(18)F]FDG-PET/CT was negative in 7 out of 8 patients. Among malignant lesions MDCT revealed mediastinum fat or infiltration of adjacent organs in 10/12 patients. On the other hand [(18)F]FDG-PET/CT showed increased radiotracer uptake in 12/12 patients. CONCLUSIONS: MDCT and [(18)F]FDG-PET/CT alone are not able to differentiate the nature of thymic lesions. However, they are two non-invasive complementary techniques which can be used to differentiate benign from high-risk malignant thymic lesions. These findings should be taken into account before surgery is performed as a diagnostic procedure.