27THE ADRENAL GLANDS

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 27.1 Arterial supply of the adrenals. I.P. = inferior phrenic artery; a = superior phrenic artery; b = middle adrenal artery; c = inferior adrenal artery.

• Fig. 27.2 Venous drainage of the adrenal gland. R.A.V. = right adrenal vein; L.A.V. = left adrenal vein; L.R. = left renal vein; LV.C. = inferior vena cava; R.R. = right renal vein.

Fig. 27.3 Tracing from a photograph of neonatal kidneys and adrenals; the latter are relatively large compared with adult adrenals, being one-third the size of the kidneys.

• Fig. 27.4 Normal adrenals as shown by CT (see text). (A) Section just above right kidney. In this example the right adrenal has well-marked lateral and medial limbs. The top of the left adrenal is also shown behind the pancreas, although frequently it is not seen at this level (L43, W512). (B) Section including top of left kidney. The left adrenal resembling an arrowhead is well seen, as is the right adrenal, although the limbs now appear shorter (L43, W572). (C) Section at slightly lower level, including tops of both kidneys (L43, W572). Note that the adrenals are separated from the kidneys by fatty aerials tissue.

• Fig. 27.4 Normal adrenals as shown by CT (see text). (A) Section just above right kidney. In this example the right adrenal has well-marked lateral and medial limbs. The top of the left adrenal is also shown behind the pancreas, although frequently it is not seen at this level (L43, W512). (B) Section including top of left kidney. The left adrenal resembling an arrowhead is well seen, as is the right adrenal, although the limbs now appear shorter (L43, W572). (C) Section at slightly lower level, including tops of both kidneys (L43, W572). Note that the adrenals are separated from the kidneys by fatty aerials tissue.

• Fig. 27.5 Calcified adrenals in a child. These were a chance finding, the IVP being performed for urinary infection.

• Fig. 27.6 Adrenal calcification (arrows) from tuberculosis on CT scan. (Courtesy of Dr J. P. R. J enkins.)

• Fig. 27.7 Ultrasound scan showing echogenic suprarenal neuroblastoma (arrows). (Courtesy of Dr C. Dicks-Mireaux.)

• Fig. 27.8 Normal adrenal glands shown by MRI (T,-weighted). (Courtesy of Professor Graham Cherryman.)

• Fig. 27.9 Low-density rounded mass in left-adrenal of a 26-year-old woman with a clinical suspicion of a phaeochromocytoma (arrow) on a coronal T,-weighted spin-echo (SE 560/25) image. Note the clinically unsuspected bilateral renal cysts (c)-von Hippel-Lindau disease. (Courtesy of Dr R. W. Whitehouse.)

• Fig. 27.10 Needle biopsy of right adrenal tumour under CT control with patient prone. Histology: adenocarcinoma from bowel (L36, W256).

• Fig. 27.11 Cushing's disease. Seleno-nor-cholesterol scintigraphy showed bilaterally symmetrical adrenal activity confirming pituitary-driven hyperplasia. CT had shown a unilateral adrenal nodule which proved to be non-functioning. L= liver; C = activity in colon.

• Fig. 27.12 Conn's syndrome. (A) Right-sided nodule shown at CT. (B) Seleno-nor-cholesterol scintigraphy showed a corresponding unilateral functioning adenoma (posterior view, day 7). (C) DMSA scintigraphy was used to confirm the anatomical location of the abnormal focus (posterior view, day 7).

• Fig. 27.13 Conn's syndrome. (A) CT revealed a left unilateral nodule. (B) Seleno-nor-cholesterol scintigraphy showed bilateral symmetrical activity (posterior view, day 7). Diagnosis: nodular hyperplasia of the adrenals. (C) DMSA scintigraphy was used to confirm the anatomical location of the adrenals (posterior view, day 7).

• Fig. 27.14 Phaeochromocytoma. (A) Heterogeneous mass shown on MRI (arrows). (B) This was confirmed to be a highly active functioning tumour on mlBG scintigraphy.

• Fig. 27.15 Cystic phaeochromocytoma. (A) An atypical tumour shown on CT as a loculated cystic mass, and (B) confirmed on posterior view mIBG scintigraphy as an actively functioning tumour of the adrenal medulla.

• Fig. 27.16 Malignant phaeochromocytoma. (A) Non-specific appearance of liver metastases on CT, and (B) shown on mIBG scintigraphy to be functioning adrenal metastases.

• Fig. 27.17 Neuroblastoma. Posterior view mIBG appearances in two cases showing intense uptake in the tumours. (Courtesy of Dr. I. Driver).

• Fig. 27.18 Paraganglioma. (A) CT showed a non-specific tumour anterior to the aorta which was found to be intensely active on (B) mIBG scintigraphy.

• Fig. 27.19 (A) MR T2-weighted axial section shows a large heterogeneous mass above the left kidney. Neuroblastoma. Sagittal (C) and coronal (B) T 1 -weighted spin-echo (TR/TE 400/15 ms) images showing multiple ganglioneuromas. (C) A large right dumb-bell shaped paravertebral mass extends across to the left. In (B) the mass is seen to extend anterior to the spine with displacement of the aorta, and it also extends posteriorly into the spinal canal. There is destruction and collapse of the body of one of the lower thoracic vertebra. Another ganglioneuroma is present in the left intercostal region and is well shown in (C). (Courtesy of Dr C. Dicks-Mireaux.)

• Fig. 27.19 (A) MR T2-weighted axial section shows a large heterogeneous mass above the left kidney. Neuroblastoma. Sagittal (C) and coronal (B) T 1 -weighted spin-echo (TR/TE 400/15 ms) images showing multiple ganglioneuromas. (C) A large right dumb-bell shaped paravertebral mass extends across to the left. In (B) the mass is seen to extend anterior to the spine with displacement of the aorta, and it also extends posteriorly into the spinal canal. There is destruction and collapse of the body of one of the lower thoracic vertebra. Another ganglioneuroma is present in the left intercostal region and is well shown in (C). (Courtesy of Dr C. Dicks-Mireaux.)

• Fig. 27.20 Contiguous postcontrast CT scans showing a small right adrenal adenoma (a). Note this small adenoma is only visible on one of the adjacent scans. Normal left adrenal gland. (Courtesy of Dr J. P. R. Jenkins.)

• Fig. 27.21 (A) Ultrasound scan shows a large irregular mass (arrows) above the right kidney. Adrenal carcinoma. K = kidney. (B) CT shows the mass extending anteriorly and invading muscle posteriorly. Ao = aorta. (Courtesy of Dr Janet Murfitt.) (C) MR T 2 -weighted coronal sections show a large, mainly low-density mass above the left kidney. Carcinoma of left adrenal.

• Fig. 27.21 (A) Ultrasound scan shows a large irregular mass (arrows) above the right kidney. Adrenal carcinoma. K = kidney. (B) CT shows the mass extending anteriorly and invading muscle posteriorly. Ao = aorta. (Courtesy of Dr Janet Murfitt.) (C) MR T 2 -weighted coronal sections show a large, mainly low-density mass above the left kidney. Carcinoma of left adrenal.

• Fig. 27.22 Adrenal carcinoma (m) surrounding the left adrenal vein (arrow), abutting onto the abdominal aorta (A) and infiltrating the psoas muscle (p) on a postcontrast CT scan. (Courtesy of Dr J. P. R. Jenkins.)

• Fig. 27.23 (A) Large mass in left adrenal. Note the nodular calcification in the tumour and low-density areas in the liver. Adrenal carcinoma presenting with Cushing's syndrome (L36, W256). (B) Coronal reconstruction of tumour (L38, W128).

• Fig. 27.24 (A) Same patient as Fig. 27.23, showing deposits in liver at narrow window (L63, W64). (B) Six months later, and following removal of adrenal tumour, deposits have increased in size (L50, W64).

• Fig. 27.25 (A) Large metastasis in right adrenal (L36, W256). (B) Bilateral metastases (arrows) in the adrenals from bronchial carcinoma (L45, W256).

• Fig. 27.26 CT scan of bilateral enlarged adrenal glands (m) from lymphomatous infiltration. (Courtesy of Dr J. P. R. Jenkins.)

• Fig. 27.27 Coronal MRI scan (T 2 -weighted) shows bilateral adrenal metastases (arrows) as high-signal masses. Primary lung carcinoma with collapse of right upper lobe is also well shown. (Courtesy of Dr Gordon Thomson and Bristol MRI Centre.)

• Fig. 27.28 (A,B) Right adrenal lipoma (arrow). Coronal reconstruction of and show a diagnostic bright hyperechoic appearance. low-density mass (-67 HU) ([46, 41024).

• Fig. 27.29 Adrenal cyst (c) measuring 11 HU on a postcontrast CT scan. Normal enhancing left adrenal gland. (Courtesy of Dr J. P. R. Jenkins.)

• Fig. 27.30 (A) Bilateral adrenal hyperplasia (L36, W512). (B,C) Hypertrophied right and left adrenals in another patient (L36, W51 2).

• Fig. 27.30 (A) Bilateral adrenal hyperplasia (L36, W512). (B,C) Hypertrophied right and left adrenals in another patient (L36, W51 2).

• Fig. 27.31 (A) Left adrenal phlebogram showing small Conn's tumour (arrow). (B) Right adrenal phlebogram showing Conn's tumour.

• Fig. 27.32 MR study. T 2 -weighted image shows a small 1 cm adenoma (arrow) behind the IVC. Right-sided Conn's tumour.

• Fig. 27.33 Left-sided Conn's tumour measuring 1.2 cm in diameter.

• Fig. 27.34 Right-sided Conn's tumour 1.9 cm in diameter. Normal left adrenal also well shown (L36, W256).

• Fig. 27.35 Small left Conn's tumour 0.8 cm in diameter and marked by white dot. (Density 20 HU-L43, W512).

• Fig. 27.36 Right-sided Conn's tumour shown by scintigraphy 7 days post injection.

• Fig. 27.37 Inferior vena cavography in a patient with a large phaeochromocytoma lying posterior and medial to the inferior vena cava.

• Fig. 27.38 Left ventricular angiocardiogram. This patient presented with mitral incompetence. (A) There is evidence of marked mitral incompetence. (B, C) Pathological vessels are shown arising from the aorta to supply a large vascular mass above the left atrium. Phaeochromocytoma removed by surgery.

• Fig. 27.39 Ultrasound scan shows large rounded tumour (arrows) above upper pole of right kidney (Same case as Fig. 27.46.)

• Fig. 27.40 (A) Giant bilateral cystic phaeochromocytoma displacing the kidneys downward and liver upward ([36, W128). (B) Coronal reconstruction through tumours and downward-displaced kidneys (L36, W64).

• Fig. 27.41 MR T2 - weighted image shows bilobed high-signal tumour above the right kidney. (A) Coronal, (B,C) Axial sections. The posteromedial segment of the tumour lay behind the crus of the diaphragm and would have been missed at surgery without forewarning. (Courtesy of Dr R. Whitehouse.)

• Fig. 27.41 MR T2 - weighted image shows bilobed high-signal tumour above the right kidney. (A) Coronal, (B,C) Axial sections. The posteromedial segment of the tumour lay behind the crus of the diaphragm and would have been missed at surgery without forewarning. (Courtesy of Dr R. Whitehouse.)

• Fig. 27.42 Small phaeochromocytoma (arrow) (3 cm diameter) anterior to upper pole of right kidney (L45, W51 2).

• Fig. 27.43 Phaeochromocytoma (5 x 3.5 cm) in left adrenal (arrow) L41,W256

• Fig. 27.44 Large phaeochromocytoma (7 x 8 cm) in right adrenal and displacing liver (L36, W256).

• Fig. 27.45 Ectopic small phaeochromocytoma (arrow) (3 cm diameter) anterior to left hilum (L36, W256).

• Fig. 27.46 (A) Scintiscan using mlBG shows large right phaeochromocytoma (12th rib marked). (B) CT of same patient confirms a large phaeochromocytoma (7 cm) (L45, W512). The tumour was also shown by ultrasound (Fig. 27.39).

• Fig. 27.47 MR T2 -weighted (A,B) coronal sections through kidneys and anterior to kidneys; (C) axial section. High-signal highly vascular tumour mass lying anterior to the hilum of the left kidney. Large drainage veins seen in (B) phaeochromocytoma. (Courtesy of Dr Philip Gishan.)

• Fig. 27.47 MR T2 -weighted (A,B) coronal sections through kidneys and anterior to kidneys; (C) axial section. High-signal highly vascular tumour mass lying anterior to the hilum of the left kidney. Large drainage veins seen in (B) phaeochromocytoma. (Courtesy of Dr Philip Gishan.)

• Fig. 27.48 (A) Deposits in liver (L36, W128). (B) Glandular masses around the aorta (L36, W256). The patient had a malignant phaeochromocytoma removed 6 months previously.

• Fig. 27.49 Sclerotic bone deposits in same patient as Fig. 27.48.

• Fig. 27.50 Intrathoracic paravertebral tumour in a 12-year-old boy shown to right of lower spine (arrow). Further intra-abdominal tumours were shown. There was a familial history. (Courtesy of Dr F. Starer.)