Adrenocortical adenoma

Case contributed by Dr Mohamed Abdel-Tawab Mohamed

Presentation

Uncontrolled diabetes and hypertension, weight gain mainly in the abdomen with moon face, polyphagia, hair loss, bone pain and loss of teeth.

Patient Data

Age: 30
Gender: Female
CT
  • Left suprarenal mass lesion is seen measuring 4.7 x 3.6 x 4.2 cm. It shows homogenous post contrast enhancement with clear fat planes around.
  • It shows enhancement as follows:
    • Unenhanced phase = 37 HU.
    • Enhanced phase = 71 HU.
    • Delayed phase = 45 HU.
    • Absolute washout = 76 %
  • Liver: mildly enlarged with marked diffuse fatty infiltration

Histopathology

  • Nature of Specimen : Left adrenalectomy
  • Gross : Adrenalectomy specimen measured 7x5x4 cm and weighing 50 rims, surrounded by normal looking fatty tissue measured 0.5 cm at maximum thickness Serialing showed nodule with orange yellow color measured 5x4x3 cm (capsule was inked black).
  • Microscopic :  Sections examined from the specimen received revealed a circumscribed mass formed of groups of adreno-cortical cells, mostly arranged in acinar and trabecular pattern with clear or oesinophilic cytoplasm and central rounded nuclei. There is moderate vascularity. There is focal cystic changes. No nuclear atypia. No necrosis. No malignancy.
  • Diagnosis :  Left suprarenal mass, Left adrenalectomy, adrenocortical adenoma.

Case Discussion

  • Pathologically proven left adrenocrtical adenoma, presented as a functioning adenoma with manifestation of cushing disease.
  • CT protocol in such cases is CT washout which has two types; absolute and relative. The absoulte one can only be calculated when you have non-contrast phase where CT washout = (Enhanced CT - Delayed CT) / (Enhanced CT - unenhanced CT) x 100%.
  • Relative washout (non-contrast is not done) = (Enhanced CT - Delayed CT) / (Enhanced CT) x 100%.
  • The enhanced phase is aquired at 60 sec while delayed phase is at 15 minutes.
  • To diagnose adrenal adenoma according to the above mentioned CT washout rate, we need:
  • In our case the absolute washout was 76%, diagnostic of adrenal adenoma.
  • The essential step in obtaining accurate CT washout after adjusting the CT phases, is to fix the level and size of ROI (region of interest). To fix the level of measurement, scanning should start from the same level in all phases in order to obtain measurements in the same numbered slice, otherwise you should adjust the level manually considering the respiratory movement of abdominal organs. The other point is to fix the size of ROI by propagating or duplicating it in the other phases. 
  • The maked fatty infiltration of the liver is attributed to manifestations of cushing diesase.

 

Thanks to Dr. Mostafa Ahmed Sayed Hamada

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Case information

rID: 52319
Published: 28th Dec 2017
Last edited: 14th Aug 2019
System: Urogenital
Inclusion in quiz mode: Included
Institution: Assiut University

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