Adrenal Glands and Kidneys

J. Paul Nielsen, MD, MPH

Adrenal Masses
M-

Metastasis E- Enlargement (Hyperplasia) N- Neuroblastoma

C-

Carcinoma A- Adenoma M- Myelolipoma P- Pheochromocytoma

Others

Hemorrhage

Lymphoma
Ganglioneuroblastoma

Adrenal contain high 1. 70% of adenomasAdenomas

intracellular fat (lipid-rich adenomas) and will be of low attenuation on unenhanced CT. 2. Adenomas rapidly wash out contrast.

Unenhanced CT.
A density equal to or below 10 HU is considered diagnostic of adenoma. 30% of adrenal adenomas do not contain enough intracellular lipid to have a density of less than 10 HU and cannot be differentiated from malignant masses on an unenhanced CT.

Adrenal mass workup

adrenal adenoma MR

Lipid poor adenoma

Myelolipoma
Myelolipomas are benign tumors
composed of bone marrow elements. Usually they are easy to recognize on CT or MR because they contain areas of fat. Calcifications are seen in 20% of cases.

adrenal myelolipoma

 ACTH-dependent Cushing syndrome

(80-85% of cases) enlarged

Adrenal glands often symmetrically

Limbs of adrenal gland > 10 mm
supports this diagnosis

Adrenal Hyperplasia

Usually both adrenal glands involved No discrete mass or nodule seen as

rule

Cushing syndrome can show nodular

hyperplasia

Pheo
paragangliomas arising from the
adrenal medulla.

They are hormonally active in 90% of

cases.

Morphologic findings on CT and MRI

include large variation in size, homogeneity, and margination of the tumours and significant enhancement in most cases. On MRI tumours have a low SI on T1-weighted images and a very high SI on T2-weighted images.

pheo in bladder

adrenal calcs

adrenal hemorrhage

post hemorrhagic adrenal cyst

adrenal mets

adrenal carcinoma

Renal Cystic Disease

Differentiate cysts from AML and cystic
RCC using Bosniak
Disease (ADPKD) (Adults)

Autosomal Dominant Polycystic Kidney

Autosomal Recessive Polycystic Kidney

Disease (ARPKD) (Peds)

Medullary Sponge Kidney Uremic Medullary Cystic Disease Von Hippel Lindau

 The Bosniak classification system, which is based on imaging

findings, can be used to differentiate benign renal cysts from angiomyolipomas and renal cell carcinomas

Renal Cysts

On CT hyperdense means: > 20 HU on a NECT

enhance to 88 HU after IV contrast

bosniak 2

Parapelvic Cyst

Calyceal Diverticulum

Adult Polycystic Kidney Disease

Note the enormous kidneys filled with both serous and hemorrhagic cysts

PCKD

autosomal recessive polycystic disease

Here is a cut section of a kidney with recessive polycystic kidney disease (RPKD). Note that the cysts are fairly small but uniformly distributed throughout the parenchyma so that the disease is usually symmetrical in appearance, with both kidneys markedly enlarged. The recurrence risk for this disease is, of course, 25% because of the autosomal recessive inheritance pattern. Affected babies usually do not survive long.

Medullary Sponge Kidney

benign congenital
disorder characterized by dilatation of collecting tubules in one or more renal papillae

uremic cystic kidney disease in the Multiple cystic disease occurring

diseased kidneys of patients with endstage renal insufficiency

Acquired Cystic Disease

This patient has Acquired Cystic Disease related to prolonged dialysis

Von Hippel Lindau

multiple renal and pancreatic cysts,
pheos

multiple and b/l RCC retinal angiomas and cerebellar

hemangioblastomas

inherited auto-dominant

VHL

renal TB

Benign Neoplasms
Renal Papillary Adenoma small, incidental adenomas arising from the renal tubules Renal Fibroma small foci of collagenous tissue found within the pyramids Renal Oncocytoma appears as a well-encapsulated area of uniform signal (hypointense on T1, variable on T2) that may become very large (up to 12 cm) frequently shows a central star-shaped scar or area of necrosis Angiomyolipoma benign, unifocal, expanding mass composed of an abundance of fat, smooth muscle, and neovascularity with a tendency to form aneurysms occurs in a bilateral, multifocal form in patients with tuberous sclerosis

Angiomyolipoma

CT w/contrast

T1-MR w/gad

Methods for diagnosis: Fat within the tumor is bright on non-fat-suppressed T1-weighted images and dark on fat-suppressed images. In contrast, focal hemorrhage appears bright regardless of fat suppression. use chemical-shift imaging techniques: angiomyolipomas show the characteristic India ink artifact (a rim of low signal intensity at the interface between the tumor and renal parenchyma) on T1 -weighted out-of-phase images. Contrast enhancement is heterogenous and spares fatty areas.

Malignant Neoplasms
Wilms Tumor occurs in children, usually between the ages of 2 and 5 usually appears as a large, solitary, wellcircumscribed mass with occasional foci of hemorrhage, cyst formation, and necrosis Renal Cell Carcinoma most characteristic finding: spherical mass of signal intensity different from adjacent normal renal parenchyma due to frequent hemorrhage and necrosis commonly arise in the poles of the kidney clear cell type is unifocal and large (3 to 15 cm in diameter) papillary type is usually bilateral and multifocal

Wilms Tumor
this large tumor may markedly displace the entire kidney a mixture of attenuation values is seen, due to the combination of blastemic, stromal, and epithelial tissue with occasional foci of hemorrhage and necrosis usually demonstrates moderate vascularity

Renal Cell Carcinoma

The diagnosis of renal cell carcinoma relies on contrast enhancement. Solid malignant tumors may immediately enhance in density to the level of the surrounding normal renal parenchyma, but the density quickly decreases. Foci of old hemorrhage, necrosis, or simple cysts do not enhance and maintain a low signal intensity.

Renal Cell Carcinoma

MRI features: Spherical shape Fails criteria of a simple cyst (thickened, irregular walls with significant septation and nonperipheral calcification) Lacks internal fat Enhances with contrast