Department of Radiology, University of Szeged

Imaging of the suprarenal glands

Dr. András Palkó

Department of Radiology, University of Szeged

Methods of examination:

• plain x-ray (radiography, fluoroscopy, tomography)

• x-ray with contrast material

• ultrasound (b-mode, Doppler, color, duplex)

• computed tomography

• magnetic resonance imaging

• x-ray-, US-, CT-guided intervention

• isotope

Department of Radiology, University of Szeged

Space occupying lesion I. (benign)

• hyperplasia (F/N)

• pseudotumor (N)

• bleeding (N): acute - > 40 HU, old - fluid-fluid level

• cyst, pseudocyst (N): 15 % calcified

• adenoma (F/N): 1-5 cm, <0 / 10 / <10 HU,

moderate enhancement, rarely calcified

• myelolipoma (N): fat density, moderate enhancement,

20 % calcified

F/N: function y/n

Department of Radiology, University of Szeged

Space occupying lesion II. (malignant):

• Medullary:

– pheochromocytoma

(paraganglioma) (F):

enhancement,

calcification, avoid

biopsy (?!)

– multiple endocrine

neoplasia (MEN) (F)

– neuroblastoma (N): 90

% calcified, > 5 cm

• Cortical:

– Adrenocortical

carcinoma (F/N): > 5

cm, heterogeneous

enhancement,

necrosis, bleeding, 50

% calcified

– metastasis (N):

heterogeneous

enhancement, bilateral,

irregular

– lymphoma (N)

F/N: function y/n

Department of Radiology, University of Szeged

Normal left suprarenal gland

Department of Radiology, University of Szeged

Normal right suprarenal gland

Department of Radiology, University of Szeged

Adrenal hemorrhage

Department of Radiology, University of Szeged

Cystic mass

Department of Radiology, University of Szeged

Hyperplasia

Department of Radiology, University of Szeged

Hypoperfusion shock

Department of Radiology, University of Szeged

Adenoma

Department of Radiology, University of Szeged

Adenoma

Department of Radiology, University of Szeged

Adenocarcinoma

Department of Radiology, University of Szeged

Pheochromocytoma

Department of Radiology, University of Szeged

Phaeochromocytoma

Department of Radiology, University of Szeged

Phaeochromocytoma

Department of Radiology, University of Szeged

Adrenocortical carcinoma

Department of Radiology, University of Szeged

Neuroblastoma

Department of Radiology, University of Szeged

Metastasis

Department of Radiology, University of Szeged

Biopsy

Department of Radiology, University of Szeged

Imaging of other retroperitoneal

organs

Department of Radiology, University of Szeged

Department of Radiology, University of Szeged

Department of Radiology, University of Szeged

Department of Radiology, University of Szeged

Retroperitoneal lymphadenomegaly:

• malignant lymphoma

• lymphogenic metastasis

• inflammation, infection

• sarcoidosis

• amyloidosis

• Castleman disease

• Whipple disease

• HIV adenopathy

Department of Radiology, University of Szeged

Retroperitoneal lymphatic regions:

• retrocrural (lung, mesothelioma, lymphoma)

• pancreatico-duodenal (lymphoma, pancreas, colon, stomach,

lung, breast)

• periaortic-pericaval-interaortocaval (lymphoma, kidney, testicle, uterine cervix, prostate, ovary)

• celiac – superior mesenteric artery region (any abdominal tumor)

Department of Radiology, University of Szeged

Department of Radiology, University of Szeged

Threshold value of largest axial lymph

node diameter

• retrocrural: > 6 mm

• pancreatico-duodenal: > 10 mm

• periaortic-pericaval-interaortocaval: > 10 mm

• celiac – superiopr mesenteric artery region: > 9 mm

Department of Radiology, University of Szeged

Limitation of detectability:

• US may be impeded by bowel gas and large body diameter

• CT & MR may be hampered by the lack of retroperitoneal fat

• US/CT/MR are not able to recognize pathologic changes in a normal

size lymph node

• most of lymphatic regions are unavailable for lymphography

Department of Radiology, University of Szeged

Limitations of characterisation:

• lymph nodes of normal size may harbor pathologic foci

• lymph node enlargement may be of benign or malignant

origin

• it may be difficult to differentiate enlarged lymph nodes

from cross-section of vessels/bowels by US/CT/MR

• filling defect detected by lymphography may be of

benign nature (fibrosis, fat)

Department of Radiology, University of Szeged

RCC metastasis

Department of Radiology, University of Szeged

NHL

Department of Radiology, University of Szeged

Diseases of the aorta

• atherosclerosis

• aneurysm (sclerosis, infection, injury)

– thrombosis

– dissection

– bleeding (chronic)

– bleeding (rupture)

• postoperative condition

Department of Radiology, University of Szeged

AAA rupture

3

4

Department of Radiology, University of

Szeged, Hungary

Department of Radiology, University of Szeged

AAA contained rupture

Department of Radiology, University of Szeged

AA dissection

3

6

Department of Radiology, University of Szeged

AA dissection

3

7

Department of Radiology, University of Szeged

AAA endoprothesis

Department of Radiology, University of Szeged

Endoleak

Department of Radiology, University of Szeged

Diseases of the IVC

• congenital anomalies

• thrombosis

• tumor thrombus

• external compression

• cava filter

Department of Radiology, University of Szeged

VCI tumor thrombus

Department of Radiology, University of Szeged

Retroperitoneal tumors:

Malignant

• fibrosarcoma

• malignant teratoma

• liposarcoma

• leiomyosarcoma

• rhabdomyosarcoma

• fibrous histiocytoma

• tumor of the kidney,

suprarenal gland,

pancreas

Benign

• haemangiopericytoma

• lymphangioma

• neurinoma

• teratoma

• Schwannoma

• fibrosus histiocytoma

• neurilemmoma

• lipoma

Department of Radiology, University of Szeged

Liposarcoma

Department of Radiology, University of Szeged

Rhabdomyosarcoma

Department of Radiology, University of Szeged

Department of Radiology, University of Szeged

Other retroperitoneal changes

• retroperitoneal fibrosis

• gas (perforation, emph. pyelonephr.)

• pseudocyst

• urinoma

• echinococcus cyst

• abscess (psoas!)

• haematoma

• lymphocele

• meningocele

• retrocaval ureter

Department of Radiology, University of Szeged

Haematoma

Department of Radiology, University of Szeged

Retroperitoneal fibrosis

Department of Radiology, University of Szeged

Abscedating pyelonephritis

Department of Radiology, University of Szeged

Psoas abscess

Department of Radiology, University of Szeged

Retroperitoneal abscess

Department of Radiology, University of Szeged

Rectum perforation

Department of Radiology, University of Szeged

Celiac ganglion blockade