January 31, 2019

Malignant Adrenal Masses

17 minutes

In this video lecture, we discuss the diagnosis and imaging appearance of malignant adrenal masses: adrenal metastases including collision tumor, adrenocortical carcinoma and adrenal lymphoma.

Key points include:

Adrenal metastases are the most common malignant lesion involving the adrenal gland.

Lung carcinoma is the most common primary malignancy to metastasize to the adrenal glands.

Adrenal metastases are often bilateral and greater than 3 cm in size.

When malignant adrenal lesions are compared to adenomas, SUV cutoff of 3.1 has a 99% negative predictive value.

Adrenal-to-liver SUV ratio cutoff value of 1.4 has a specificity of 100% in differentiating adrenal adenomas and metastases.

Collision tumors are two histologically distinct tumors that abut or are near each other in the adrenal gland, and PET/CT is the best way to characterize these lesions without biopsy.

An enlarging defect within adrenal signal dropout on T1-weighted opposed-phase GRE images is suspicious for a metastatic collision tumor abutting a lipid-rich adrenal adenoma.

Renal cell carcinoma metastases can be slow growing and occur many years after the initial tumor presentation.

Adrenocortical carcinoma has a bimodal age distribution, may be hormonally functioning and has a poor prognosis.

Adrenocortical carcinoma usually presents as a large (greater than 6 cm) mass with internal hemorrhage, necrosis and sometimes calcification.

Venous invasion is common with adrenocortical carcinoma.

Adrenal lymphoma will be round or adreniform in shape and frequently shows restricted diffusion, a feature that can be helpful in differentiating from adrenal hyperplasia.

Diffuse large B-cell lymphoma is the most common type of adrenal lymphoma, and patients usually present with B-cell symptoms and/or adrenal insufficiency.

Adrenal lymphoma is usually bilateral and may invade the adjacent kidney(s).

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By Daniel J. Kowal, MD

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