ULTRASONIC GRETCHEN
SPECTRUM OF ADRENAL MASSES
A. W. GOODING,
M.D.
From the Ultrasound Section, Radiology Service, Veterans Administration Hospital and the University of California School of Medicine, San Francisco, California
ABSTRACT -Adrenal masses are amenable to ultrasonic examination. The ultrasonic characteristics of eight adrenal masses in 6 patients are described. In particular, an ultrasonic study of the natural history and progression of a large adrenal adenoma is reported. Adrenal masses on the right side may mimic right posterior liver masses on transverse scans alone. They may compress and displace the liver with expansion. Posterolateral impressions on the inferior vena cava occur. Differentiation from a superior pole renal mass is not always possible.
Under ideal circumstances the normal adrenal gland can be delineated with ultrasound by the meticulous technique espoused by Sample. ’ Adrenal masses are also amenable to sonic detection; the ultrasonic appearance of neoplasms2-13 hemorrhage,14*15 and cyst” have been described. This study reports a series of 6 patients with eight adrenal masses in order to elaborate on the diagnostic nuances of masses in this area of the retroperitoneum and to describe, in particular, the natural history and progression of a large adrenal adenoma. Material
and Methods
The patients were scanned with a gray scale Picker EDC ultrasonographic unit, using a 19 mm. 2.5 MHz focused transducer. Mineral oil was the coupling agent. Polaroid films of the image were taken. Prone, supine, and occasional decubitus and costal margin views were obtained at l-cm. intervals in both transverse and longitudinal planes. One case each of primary adrenal carcinoma, adrenal adenoma, and adrenal hematoma was studied. Three patients had adrenal metastases from primary bronchogenic carcinoma, bilateral in 2 patients, the bilaterality unsuspected in both instances. All cases were proved at surgery or autopsy.
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII.
NUMBER 2
Case Report The patient with a right adrenal adenoma had been followed over a ten-year period for a mass in the right upper abdominal quadrant that was relatively asymptomatic. Multiple amorphous calcifications were present on plain films in the right upper quadrant (Fig. 1A). The suspected, but erroneous diagnosis was probable echinococcal disease of the liver. An hepatic arteriogram three years prior to exploration revealed stretching of the right hepatic arteries about an avascular mass. The first sonogram two years before exploration revealed a large solid mass in the right upper quadrant with multiple calcifications, interspersed with small fluid collections (Fig. 1B). The left lobe of the liver was interpreted as large, but normal in configuration. Scans at six-month intervals revealed gradual enlargement of the mass with the development of multiple large fluid components in association with dense calcifications (Fig. 1C). A computerized tomographic examination confirmed the ultrasonic findings, which suggested involvement of the entire right lobe of the liver (Fig. 1D). At surgery, an enormous degenerated cystic adrenal adenoma was removed. Both right and left lobes of normal liver were displaced to the mid epigastrium and left upper quadrant. The
211
FIGURE 1. (A) Plain film of abd omen demonstrates multiple amorphous calcifications in right upper quadrant within an adrenal adenoma (Case 2). (B) Supine transverse sonogram shows large solid mass in right upper quadrant, containing calcifications and small cystic areas. This adrenal adenoma (arrows) replaces liver and impresses laterally inferior vena cava (V), which is elevated. (C) Supine transverse sonogram of same adrenal adenoma two years later demonstrates large central fluid-jlled areas (arrows) in mass surrounded by calci$cations. (D) Computerized tomographic scan of adrenal adenoma (arrows) shows huge ca1ci.c right upper quadrant mass felt to be compatible with right hepatic mass. Central area did not enhance with contrast, while periphery of mass enhances slightly. patient is alive surgery.
and well
Results
FIGURE 2. Prone longitudinal scan of right kidney (K) reveals transsonic mass, adrenal metastasis (A), anteromedially (Case 5).
212
eleven
(Table
months
after
I)
The idiopathic adrenal hematoma was complex in character; all the other masses were neoplasms, solid ultrasonically, except for the adrenal adenoma which contained multiple calcifications and large areas of cystic degeneration. One adrenal metastasis was relatively echo-free (Fig. 2). The other neoplasms generated echoes. On supine transverse scans alone, a right adrenal mass mimicked the appearance of a mass in the posteroinferior right lobe of the liver (Fig. 3A). Prone and supine longitudinal scans depicted more precisely the retroperitoneal origin of the mass (Fig. 3B).
UROLOGY
/ FEBRUARY 1979 / VOLUME
XIII,
NUMBER 2
TABLE
Case
Pathologic
Condition
I.
Adrenal
pathologu
Size (Cm.) and Ultrasonic Character
Age/Sex
Laterality
57 M
Right
8 by 6, complex 19 by 17 by 9, large cystic components in a solid mass 12 by 12 by 10, echogenic, solid
Calcifications
1
Adrenal
2
Adrenal adenoma, nonhmctioning
61 F
Right
3
Primary adrenal carcinoma
30 M
Left
4
Adrenal metastasis (invading the kidney)
51 M
Right
8 by 8, echogenic, solid
None
5
Adrenal
67 M
Right
9 by 5, relatively echo-free, solid
None
Left
5 by 5, echogenic,
6
Adrenal
hematoma
metastasis
metastasis
57 M
Right
Left
None
solid
10 by 10, primarily echogenic with areas of decreased echo production, solid 6 by 6, echogenic, solid
Multiple
None
None
None
Relationship of Mass to Kidney Separate from and superior to right kidney Right kidney depressed inferiorly Distinct from left kidney which was depressed inferiorly and posteriorly Superior mass encompassed upper pole of right kidney but was sharply demarcated from it Anterior, superomedial, immediately adjacent to kidney Anterior, superomedial, immediately adjacent to kidney Superomedial, immediately adjacent to kidney Superomedial, immediately adjacent to kidney
FIGURE 3. (A) Supine transverse scan depicts mass in what appears to be right posterior lobe of liver, but which is actually adrenal metastasis (arrows) (Case 4). Inferior vena cava (V) is compressed from posterolateral direction by metastasis. (B) Supine longitudinal scan of same Case 4 delineates adrenal metastasis (arrows) invading upper pole of right kidney (Kj.
The larger right adrenal masses (Cases 2, 4, and 6) caused the liver to be slightly compressed and arced over the tumor with a discrete border delineated between the two on longitudinal scans (Fig. 4). In 3 cases of right adrenal neoplasia, the tumor elevated and compressed the inferior vena cava posterolaterally (Cases 2, 4, and 6) (Figs. lB, 3A). Four adrenal metastases were immediately adjacent to, but clearly separate from the kidney in a superomedial position. In 1 case of adrenal metastasis (Case 4), the superior mass mimicked a mass originating from the upper pole of the right kidney; and although a sharp demarcation
UROLOGY
I
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
FIGURE 4. Supine longitudinal scan demonstrates huge right adrenal metastasis (arrows) compressing liver (L) which arcs over it (Case 6).
2
213
between kidney and mass was apparent, a renal origin could not be excluded. One patient with adrenal metastasis (Case 5) had an associated ipsilateral solid renal mass which suggested the possibility of malignancy. This proved to be a renal metastasis. Comment The adrenal adenoma was nonfunctioning endocrinologically and grew over a number of years, causing few symptoms. Yet the intrinsic ultrasonic character of the mass changed from that of a solid calcified tumor with some small cystic areas to that of a large neoplasm with multiple fluid-filled areas of central necrosis. Pathologically, the typical adrenocortical adenoma is a nonfunctioning lesion 1 to 5 cm. in diameter.” Larger adenomas may occur up to 12 cm. in diameter with hemorrhage, cystic degeneration, and calcification, but these findings are more commonly associated with adrenal carcinema.” The adenoma of this report is decidedly unusual in both size (19 by 19 by 7 cm.) and weight (1,050 Gm.), the normal adult female adrenal gland weighing 4.1* 0.8 Gm. l7 As retroperitoneal adrenal masses enlarge, they tend to displace adjacent viscera and may even abut the anterior abdominal wall as in Case 2 (adrenal adenoma) and Case 3 (primary adrenal carcinoma). Adrenal masses can be confused with intrinsic liver masses (Case 2), especially on supine transverse scans alone. The retroperitoneal relationships are best defined using supine and prone longitudinal scans, although scans in lateral decubitus and costal margin projections may be needed for a complete assessment. Even with the best techniques, it is not always possible to delineate the origin of a huge abdominal mass as originating from the adrenal gland. An adrenal mass replacing the upper pole of the kidney could not be distinguished from an upper pole renal mass by sonography alone (Case 4). Arteriography revealed the enlarged adrenal arterial supply. The pathologic specimen demonstrated the adrenal metastasis to be invading the upper pole of the right kidney. Adrenal masses on the right side can elevate and compress the inferior vena cava by a posterolateral mass effect. l3 Similar posterior mass effects on the inferior vena cava have been de-
214
scribed from metastatic carcinoma of the pancreas and renal cell carcinoma.18 Ultrasonography is a noninvasive means to detect adrenal metastases, which are often bilateral. Adrenal metastases most commonly arise from squamous cell carcinoma of the lung, occurring in one third of the cases. r’ Breast carcinoma also metastasizes frequently to the adrenal (30 per cent), as does melanoma, carcinoma of the stomach, large intestine, pancreas, kidney, and thyroid. These may be clinically unsuspected. Ultrasonography can monitor these patients without further biologic hazard and may be used to define the radiation ports for palliative therapy. lg Veterans Administration Hospital 4150 Clement Street San Francisco, California 94121 References 1. Sample WS: A new technique for the evaluation of the adrenal gland with gray scale ultrasonography, Radiology 124: 463 (1977). 2. Bimholz JC: Ultrasound imaging of adrenal mass lesions, ibid. 193: 163 (1973). 3. Smith EH, and Bartrum RJ: Ultrasonic evaluation of pararenal masses, J.A.M.A. 231: 51 (1975). 4. Davidson JK, et al: Adrenal venography and ultrasound in the investigation of the adrenal gland: an analysis of 58 cases, Br. J. Radio]. 48: 435 (1975). 5. Gee WF, et al: Adrenal myelohpoma, Urology 5: 562 (1975). 6. Ghorashi B, and Holmes JH: Gray scale sonographic appearance of an adrenal mass: a case report, J. Clin. Ultrasound 4: 121 (1976). 7. Marchal G, and Baert AI: Echography of suprarenal masses, Radiologe 16: 337 (1976). 8. Kehlet H, et al: Comparative study of ultrasound, Pa’ II9 iodocholesterol scintigraphy and aortography in locahsing adrenal lesions, Br. Med. J. 2: 665 (1976). 9. Forsythe JR, Gosink BB, and Leopold GR: Ultrasound in the evaluation of adrenal metastases, J. Clin. Ultrasound 5: 31 (1977). 10. Bell RL, and Riddell DH: Ultrasound of a pheochromocytoma, Tenn. Med. Assoc. J. 70: 111 (1977). 11. Behan M, et al: Myelohpoma of the adrenal: two cases with ultrasound and CT findings, A.J.R. 129: 993 (1977). 12. Hailer JO, et al: Left adrenal neuroblastoma with normalappearing urogram, ibid. 129: 1951 (1977). 13. Bernardino ME, Goldstein HM, and Green B: Gray scale ultrasonography of adrenal neoplasms, ibid. 130: 741 (1978). 14. Goldberg LM, and Deeths HJ: Perirenal hemorrhage in the newborn, Urology 7: 98 (1976). 15. Pond GD, and Haber K: Echography: a new approach to the diagnosis of adrenal hemorrhage of the newborn, J. Can. Assoc. Radiol. 27: 40 (1976). 16. Schieble W, et al: Percutaneous aspiration of adrenal cysts, A. J.R. 128: 1013 (1977). 17. Sommers SC: The adrenal glands, in Anderson WAD, and Kissane JM, Eds: Pathology, St. Louis, C. V. Mosby, 1977, vol. 2, pp. 1658-1679. 18. Gosink BB: The inferior vena cava: mass effects, A. J.R. 130: 533 (1978). 19. Brascho DJ: Tumor localization and treatment planning with ultrasound, Cancer 39: 697 (1977).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
2
SPECTRUM OF ADRENAL MASSES
A. W. GOODING,
M.D.
From the Ultrasound Section, Radiology Service, Veterans Administration Hospital and the University of California School of Medicine, San Francisco, California
ABSTRACT -Adrenal masses are amenable to ultrasonic examination. The ultrasonic characteristics of eight adrenal masses in 6 patients are described. In particular, an ultrasonic study of the natural history and progression of a large adrenal adenoma is reported. Adrenal masses on the right side may mimic right posterior liver masses on transverse scans alone. They may compress and displace the liver with expansion. Posterolateral impressions on the inferior vena cava occur. Differentiation from a superior pole renal mass is not always possible.
Under ideal circumstances the normal adrenal gland can be delineated with ultrasound by the meticulous technique espoused by Sample. ’ Adrenal masses are also amenable to sonic detection; the ultrasonic appearance of neoplasms2-13 hemorrhage,14*15 and cyst” have been described. This study reports a series of 6 patients with eight adrenal masses in order to elaborate on the diagnostic nuances of masses in this area of the retroperitoneum and to describe, in particular, the natural history and progression of a large adrenal adenoma. Material
and Methods
The patients were scanned with a gray scale Picker EDC ultrasonographic unit, using a 19 mm. 2.5 MHz focused transducer. Mineral oil was the coupling agent. Polaroid films of the image were taken. Prone, supine, and occasional decubitus and costal margin views were obtained at l-cm. intervals in both transverse and longitudinal planes. One case each of primary adrenal carcinoma, adrenal adenoma, and adrenal hematoma was studied. Three patients had adrenal metastases from primary bronchogenic carcinoma, bilateral in 2 patients, the bilaterality unsuspected in both instances. All cases were proved at surgery or autopsy.
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII.
NUMBER 2
Case Report The patient with a right adrenal adenoma had been followed over a ten-year period for a mass in the right upper abdominal quadrant that was relatively asymptomatic. Multiple amorphous calcifications were present on plain films in the right upper quadrant (Fig. 1A). The suspected, but erroneous diagnosis was probable echinococcal disease of the liver. An hepatic arteriogram three years prior to exploration revealed stretching of the right hepatic arteries about an avascular mass. The first sonogram two years before exploration revealed a large solid mass in the right upper quadrant with multiple calcifications, interspersed with small fluid collections (Fig. 1B). The left lobe of the liver was interpreted as large, but normal in configuration. Scans at six-month intervals revealed gradual enlargement of the mass with the development of multiple large fluid components in association with dense calcifications (Fig. 1C). A computerized tomographic examination confirmed the ultrasonic findings, which suggested involvement of the entire right lobe of the liver (Fig. 1D). At surgery, an enormous degenerated cystic adrenal adenoma was removed. Both right and left lobes of normal liver were displaced to the mid epigastrium and left upper quadrant. The
211
FIGURE 1. (A) Plain film of abd omen demonstrates multiple amorphous calcifications in right upper quadrant within an adrenal adenoma (Case 2). (B) Supine transverse sonogram shows large solid mass in right upper quadrant, containing calcifications and small cystic areas. This adrenal adenoma (arrows) replaces liver and impresses laterally inferior vena cava (V), which is elevated. (C) Supine transverse sonogram of same adrenal adenoma two years later demonstrates large central fluid-jlled areas (arrows) in mass surrounded by calci$cations. (D) Computerized tomographic scan of adrenal adenoma (arrows) shows huge ca1ci.c right upper quadrant mass felt to be compatible with right hepatic mass. Central area did not enhance with contrast, while periphery of mass enhances slightly. patient is alive surgery.
and well
Results
FIGURE 2. Prone longitudinal scan of right kidney (K) reveals transsonic mass, adrenal metastasis (A), anteromedially (Case 5).
212
eleven
(Table
months
after
I)
The idiopathic adrenal hematoma was complex in character; all the other masses were neoplasms, solid ultrasonically, except for the adrenal adenoma which contained multiple calcifications and large areas of cystic degeneration. One adrenal metastasis was relatively echo-free (Fig. 2). The other neoplasms generated echoes. On supine transverse scans alone, a right adrenal mass mimicked the appearance of a mass in the posteroinferior right lobe of the liver (Fig. 3A). Prone and supine longitudinal scans depicted more precisely the retroperitoneal origin of the mass (Fig. 3B).
UROLOGY
/ FEBRUARY 1979 / VOLUME
XIII,
NUMBER 2
TABLE
Case
Pathologic
Condition
I.
Adrenal
pathologu
Size (Cm.) and Ultrasonic Character
Age/Sex
Laterality
57 M
Right
8 by 6, complex 19 by 17 by 9, large cystic components in a solid mass 12 by 12 by 10, echogenic, solid
Calcifications
1
Adrenal
2
Adrenal adenoma, nonhmctioning
61 F
Right
3
Primary adrenal carcinoma
30 M
Left
4
Adrenal metastasis (invading the kidney)
51 M
Right
8 by 8, echogenic, solid
None
5
Adrenal
67 M
Right
9 by 5, relatively echo-free, solid
None
Left
5 by 5, echogenic,
6
Adrenal
hematoma
metastasis
metastasis
57 M
Right
Left
None
solid
10 by 10, primarily echogenic with areas of decreased echo production, solid 6 by 6, echogenic, solid
Multiple
None
None
None
Relationship of Mass to Kidney Separate from and superior to right kidney Right kidney depressed inferiorly Distinct from left kidney which was depressed inferiorly and posteriorly Superior mass encompassed upper pole of right kidney but was sharply demarcated from it Anterior, superomedial, immediately adjacent to kidney Anterior, superomedial, immediately adjacent to kidney Superomedial, immediately adjacent to kidney Superomedial, immediately adjacent to kidney
FIGURE 3. (A) Supine transverse scan depicts mass in what appears to be right posterior lobe of liver, but which is actually adrenal metastasis (arrows) (Case 4). Inferior vena cava (V) is compressed from posterolateral direction by metastasis. (B) Supine longitudinal scan of same Case 4 delineates adrenal metastasis (arrows) invading upper pole of right kidney (Kj.
The larger right adrenal masses (Cases 2, 4, and 6) caused the liver to be slightly compressed and arced over the tumor with a discrete border delineated between the two on longitudinal scans (Fig. 4). In 3 cases of right adrenal neoplasia, the tumor elevated and compressed the inferior vena cava posterolaterally (Cases 2, 4, and 6) (Figs. lB, 3A). Four adrenal metastases were immediately adjacent to, but clearly separate from the kidney in a superomedial position. In 1 case of adrenal metastasis (Case 4), the superior mass mimicked a mass originating from the upper pole of the right kidney; and although a sharp demarcation
UROLOGY
I
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
FIGURE 4. Supine longitudinal scan demonstrates huge right adrenal metastasis (arrows) compressing liver (L) which arcs over it (Case 6).
2
213
between kidney and mass was apparent, a renal origin could not be excluded. One patient with adrenal metastasis (Case 5) had an associated ipsilateral solid renal mass which suggested the possibility of malignancy. This proved to be a renal metastasis. Comment The adrenal adenoma was nonfunctioning endocrinologically and grew over a number of years, causing few symptoms. Yet the intrinsic ultrasonic character of the mass changed from that of a solid calcified tumor with some small cystic areas to that of a large neoplasm with multiple fluid-filled areas of central necrosis. Pathologically, the typical adrenocortical adenoma is a nonfunctioning lesion 1 to 5 cm. in diameter.” Larger adenomas may occur up to 12 cm. in diameter with hemorrhage, cystic degeneration, and calcification, but these findings are more commonly associated with adrenal carcinema.” The adenoma of this report is decidedly unusual in both size (19 by 19 by 7 cm.) and weight (1,050 Gm.), the normal adult female adrenal gland weighing 4.1* 0.8 Gm. l7 As retroperitoneal adrenal masses enlarge, they tend to displace adjacent viscera and may even abut the anterior abdominal wall as in Case 2 (adrenal adenoma) and Case 3 (primary adrenal carcinoma). Adrenal masses can be confused with intrinsic liver masses (Case 2), especially on supine transverse scans alone. The retroperitoneal relationships are best defined using supine and prone longitudinal scans, although scans in lateral decubitus and costal margin projections may be needed for a complete assessment. Even with the best techniques, it is not always possible to delineate the origin of a huge abdominal mass as originating from the adrenal gland. An adrenal mass replacing the upper pole of the kidney could not be distinguished from an upper pole renal mass by sonography alone (Case 4). Arteriography revealed the enlarged adrenal arterial supply. The pathologic specimen demonstrated the adrenal metastasis to be invading the upper pole of the right kidney. Adrenal masses on the right side can elevate and compress the inferior vena cava by a posterolateral mass effect. l3 Similar posterior mass effects on the inferior vena cava have been de-
214
scribed from metastatic carcinoma of the pancreas and renal cell carcinoma.18 Ultrasonography is a noninvasive means to detect adrenal metastases, which are often bilateral. Adrenal metastases most commonly arise from squamous cell carcinoma of the lung, occurring in one third of the cases. r’ Breast carcinoma also metastasizes frequently to the adrenal (30 per cent), as does melanoma, carcinoma of the stomach, large intestine, pancreas, kidney, and thyroid. These may be clinically unsuspected. Ultrasonography can monitor these patients without further biologic hazard and may be used to define the radiation ports for palliative therapy. lg Veterans Administration Hospital 4150 Clement Street San Francisco, California 94121 References 1. Sample WS: A new technique for the evaluation of the adrenal gland with gray scale ultrasonography, Radiology 124: 463 (1977). 2. Bimholz JC: Ultrasound imaging of adrenal mass lesions, ibid. 193: 163 (1973). 3. Smith EH, and Bartrum RJ: Ultrasonic evaluation of pararenal masses, J.A.M.A. 231: 51 (1975). 4. Davidson JK, et al: Adrenal venography and ultrasound in the investigation of the adrenal gland: an analysis of 58 cases, Br. J. Radio]. 48: 435 (1975). 5. Gee WF, et al: Adrenal myelohpoma, Urology 5: 562 (1975). 6. Ghorashi B, and Holmes JH: Gray scale sonographic appearance of an adrenal mass: a case report, J. Clin. Ultrasound 4: 121 (1976). 7. Marchal G, and Baert AI: Echography of suprarenal masses, Radiologe 16: 337 (1976). 8. Kehlet H, et al: Comparative study of ultrasound, Pa’ II9 iodocholesterol scintigraphy and aortography in locahsing adrenal lesions, Br. Med. J. 2: 665 (1976). 9. Forsythe JR, Gosink BB, and Leopold GR: Ultrasound in the evaluation of adrenal metastases, J. Clin. Ultrasound 5: 31 (1977). 10. Bell RL, and Riddell DH: Ultrasound of a pheochromocytoma, Tenn. Med. Assoc. J. 70: 111 (1977). 11. Behan M, et al: Myelohpoma of the adrenal: two cases with ultrasound and CT findings, A.J.R. 129: 993 (1977). 12. Hailer JO, et al: Left adrenal neuroblastoma with normalappearing urogram, ibid. 129: 1951 (1977). 13. Bernardino ME, Goldstein HM, and Green B: Gray scale ultrasonography of adrenal neoplasms, ibid. 130: 741 (1978). 14. Goldberg LM, and Deeths HJ: Perirenal hemorrhage in the newborn, Urology 7: 98 (1976). 15. Pond GD, and Haber K: Echography: a new approach to the diagnosis of adrenal hemorrhage of the newborn, J. Can. Assoc. Radiol. 27: 40 (1976). 16. Schieble W, et al: Percutaneous aspiration of adrenal cysts, A. J.R. 128: 1013 (1977). 17. Sommers SC: The adrenal glands, in Anderson WAD, and Kissane JM, Eds: Pathology, St. Louis, C. V. Mosby, 1977, vol. 2, pp. 1658-1679. 18. Gosink BB: The inferior vena cava: mass effects, A. J.R. 130: 533 (1978). 19. Brascho DJ: Tumor localization and treatment planning with ultrasound, Cancer 39: 697 (1977).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
2
