Practice

Rational Imaging

Definitive characterisation of adrenal lesions

BMJ 2009; 338 doi: 10.1136/bmj.a3092 (Published 19 January 2009)
Cite this as: BMJ 2009;338:a3092

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  1. J C Miller, medical writer,
  2. M A Blake, radiologist,
  3. G W L Boland, radiologist
  1. 1Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA
  1. Correspondence to: G W L Boland gboland{at}partners.org
  • Accepted 1 May 2008

This article explores the radiological investigations for characterising adrenal lesions, focusing on adrenal protocol computed tomography, positron emission tomography, chemical shift magnetic resonance imaging, and nuclear scintigraphy

Learning points

  • Incidental adrenal lesions are often detected by computed tomography (CT) and magnetic resonance imaging (MRI)

  • The diagnosis is highly dependent on whether the individual has a known history of cancer, with most lesions proving benign in patients without known cancer

  • Characterisation of the adrenal lesion is essential in patients with a history of malignancy so that the disease can be staged and treatment decided

  • Most lesions can be characterised using adrenal protocol CT, although a few indeterminate lesions may require MRI, nuclear imaging, and/or percutaneous biopsy

  • Functional adenomas and pheochromocytomas are best detected by laboratory tests

The patient

A woman in her 60s presented with a three week history of a productive cough and haemoptysis. A chest x ray film showed a 2.9 cm right upper lobe lung mass. Bronchoscopy and biopsy found non-small cell lung cancer. Staging, contrast enhanced computed tomography (CT) of the chest confirmed the upper lobe lung mass but showed no evidence of metastatic disease in the chest or liver. However, a 2.3 cm smooth walled, left adrenal mass was identified (fig 1⇓). No prior CT examinations were available for comparison; growth of an adrenal mass is highly suggestive of a malignancy, whereas benign lesions are stable or grow very slowly.1 Biochemical analysis was negative for pheochromocytoma and adrenocortical functioning tumour.

Fig 1 Contrast enhanced staging computed tomogram in a 65 year old woman with a recent diagnosis of non-small cell lung cancer showing a 2.3 cm smooth walled left adrenal mass (arrow)

Adrenal masses are common findings whose prevalence increases with age.1 2 3 4 5 In patients without any known cancer, almost all of these masses …

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