L13 - Adrenal Glands Imaging.pdf

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 11 Adrenal Glands Imaging Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Readings 1. Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic Ultrasound Vol.1, 4th Ed....

FRD40721 - Radiography & Medical Imaging Science ( Ultrasound Imaging ) Lecture 11 Adrenal Glands Imaging Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Readings 1. Rumack, CM Wilson, SR Charboneau, JW 2011, Diagnostic Ultrasound Vol.1, 4th Ed. Mosby, St. Louis 2. Bates, JA 2011, Abdominal Ultrasound: How, Why and When, 3rd Ed. Churchill Livingstone, Edinburgh 3. Moore, KL Dalley, AF 2006, Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins Company, Canada. 4. Moore, KL Persaud, TVN 2003, The Developing Human: Clinically Oriented Embryology, 7th Ed. Saunders, USA. Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Introduction • Adrenal Glands are difficult to assess with Ultrasound • More readily seen in children • Fetal adrenal glands large compared with kidneys - rapidly shrink 2-3 wks after birth Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Anatomy • Paired endocrine organs superior and medial borders of kidneys • Enclosed with kidneys in Gerota’s fascia • Surrounded by adipose tissue • Level 11th/12th thoracic rib • Lateral to L1 Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Anatomy  Measurements: 5cm long, 2cm wide, 4.5cm thick (larger at birth)  Central fold or ridge (points anteromedially)  Medial wing  Lateral wing Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Physiology-Hormones • The outer cortex produces; - Cortisol, aldosterone and androgens. • The inner medulla produces; - Epinephrine (adrenaline) and norepinephrine Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Function Cortex: • Cortisol-mobilises fats, proteins and carbohydrates • Aldosterone-regulates blood pressure • Androgen-precursor to testosterone Medulla: • Adrenaline and Noradrenaline; facilitate immediate physical reactions associated with a preparation for violent muscular action. Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Anatomy Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Anatomy www.anatomy.tv Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Anatomy - Relational Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound Technique - Right • Similar to upper pole right kidney • More difficult with cirrhotic, fatty or neoplastic liver SUBCOSTAL APPROACH: – Supine, LPO or left decubitus, right arm stretched above head – Liver moved below costal margin with deep inspiration Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound Technique - Right INTERCOSTAL TECHNIQUE: – – – – Subcostal approach blocked by gas in GIT Supine, LPO or left decubitus, arm above head Scan intercostally in mid axillary line Gentle respiration or gentle suspension Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound Technique - Left • More difficult - smaller acoustic window • Gas more of a problem • Fill stomach with water INTERCOSTAL APPROACH: – Best technique, supine with arm stretched above head – Gentle respiration or gentle suspended SUBCOSTAL APPROACH: – Plump or enlarged spleen may be forced beneath costal margin with deep inspiration Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound - Normal Appearances • Can be seen in most patients • RIGHT : Ovoid • LEFT : Triangular , Concave/straight border • Less echogenic than perirenal fat • Medulla more echogenic than cortex Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound - Paediatric Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Ultrasound Paediatric Adrenal Gland Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals Adult R adrenal gland fchs.ac.ae Mimics / Pitfalls • • • • • • • Thickened diaphragmatic crus Accessory spleen Gastric fundus Gastric diverticulum Renal vein Lymphadenopathy Upper pole renal cysts / mass Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals • Tail of pancreas • Liver metastases • Hypertrophied caudate lobe • Spleen / kidney lobulations fchs.ac.ae Pathology - Haemorrhage • Spontaneous or post-traumatic • Spontaneous uncommon in adult population, mainly paediatric • If bilateral risk of acute adrenal insufficiency • Most haematomas resolve over time Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Haemorrhage ULTRASOUND; • Acute - bright hyperechoic mass in renal bed • Smaller and anechoic with time • Focal areas of calcification with resolution • Most traumatic haematomas round/ovoid, originating in medulla Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Haemorrhage Right adrenal haemorrhage, septated cystic mass with internal echoes Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Cysts • Incidental, simple cysts uncommon • 15% - bilateral • Most common 30 - 40 yrs • Usually asymptomatic • Must be distinguished from renal, splenic or pancreatic cysts Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Cysts ULTRASOUND : – Similar characteristics as elsewhere; but internal debris often noted – 15% peripheral wall calcification Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Cysts Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Pathology - Benign Neoplasms • • • • • • Adenoma Myelolipoma Pheochromocytoma Ganglioneuroma Haemangiomas teratoma • • • • • Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals Lipoma Fibroma Leiomyoma Osteoma neurofibroma fchs.ac.ae Benign Neoplasm • Most are incidental findings • Ultrasound appearances are non-specific • May locate mass to adrenal but cannot specify histology Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Benign Neoplasms - Adenoma • 10% bilateral, incidence increasing with age • Assoc with HT, diabetes, hyperthyroidism, RCC Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Benign Neoplasms - Adenoma • ULTRASOUND – Small – Solid – Round – Well defined Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Benign Neoplasms - Myelolipoma ULTRASOUND – Typically hyperechoic mass in adrenal bed (if significant amount of fat) – Homogeneous or heterogeneous – If predominantly myeloid, isoechoic or hypoechoic – Internal haemorrhage common – Focal areas calcification Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Benign Neoplasms - Myelolipoma Very echogenic due to fat and muscle content. Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Carcinomas • Adrenal cortical cancer • Lymphoma • Metastases Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Carcinomas ULTRASOUND – Solid – Irregular – Can be very large – Homogeneous when small – Heterogeneous with cystic areas due to haemorrhage and necrosis as mass grows Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Carcinomas Large adrenal carcinoma Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Metastases • Most common primary - lung, breast, kidney, thyroid, colon • Most clinically silent • Unilateral/bilateral • Central haemorrhage • Calcification - rare Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae Metastases Adrenal metastasis of a lung carcinoma with tumor invasion in the inferior vena cava Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae QUESTIONS???? Course: FRD3061 Medical Imaging Science and Methods2 Ultrasound 1 Lecture 6A: Adrenals fchs.ac.ae