IMAGES Chapter 32 - Adrenal Glands and Kidneys Flashcards
IDENTIFY. [FIGURE 32.1]
NORMAL ADRENAL GLANDS
Contrast-enhanced CT image (A) and coronal T2-weighted MR image (B) show the normal appearance
of the adrenal glands (arrows).
DIAGNOSIS ? [FIGURE 32.2]
INCIDENTALOMA
A. Image from MDCT performed without contrast to assess for ureteral stones shows a 30 × 17 mm nodule
(arrow) arising from the right adrenal gland. The nodule is sharply marginated, oval, and homogeneous in attenuation.
B. Range-of-interest
(ROI) measurement on the same image shows an average (AV) attenuation of 6.90 HU with a standard deviation (SD) of 14.63 and area (AR) of
80.24 mm 2 . This attenuation measurement combined with the imaging features of the lesion is diagnostic of benign lipid-rich cortical adenoma.
Note that this 5-mm thick slice was selected because it was at the center of the lesion. The ROI cursor is centered within the cross-sectional area of the lesion, and the ROI measures greater than 50% of the cross-sectional area. ROI measurements must be made according to the standards established for adrenal lesion characterization on CT.
DIAGNOSIS ? [FIGURE 32.3]
Image from MDCT in a patient with lung cancer .
ADRENAL METASTASIS
Image from MDCT in a patient with lung cancer reveals a large (6 × 5 cm) solid mass (M) replacing
the left adrenal gland. The mass is irregular in shape, poorly marginated with tissue strands extending into the adjacent fat, and has heterogeneous attenuation. This features are highly indicative of malignancy, and in this patient, metastatic lung cancer in the adrenal gland.
DIAGNOSIS ? [FIGURE 32.4]
BENIGN LIPID-POOR ADRENAL ADENOMA
A. Precontrast scan shows a small right adrenal mass
(arrow) with an attenuation of 16 H, too high to characterize the lesion as a lipid-rich adrenal adenoma.
B. Image at 1-minute postintravenous contrast administration shows enhancement attenuation of the lesion (arrow) at 41 H.
C. Delayed image obtained at 15-minute postcontrast administration shows a delayed attenuation of the lesion (arrow) at 19 H.
Absolute percentage washout (APW) calculates to 88% (see Table 32.2).
Relative percentage washout calculates to 53%.
These findings characterize this
lesion as a lipid-poor adrenal adenoma
(see Table 32.1 ).
DIAGNOSIS ? [FIGURE 32.5]
ADRENAL METASTASES
Contrast-enhanced CT demonstrates
bilateral inhomogeneous adrenal masses (arrows). Adrenal protocol CT with delayed images showed minimal contrast washout at 15 minutes,
indicating a high likelihood of malignancy. The lesions are metastases from lung carcinoma.
DIAGNOSIS ? [FIGURE 32.6]
BENIGN LIPID-RICH ADRENAL ADENOMA
Chemical shift MR imaging is used to characterize a lipid-rich adenoma in a patient with a history of renal cell carcinoma.
A. In-phase MR image shows a small right adrenal mass (arrow) with signal intensity slightly less than that
of the liver.
B. Opposed-phase MR image shows the distinct loss of signal intensity in the lesion (arrow) caused by intracellular fat that characterizes
lipid-rich adrenal adenomas.
Note the black band (arrowhead) at interfaces between soft tissue and fat produced by chemical shift artifact.
This finding allows immediate recognition of the opposed-phase MR image.
DIAGNOSIS ? [FIGURE 32.7]
ADRENAL METASTASIS
A. CT image from PET-CT shows a small nodule (between red cursors) arising from the left adrenal
gland. CT attenuation was 23 H.
B. The corresponding PET image from PET-CT shows marked FDG uptake within the lesion (between red
cursors) indicating metastatic disease in this patient with lung cancer.
Note that the radionuclide activity within the adrenal lesion is substantially higher than the radionuclide activity in the liver (L).
DIAGNOSIS ? [FIGURE 32.8]
Postcontrast MDCT image in a patient with blunt abdominal trauma from a motor vehicle
collision revealed a left adrenal mass (arrow).
“INCIDENTAL” PHEOCHROMOCYTOMA
Subsequent clinical evaluation
indicated evidence of pheochromocytoma. Adrenalectomy confirmed the diagnosis. Pheochromocytoma is quite variable in imaging
appearance. This lesion closely resembles an adrenal cortical adenoma.k, top of left kidney.
DIAGNOSIS ? [FIGURE 32.9]
PHEOCHROMOCYTOMA
WITH SPONTANEOUS HEMORRHAGE
Postcontrast CT shows a heterogeneous adrenal mass
(M) with hemorrhage (arrowheads) into the
perinephric space.
The inferior venacava (IVC) is displaced anteriorly
by the mass. Ao, aorta; LK, left kidney.
DIAGNOSIS ? [FIGURE 32.10]
PHEOCHROMOCYTOMA IN THE BLADDER WALL
T2-weightedsagittal plane MR image demonstrates a lobulated mass (arrows) in the posterior wall of the bladder (B).
Surgical excision confirmed a pheochromocytoma.
DIAGNOSIS?
GIVE THREE DIFFERENTIAL DIAGNOSES.
[FIGURE 32.11]
ADRENAL HYPERPLASIA
Differential considerations include:
hyperplasia, metastases, and granulomatous disease.
The limbs of both adrenal glands (arrows) are thickened and somewhat nodular.
Note the anatomic landmarks for the adrenal glands:
d, crura of the diaphragm; L, right lobe of the liver;
IVC, inferior vena cava; Ao, aorta.
DIAGNOSIS ? [FIGURE 32.12]
Lesion (between arrows ) of the left adrenal gland has large internal areas of fat density identical to the surrounding retroperitoneal fat.
ADRENAL MYELOLIPOMA
Inhomogeneous attenuation is
common and results from bone marrow hemopoietic tissue mixed with bone marrow fat.
DIAGNOSIS ? [FIGURE 32.13]
ADRENAL HEMORRHAGE
Postcontrast CT shows posttraumatic hemorrhage
(arrow) into the right adrenal gland.
Blunt trauma to the abdomen compresses the right adrenal gland between the liver (L) and the spine (S) resulting in adrenal hemorrhage.
This patient also has areas of fracture and hemorrhage
(arrowheads) within the liver as well as a biloma (B).
DIAGNOSIS ? [FIGURE 32.15]
CT shows a well defined fluid-density lesion (arrow) of the right adrenal gland.
Calcification (arrowhead) is evident in the wall and in the septation.
POST-HEMORRHAGIC ADRENAL CYST
DIAGNOSIS ? [FIGURE 32.14]
Plain radiograph of the abdomen in a 4-year-old child
ADRENAL CALCIFICATION
Plain radiograph of the abdomen in a 4-year-old child
demonstrates calcifi cation of both adrenal glands
(arrows) resulting from bilateral adrenal hemorrhage as an infant.
DIAGNOSIS ? [FIGURE 32.16]
T2-weighted MR image with fat suppression
ADRENAL CARCINOMA
T2-weighted MR image with fat suppression shows a large inhomogeneous mass (M) replacing the
right adrenal gland.
Areas of high- and low signal intensity represent necrosis and hemorrhage.
The patient has a malignant right pleural effusion (arrow). GB, gallbladder.
Conventional Excretory Urogram Versus CT-Urogram.
[FIGURE 32.17]
The spatial resolution of conventional radiography
is significantly ______ than that of CT.
However, CT offers the major advantage of markedly __
compared to conventional radiography, allowing much ________ for detection of parenchymal renal lesions.
HIGHER;
INCREASED CONTRAST RESOLUTION;
HIGHER SENSITIVITY
A. A radiograph of the left kidney taken 5 minutes
after intravenous contrast injection during a conventional excretory urogram demonstrates the enhanced renal parenchyma
(between arrowheads) and the filled collecting system
(P). The calyces (white arrow) are sharp and cupshaped to accept the apex of the medullary pyramids.
Upper pole calyces ( black arrow) are usually compound because of drainage of multiple pyramids.
Oblique views may be needed to confirm the normal appearance of calyces oriented anteriorly or posteriorly (curved arrow).
The normal kidney is equal in length to between three and four vertebral bodies.
B. Coronal plane, reconstructed, pyelogram-phase image from a CT-urogram shows similar anatomy.
The detail of the calyces seen with the excretory
urogram is clearly sharper than that shown with the CT-urogram.
DIAGNOSIS ? [FIGURE 32.18]
Image from a postcontrast CT
demonstrates the two kidneys extending across the spine and joined at their lower poles (arrow).
The kidneys are low in position in the abdomen
stopped in their ascent by the inferior mesenteric artery
(arrowhead).
HORSESHOE KIDNEY
DIAGNOSIS ? [FIGURE 32.19]
RENAL CELL CARCINOMA
Pyelogram-phase image from a CT-urogram shows an exophytic solid mass (arrow) projecting from
the lateral aspect of the kidney.
The mass shows heterogeneous enhancement less than that of the renal parenchyma during this phase.
Pathology revealed a conventional clear cell carcinoma
. Low attenuation areas within the tumor proved to be the foci of necrosis and hemorrhage.
DIAGNOSIS ? [FIGURE 32.20]
CYSTIC RENAL CELL CARCINOMA
Axial postcontrast image from MDCT reveals a cystic tumor (arrow) projecting from the
lateral aspect of the right kidney.
The lesion has shaggy thick walls, with indistinct stranding extending into the perirenal fat.
A distinct nodule (arrowhead) of enhancing soft tissue extends from the tumor into the perirenal fat.
While soft-tissue stranding is nonspecific, a distinct
tumor nodule in the perirenal fat is highly indicative of tumor extension outside of the renal capsule.
DIAGNOSIS ? [FIGURE 32.21]
MULTICYSTIC RENAL CELL CARCINOMA
A. Contrast-enhanced CT scan reveals a low attenuation, well-defined mass (arrow) in the left
kidney. Subtle enhancement of internal septations is present.
B. A US image in a different patient shows a multicystic mass (between open arrows) arising from the lateral aspect of the left kidney (between white arrows).
In both patients, the thin septations were lined by clear cells typical of renal carcinoma.
DIAGNOSIS ? (iNCLUDE SPECIFIC LOCATIONS)
[FIGURE 32.22]
TUMOR THROMBUS IN THE
RENAL VEIN AND INFERIOR VENA CAVA
Coronal plane image from an MR angiogram shows an irregularly enhancing mass (arrow) replacing the upper pole of the right kidney.
Enhancing tumor thrombus (arrowhead) extends continuously from the renal mass through the renal vein and into the lumen of the inferior vena cava.
Enhancement differentiates tumor thrombus
from bland thrombus.
The right renal artery (curved arrow) is well shown.
DIAGNOSIS ? [FIGURE 32.23]
Postcontrast CT demonstrates a tumor infiltrating the left kidney.
ANGIOMYOLIPOMA
Areas of fat density (arrow) are mixed with strands and foci of soft-tissue density. The appearance is
characteristic of angiomyolipoma.
Compare the fat density regions within the tumor with subcutaneous and retroperitoneal fat.
DIAGNOSIS ? [FIGURE 32.25]
METASTASES TO THE KIDNEY
Metastases to the Kidney. In a patient with lung cancer,
the ill-defined low attenuation lesions (arrows) in the renal parenchyma of both kidneys represent metastatic disease.
Metastases are typically infiltrative and poorly defined.
DIAGNOSIS ? [FIGURE 32.24]
RENAL LYMPHOMA
Non–Hodgkin lymphoma (arrows) infiltrates the perirenal space partially surrounding both kidneys.
Note the impaired contrast enhancement of the right kidney caused by lymphomatous involvement of the right renal blood vessels (arrowhead). The tumor infiltrates the sinus and parenchyma of the right kidney.
DIAGNOSIS ? [FIGURE 32.26]
SIMPLE RENAL CYST
A large cyst (arrow) arising from the right kidney shows characteristic CT features. The cyst is of uniform
low density, has a sharp margin with the renal parenchyma, and its wall is imperceptible.
DIAGNOSIS ? [FIGURE 32.27.]
COMPLICATED RENAL CYST
Postcontrast MDCT demonstrates a small simple renal cyst (arrow) and a larger renal cyst complicated
by a thin rim of calcifi cation in its wall (arrowhead). This
larger cyst would be classified as a benign renal cyst, Bosniak II.
DIAGNOSIS ? [FIGURE 32.28]
RENAL ABSCESS
The right renal abscess (A) has characteristic
thick walls and septations and internal fluid density. Edema reduces the CT density of the renal parenchyma adjacent to the mass (black arrow) and infiltrates the perirenal space (white arrow).
This patient also has multiple small renal cysts caused by autosomal dominant polycystic disease.
DIAGNOSIS ? [FIGURE 32.29]
ADULT DOMINANT POLYCYSTIC KIDNEY DISEASE
T2-weighted MR in coronal plane shows extensive replacement of the renal parenchyma with innumerable noncommunicating cysts of various sizes.
Cysts are also seen in the liver (L). Both kidneys (RK, LK) are massively enlarged.
DIAGNOSIS ? [FIGURE 32.30]
The patient has been on hemodialysis for 8 years.
ACQUIRED UREMIC CYSTIC KIDNEY DISEASE
Noncontrast CT reveals both kidneys (arrows) are small and contain numerous small cysts.
DIAGNOSIS ? [FIGURE 32.31]
A. High-resolution US image of the massively enlarged right kidney in a newborn infant shows the innumerable dilated and elongated tubules that characterize this condition.
B. Contrast-enhanced CT in a 5-year-old child shows massive kidneys. The enhanced cortex (arrow) is thinned and nonenhanced collecting tubules (T) in the medulla are enlarged. No discrete cysts are
evident.
AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE
DIAGNOSIS ? [FIGURE 32.32]
NEPHROCALCINOSIS IN THE
MEDULLARY SPONDGE KIDNEY
Conventional radiograph demonstrates innumerable calcifications in the medullary regions of both kidneys. The stones form in dilated collecting tubules in the medullary pyramids in this patient with medullary
sponge kidney.
DIAGNOSIS ? [FIGURE 32.33]
RENAL ARTERIOVENOUS MALFORMATION
Coronal plane image from a CT-angiogram dramatically demonstrates the tangle of large vessels within the right kidney with enlarged supplying arteries and draining veins.
DIAGNOSIS ? [FIGURE 32.34]
ACUTE PYELONEPHRITIS
Edema and swelling associated with acute renal infection cause wedge-shaped defects (arrowheads) in the enhanced parenchyma of the right kidney.
The left kidney is normal.
DIAGNOSIS? [FIGURE 32.35]
PERIRENAL ABSCESS
Contrast-enhanced CT scan discloses a low-density fluid collection (A) in the perirenal space between the right kidney (RK) and the thickened renal fascia (arrowhead). Gas bubbles (arrow) are seen within the perirenal abscess.
DIAGNOSIS ? [FIGURE 32.36]
EMPHYSEMATOUS PYELONEPHRITIS
Conventional radiograph of the left kidney shows striations in the renal parenchyma caused by interstitial gas. This finding is indicative of life-threatening infection.
DIAGNOSIS ? [FIGURE 32.37]
REFLUX NEPHROPATHY
Image of the right kidney from a CT-urogram of an adult patient shows the characteristic findings of reflux nephropathy.
A deep cortical scar overlies a blunted calyx
(arrow). In adults, these findings usually reflect renal injury that occurred during childhood.
DIAGNOSIS ? [FIGURE 32.39]
END-STAGE RENAL TUBERCULOSIS
The right kidney is small, nonfunctioning, and completely calcified because of chronic tuberculous infection. This appearance has been called a “putty kidney” reflecting the physical texture of caseous necrosis mixed with calcification.
DIAGNOSIS ? [FIGURE 32.38]
XANTHOGRANULOMATOUS PYELONEPHRITIS
Postcontrast CT shows a poorly functioning right kidney with a large obstructing stone (black arrow) occupying the renal pelvis. Calyces (arrowhead) are dilated and the parenchyma is atrophic and replaced by inflammatory tissue. Indolent abscess (white arrows) extends through the renal capsule and perirenal space into the subcutaneous tissues.
DIAGNOSIS ? [FIGURE 32.40]
HIV NEPHROPATHY
Postcontrast CT shows the mottled striated nephrogram seen with HIV nephropathy.
