Let's talk about a few issues within the
adrenals and we will begin by looking at incidentalomas,
as the name implies.
Adrenal masses incidentally detected up to
one and a half percent of your abdominal scans?
Majority of these are non-functioning adrenal
adenomas, but can represent hormonally active
or even malignant lesions.
So, there is further workup that you're
always making sure to confirm or to diagnose
your patient accordingly.
Pheochromocytoma may be asymptomatic and remember,
a pheochromocytoma would be a adenoma that's
located inside your adrenal medulla.
It's an adenoma, a pheochromocytoma; it
is not a cancer.
It's not-It's not malignant, it's not
All Adrenal incidentaloma patients should be screened for an asymptomatic pheochromocytoma.
This is typically done with the CT,
but biochemical screening can be done if the unenhanced CT attenuation is greater than or equal to 10 HU.
These patients should also be screened for Cushing's syndrome,
though primary hyperaldosteronism workup is not indicated unless there are clincal symptoms present.
Biopsy cannot differentiate benign from malignant
primary adrenal tumours, but has a role in
evaluating possible adrenal metastases in
patients with known extra-adrenal primary
So, if you were to take a look at that adenoma,
biopsy would not be your next step of management
necessarily to distinguish between benign
and malignant, but if it's coming from,
let's say, a renal cell cancer that's
metastasized to the adrenals, sure.
The biopsy will help you differentiate between
the two because it will show you the histology
of where the metastasis is coming from.
Adrenal imaging is important.
Lesions less than 10 Hf are noncontrast CT
are almost always benign or may or may not
Greater than 50 percent washout of enhancement
adrenal protocol CT also suggest benign adenoma,
unless there is a very high peak enhancement
which raises possibility of pheochromocytoma.
So, usually if it's less than 10, usually
tends to be benign, but that is not a guarantee.
Lesions greater than four centimetres increase
suspicion of malignancy and should be automatically
next step of management surgically removed
upon adrenal imaging.
Pheochromocytoma usually a vascular tumour,
increased T2 signal on MRI and you would then
find enhancement adrenal protocol CT, meaning
to say that if you're doing an avid arterial
phase enhancement, all of these would then
help you distinguish a pheochromocytoma from
others, usually, a vascular tumour.
Remember, if you have a pheochromocytoma outside
of the adrenal medulla, as far as you're
concerned, you would then consider that to
be a paraganglion.