Radiography
Findings
Because adrenal carcinomas are often large at presentation, radiographs of the abdomen may demonstrate mass effect from the tumor. The calcifications observed in more than 30% of patients are often more difficult to detect with abdominal radiographs than with on CT scanning.
On excretory urography, adrenal carcinoma often causes mass effect on the ipsilateral superior pole of the kidney, usually displacing the upper pole of the kidney laterally and, when large enough, inferiorly.
With the advent of cross-sectional imaging, the evaluation, staging, and treatment of adrenocortical carcinoma have vastly improved. CT should be the first imaging of choice to define an adrenal mass such as adrenocortical carcinoma.
Computed Tomography
A 68-year-old woman with a large right upper quadrant primary adrenocortical carcinoma with curvilinear calcification. Low-attenuation regions anteriorly are consistent with necrosis.
CT demonstrates a large heterogeneous mass, with flocculent calcifications and central necrosis (same patient as in Image 2 in Multimedia).
Findings
On CT, adrenocortical carcinoma appears as a large mass, often with central necrosis. Calcification is observed in as many as 30% of patients.
On unenhanced images, heterogeneity is often found with larger masses. On enhanced images, the tumor enhances heterogeneously, with the greatest enhancement often at the periphery and often irregular.
CT findings that increase the index of suspicion for adrenocortical carcinoma include the following:
- Large mass (>4 cm)
- Central necrosis or hemorrhage
- Heterogeneous enhancement
- Invasion into adjacent structures
- Venous extension into the renal vein or inferior vena cava
Degree of Confidence
Occasionally, differentiating an adrenal carcinoma from other pathology in the upper abdomen may be difficult because the mass is large and the fat planes are indistinct. In these patients, multiplanar MRI is the better imaging test. In particular, the imaging findings of large pheochromocytomas and metastasis may be identical. Therefore, it may be prudent to obtain spot vanillylmandelic acid (VMA) or metanephrines prior to resection to prevent a hyperintensive crisis as not all pheochromocytomas are clinically overt.
False Positives/Negatives
False-positive lesions could include exophytic renal masses and exophytic pancreatic tail masses.
Magnetic Resonance Imaging
T2-weighted MRI demonstrates a large right adrenocortical carcinoma with high signal intensity involving the right lateral aspect.
Findings
MRI often demonstrates a large mass with lower signal intensity than the liver on T1-weighted images and higher signal intensity than the liver on T2-weighted images. Often, the tumor demonstrates heterogeneously hyperintensity on T1- and T2-weighted images, due to the central necrosis and hemorrhage. Because the mass usually does not contain any significant intracellular lipid, it will not lose signal on out-of-phase imaging.
Coronal and sagittal images may be helpful in determining adrenal origin of the mass, thus differentiating it from renal cell carcinoma or hepatocellular carcinoma, especially if CT is equivocal.
Degree of Confidence
MRI is advantageous for evaluating tumors, since its depiction of vascular invasion and extension into surrounding structures often is superior to that of CT. Additionally, the most cephalad extension of the tumor must be evaluated so that the surgeon can obtain vascular control of the tumor. This can be achieved with CT but often is easier with MRI.
False Positives/Negatives
Larger adrenal adenomas are radiologically similar to adrenal cortical carcinomas. The pathologic distinction between adrenal adenoma and adrenal carcinoma is largely based on size, with the cutoff in the range of 4-5 cm.
Ultrasonography
Findings
Adrenocortical carcinoma demonstrates a homogeneous echo texture when small, but the echo pattern becomes heterogeneous with cystic areas when the tumor grows as a result of hemorrhage and necrosis.
Degree of Confidence
Because different planes are obtainable on ultrasonography, it is helpful in some patients to determine the organ of origin of the mass.
Nuclear Imaging
Findings
Nuclear scintigraphy does not play much of a role in the evaluation of adrenal carcinoma, except to exclude other lesions such as pheochromocytomas or aldosteronomas. Iodine-121 metaiodobenzylguanidine (MIBG) and indium-111 octreotide can be used to visualize pheochromocytomas, while iodine-131 6-beta-iodomethyl-19-norcholesterol (NP-59) can be used to detect aldosteronomas or other hyperfunctioning cortical tumors. Positron emission tomography imaging performed with fluorine-18 fluorodeoxyglucose (FDG) has shown some promise in differentiating benign adrenal lesions from malignant lesions.14
Angiography
Findings
Prior to cross-sectional imaging, arteriography was the preferred modality for evaluating abdominal masses. On angiograms, adrenal carcinomas are usually hypovascular masses, which helps distinguish them from hypernephromas. Little vascular shunting, puddling, or venous laking is found with adrenal carcinoma compared to renal cell carcinoma. Usually, faint tumor vascularity is seen on abdominal aortograms, and it is not until selective adrenal arteriography is performed that tumor vessels are identified. The predominant arterial supply to the adrenal gland and to adrenal carcinoma is the superior adrenal artery off the inferior phrenic artery.
More on Adrenal Carcinoma |
| Overview: Adrenal Carcinoma |
 Imaging: Adrenal Carcinoma |
| Follow-up: Adrenal Carcinoma |
| Multimedia: Adrenal Carcinoma |
| References |
| Further Reading |
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References
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Chien HP, Chang YS, Hsu PS, Lin JD, Wu YC, Chang HL, et al. Adrenal cystic lesions: a clinicopathological analysis of 25 cases with proposed histogenesis and review of the literature. Endocr Pathol. Winter 2008;19(4):274-81. [Medline].
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Maurea S, Mainolfi C, Bazzicalupo L, et al. Imaging of adrenal tumors using FDG PET: comparison of benign and malignant lesions. AJR Am J Roentgenol. Jul 1999;173(1):25-9. [Medline].
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Hutter AM Jr, Kayhoe DE. Adrenal cortical carcinoma. Clinical features of 138 patients. Am J Med. Oct 1966;41(4):572-80. [Medline].
Further Reading
Clinical guidelines
ACR Appropriateness Criteria® incidentally discovered adrenal mass.
American College of Radiology - Medical Specialty Society. 2000 (revised 2007). 8 pages. NGC:005995
The diagnosis of Cushing's syndrome: an Endocrine Society clinical practice guideline.
The Endocrine Society - Disease Specific Society. 2008. 29 pages. NGC:006662
Clinical trials
Antineoplaston Therapy in Treating Patients With Stage IV Adrenal Gland Cancer
Study of Adrenal Gland Tumors
Adrenal Tumors - Pathogenesis and Therapy
Related eMedicine topics
Adrenal Carcinoma (Oncology)
Adrenal Carcinoma (Pediatrics: General Medicine)
Adrenal Surgery
Cushing Syndrome
Li-Fraumeni Syndrome
Keywords
adrenal carcinoma, adrenal cancer, adrenal gland carcinoma, adrenal gland cancer, cancer of the adrenal gland, carcinoma of the adrenal gland
