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CT and MR Imaging of the Adrenal Glands in ACTH-independent Cushing Syndrome¹

¹ From the Departments of Academic Radiology (A.G.R., S.A.B., S.A.A.S., R.H.R.), Endocrinology (A.M.I., J.P.M., A.B.G.), and Histopathology (S.D.C.), St Bartholomew's Hospital, Dominion House, St Bartholomew's Close, London EC1A 7ED, England. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received April 2, 2003; revision requested May 7 and received June 12; accepted June 13. All authors have no financial relationships to disclose. Address correspondence to A.G.R. (e-mail: a.g.rockall@qmul.ac.uk).

View larger version (139K): [in a new window]   Figure 1a. Adrenal adenoma in a 68-year-old man. (a) Unenhanced CT scan shows a smooth, ovoid, well-defined low-attenuation mass (arrow). The CT attenuation value was -5 HU, indicating the presence of intracellular lipid. Korobkin et al (8) demonstrated a cut-off point of 18 HU, below which an adrenal lesion may be designated as a benign adenoma with a specificity of 85% and a sensitivity of 100%. (b) Contrast material-enhanced CT scan shows moderate enhancement of the mass (arrow), which gives the lesion a slightly heterogeneous appearance. (c) Axial in-phase (repetition time msec/echo time msec = 150/4.2) (top) and out-of-phase (150/1.8) (bottom) fast multiplanar spoiled gradient-echo (FMPSPGR) T1-weighted MR images (flip angle = 90°) show the mass with classic signal dropout (arrow), a finding that suggests the presence of intracellular lipid, a characteristic feature of benign adenomas. (d) On an axial fast spin-echo T2-weighted MR image (6,000/105), the adenoma (arrow) is isointense relative to the liver. (e) High-power photomicrograph (original magnification, x400; hematoxylin-eosin [H-E] stain) demonstrates a lipid-rich adrenal adenoma with abundant intracellular fat (arrow).

View larger version (142K): [in a new window]   Figure 1b. Adrenal adenoma in a 68-year-old man. (a) Unenhanced CT scan shows a smooth, ovoid, well-defined low-attenuation mass (arrow). The CT attenuation value was -5 HU, indicating the presence of intracellular lipid. Korobkin et al (8) demonstrated a cut-off point of 18 HU, below which an adrenal lesion may be designated as a benign adenoma with a specificity of 85% and a sensitivity of 100%. (b) Contrast material-enhanced CT scan shows moderate enhancement of the mass (arrow), which gives the lesion a slightly heterogeneous appearance. (c) Axial in-phase (repetition time msec/echo time msec = 150/4.2) (top) and out-of-phase (150/1.8) (bottom) fast multiplanar spoiled gradient-echo (FMPSPGR) T1-weighted MR images (flip angle = 90°) show the mass with classic signal dropout (arrow), a finding that suggests the presence of intracellular lipid, a characteristic feature of benign adenomas. (d) On an axial fast spin-echo T2-weighted MR image (6,000/105), the adenoma (arrow) is isointense relative to the liver. (e) High-power photomicrograph (original magnification, x400; hematoxylin-eosin [H-E] stain) demonstrates a lipid-rich adrenal adenoma with abundant intracellular fat (arrow).

View larger version (131K): [in a new window]   Figure 1c. Adrenal adenoma in a 68-year-old man. (a) Unenhanced CT scan shows a smooth, ovoid, well-defined low-attenuation mass (arrow). The CT attenuation value was -5 HU, indicating the presence of intracellular lipid. Korobkin et al (8) demonstrated a cut-off point of 18 HU, below which an adrenal lesion may be designated as a benign adenoma with a specificity of 85% and a sensitivity of 100%. (b) Contrast material-enhanced CT scan shows moderate enhancement of the mass (arrow), which gives the lesion a slightly heterogeneous appearance. (c) Axial in-phase (repetition time msec/echo time msec = 150/4.2) (top) and out-of-phase (150/1.8) (bottom) fast multiplanar spoiled gradient-echo (FMPSPGR) T1-weighted MR images (flip angle = 90°) show the mass with classic signal dropout (arrow), a finding that suggests the presence of intracellular lipid, a characteristic feature of benign adenomas. (d) On an axial fast spin-echo T2-weighted MR image (6,000/105), the adenoma (arrow) is isointense relative to the liver. (e) High-power photomicrograph (original magnification, x400; hematoxylin-eosin [H-E] stain) demonstrates a lipid-rich adrenal adenoma with abundant intracellular fat (arrow).

View larger version (114K): [in a new window]   Figure 1d. Adrenal adenoma in a 68-year-old man. (a) Unenhanced CT scan shows a smooth, ovoid, well-defined low-attenuation mass (arrow). The CT attenuation value was -5 HU, indicating the presence of intracellular lipid. Korobkin et al (8) demonstrated a cut-off point of 18 HU, below which an adrenal lesion may be designated as a benign adenoma with a specificity of 85% and a sensitivity of 100%. (b) Contrast material-enhanced CT scan shows moderate enhancement of the mass (arrow), which gives the lesion a slightly heterogeneous appearance. (c) Axial in-phase (repetition time msec/echo time msec = 150/4.2) (top) and out-of-phase (150/1.8) (bottom) fast multiplanar spoiled gradient-echo (FMPSPGR) T1-weighted MR images (flip angle = 90°) show the mass with classic signal dropout (arrow), a finding that suggests the presence of intracellular lipid, a characteristic feature of benign adenomas. (d) On an axial fast spin-echo T2-weighted MR image (6,000/105), the adenoma (arrow) is isointense relative to the liver. (e) High-power photomicrograph (original magnification, x400; hematoxylin-eosin [H-E] stain) demonstrates a lipid-rich adrenal adenoma with abundant intracellular fat (arrow).

View larger version (166K): [in a new window]   Figure 1e. Adrenal adenoma in a 68-year-old man. (a) Unenhanced CT scan shows a smooth, ovoid, well-defined low-attenuation mass (arrow). The CT attenuation value was -5 HU, indicating the presence of intracellular lipid. Korobkin et al (8) demonstrated a cut-off point of 18 HU, below which an adrenal lesion may be designated as a benign adenoma with a specificity of 85% and a sensitivity of 100%. (b) Contrast material-enhanced CT scan shows moderate enhancement of the mass (arrow), which gives the lesion a slightly heterogeneous appearance. (c) Axial in-phase (repetition time msec/echo time msec = 150/4.2) (top) and out-of-phase (150/1.8) (bottom) fast multiplanar spoiled gradient-echo (FMPSPGR) T1-weighted MR images (flip angle = 90°) show the mass with classic signal dropout (arrow), a finding that suggests the presence of intracellular lipid, a characteristic feature of benign adenomas. (d) On an axial fast spin-echo T2-weighted MR image (6,000/105), the adenoma (arrow) is isointense relative to the liver. (e) High-power photomicrograph (original magnification, x400; hematoxylin-eosin [H-E] stain) demonstrates a lipid-rich adrenal adenoma with abundant intracellular fat (arrow).

View larger version (114K): [in a new window]   Figure 2a. Small adenoma in a 51-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows an ovoid mass that arises from the medial limb of the left adrenal gland (arrow). A large hemangioma (*) was seen incidentally in the liver (L). (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) shows no signal dropout in the mass (arrow). This finding is uncharacteristic of adenomas, which classically show signal dropout with the out-of-phase sequence. L = liver, * = hemangioma. (c) Photomicrograph (original magnification, x400; H-E stain) shows a lipid-poor adrenal adenoma that contains predominantly eosinophilic compact cells with abundant lipofuscin pigment, which appears brown (arrow). These histologic findings may account for the lack of signal dropout in b.

View larger version (110K): [in a new window]   Figure 2b. Small adenoma in a 51-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows an ovoid mass that arises from the medial limb of the left adrenal gland (arrow). A large hemangioma (*) was seen incidentally in the liver (L). (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) shows no signal dropout in the mass (arrow). This finding is uncharacteristic of adenomas, which classically show signal dropout with the out-of-phase sequence. L = liver, * = hemangioma. (c) Photomicrograph (original magnification, x400; H-E stain) shows a lipid-poor adrenal adenoma that contains predominantly eosinophilic compact cells with abundant lipofuscin pigment, which appears brown (arrow). These histologic findings may account for the lack of signal dropout in b.

View larger version (164K): [in a new window]   Figure 2c. Small adenoma in a 51-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows an ovoid mass that arises from the medial limb of the left adrenal gland (arrow). A large hemangioma (*) was seen incidentally in the liver (L). (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) shows no signal dropout in the mass (arrow). This finding is uncharacteristic of adenomas, which classically show signal dropout with the out-of-phase sequence. L = liver, * = hemangioma. (c) Photomicrograph (original magnification, x400; H-E stain) shows a lipid-poor adrenal adenoma that contains predominantly eosinophilic compact cells with abundant lipofuscin pigment, which appears brown (arrow). These histologic findings may account for the lack of signal dropout in b.

View larger version (142K): [in a new window]   Figure 3a. Adenoma within a myelolipoma in a 44-year-old woman with Cushing syndrome. (a) Longitudinal ultrasonographic image shows a hyperechoic suprarenal mass (arrow) with an appearance consistent with that of a predominantly fat-containing lesion. (b) Unenhanced CT scan helps confirm the fatty nature of the mass (arrow). However, a relatively large soft-tissue component (*) can also be seen within the lesion. (c) Coronal spin-echo T1-weighted MR images (740/25) show a predominantly fat-containing high-signal-intensity mass (short arrows) with areas of intermediate signal intensity (long arrow). (d) Axial short inversion time inversion-recovery MR image (1,800/25, inversion time msec = 100) shows a large mass with marked signal dropout (arrow), a finding that confirms the predominantly fatty nature of the lesion. At histologic analysis, the lesion proved to be a myelolipoma containing an adenoma.

View larger version (113K): [in a new window]   Figure 3b. Adenoma within a myelolipoma in a 44-year-old woman with Cushing syndrome. (a) Longitudinal ultrasonographic image shows a hyperechoic suprarenal mass (arrow) with an appearance consistent with that of a predominantly fat-containing lesion. (b) Unenhanced CT scan helps confirm the fatty nature of the mass (arrow). However, a relatively large soft-tissue component (*) can also be seen within the lesion. (c) Coronal spin-echo T1-weighted MR images (740/25) show a predominantly fat-containing high-signal-intensity mass (short arrows) with areas of intermediate signal intensity (long arrow). (d) Axial short inversion time inversion-recovery MR image (1,800/25, inversion time msec = 100) shows a large mass with marked signal dropout (arrow), a finding that confirms the predominantly fatty nature of the lesion. At histologic analysis, the lesion proved to be a myelolipoma containing an adenoma.

View larger version (127K): [in a new window]   Figure 3c. Adenoma within a myelolipoma in a 44-year-old woman with Cushing syndrome. (a) Longitudinal ultrasonographic image shows a hyperechoic suprarenal mass (arrow) with an appearance consistent with that of a predominantly fat-containing lesion. (b) Unenhanced CT scan helps confirm the fatty nature of the mass (arrow). However, a relatively large soft-tissue component (*) can also be seen within the lesion. (c) Coronal spin-echo T1-weighted MR images (740/25) show a predominantly fat-containing high-signal-intensity mass (short arrows) with areas of intermediate signal intensity (long arrow). (d) Axial short inversion time inversion-recovery MR image (1,800/25, inversion time msec = 100) shows a large mass with marked signal dropout (arrow), a finding that confirms the predominantly fatty nature of the lesion. At histologic analysis, the lesion proved to be a myelolipoma containing an adenoma.

View larger version (113K): [in a new window]   Figure 3d. Adenoma within a myelolipoma in a 44-year-old woman with Cushing syndrome. (a) Longitudinal ultrasonographic image shows a hyperechoic suprarenal mass (arrow) with an appearance consistent with that of a predominantly fat-containing lesion. (b) Unenhanced CT scan helps confirm the fatty nature of the mass (arrow). However, a relatively large soft-tissue component (*) can also be seen within the lesion. (c) Coronal spin-echo T1-weighted MR images (740/25) show a predominantly fat-containing high-signal-intensity mass (short arrows) with areas of intermediate signal intensity (long arrow). (d) Axial short inversion time inversion-recovery MR image (1,800/25, inversion time msec = 100) shows a large mass with marked signal dropout (arrow), a finding that confirms the predominantly fatty nature of the lesion. At histologic analysis, the lesion proved to be a myelolipoma containing an adenoma.

View larger version (91K): [in a new window]   Figure 4a. Adenoma associated with a myelolipoma in a 64-year-old woman with Cushing syndrome. (a) Axial unenhanced CT scan shows a large left adrenal mass with multiple low-attenuation areas centrally (horizontal arrow) that represent pockets of fat. A speck of calcification (vertical arrow) is also noted adjacent to the fatty component. (b) Contrast-enhanced arterial-phase CT scan shows mild enhancement of the mass. (c) Axial spin-echo T1-weighted MR image (500/16) shows the mass with small central foci of high signal intensity (arrow) that correspond to the foci of fat seen at CT. (d) Axial fast spin-echo T2-weighted MR image (6,000/102) shows the mass with mixed signal intensity. Multiple high-signal-intensity foci of varying size are seen within the mass and correspond to the hematopoietic component of a myelolipoma, which in this case forms a large part of the mass (cf e). (e) Photomicrograph (original magnification, x100; H-E stain) (left) shows a myelolipoma with a capsule (C) superior to adrenocortical tissue (A), the hyperfunctioning part of the lesion. More inferiorly, there is a mixture of vacuolated fat cells (F) and hematopoietic (bone marrow) cells (H), which make up a large part of the myelolipoma. A higher-power photomicrograph of the same lesion (original magnification, x200; H-E stain) (right) demonstrates a vacuolated fat cell (F) surrounded by markedly hyperchromatic hematopoietic cells.

View larger version (99K): [in a new window]   Figure 4b. Adenoma associated with a myelolipoma in a 64-year-old woman with Cushing syndrome. (a) Axial unenhanced CT scan shows a large left adrenal mass with multiple low-attenuation areas centrally (horizontal arrow) that represent pockets of fat. A speck of calcification (vertical arrow) is also noted adjacent to the fatty component. (b) Contrast-enhanced arterial-phase CT scan shows mild enhancement of the mass. (c) Axial spin-echo T1-weighted MR image (500/16) shows the mass with small central foci of high signal intensity (arrow) that correspond to the foci of fat seen at CT. (d) Axial fast spin-echo T2-weighted MR image (6,000/102) shows the mass with mixed signal intensity. Multiple high-signal-intensity foci of varying size are seen within the mass and correspond to the hematopoietic component of a myelolipoma, which in this case forms a large part of the mass (cf e). (e) Photomicrograph (original magnification, x100; H-E stain) (left) shows a myelolipoma with a capsule (C) superior to adrenocortical tissue (A), the hyperfunctioning part of the lesion. More inferiorly, there is a mixture of vacuolated fat cells (F) and hematopoietic (bone marrow) cells (H), which make up a large part of the myelolipoma. A higher-power photomicrograph of the same lesion (original magnification, x200; H-E stain) (right) demonstrates a vacuolated fat cell (F) surrounded by markedly hyperchromatic hematopoietic cells.

View larger version (101K): [in a new window]   Figure 4c. Adenoma associated with a myelolipoma in a 64-year-old woman with Cushing syndrome. (a) Axial unenhanced CT scan shows a large left adrenal mass with multiple low-attenuation areas centrally (horizontal arrow) that represent pockets of fat. A speck of calcification (vertical arrow) is also noted adjacent to the fatty component. (b) Contrast-enhanced arterial-phase CT scan shows mild enhancement of the mass. (c) Axial spin-echo T1-weighted MR image (500/16) shows the mass with small central foci of high signal intensity (arrow) that correspond to the foci of fat seen at CT. (d) Axial fast spin-echo T2-weighted MR image (6,000/102) shows the mass with mixed signal intensity. Multiple high-signal-intensity foci of varying size are seen within the mass and correspond to the hematopoietic component of a myelolipoma, which in this case forms a large part of the mass (cf e). (e) Photomicrograph (original magnification, x100; H-E stain) (left) shows a myelolipoma with a capsule (C) superior to adrenocortical tissue (A), the hyperfunctioning part of the lesion. More inferiorly, there is a mixture of vacuolated fat cells (F) and hematopoietic (bone marrow) cells (H), which make up a large part of the myelolipoma. A higher-power photomicrograph of the same lesion (original magnification, x200; H-E stain) (right) demonstrates a vacuolated fat cell (F) surrounded by markedly hyperchromatic hematopoietic cells.

View larger version (95K): [in a new window]   Figure 4d. Adenoma associated with a myelolipoma in a 64-year-old woman with Cushing syndrome. (a) Axial unenhanced CT scan shows a large left adrenal mass with multiple low-attenuation areas centrally (horizontal arrow) that represent pockets of fat. A speck of calcification (vertical arrow) is also noted adjacent to the fatty component. (b) Contrast-enhanced arterial-phase CT scan shows mild enhancement of the mass. (c) Axial spin-echo T1-weighted MR image (500/16) shows the mass with small central foci of high signal intensity (arrow) that correspond to the foci of fat seen at CT. (d) Axial fast spin-echo T2-weighted MR image (6,000/102) shows the mass with mixed signal intensity. Multiple high-signal-intensity foci of varying size are seen within the mass and correspond to the hematopoietic component of a myelolipoma, which in this case forms a large part of the mass (cf e). (e) Photomicrograph (original magnification, x100; H-E stain) (left) shows a myelolipoma with a capsule (C) superior to adrenocortical tissue (A), the hyperfunctioning part of the lesion. More inferiorly, there is a mixture of vacuolated fat cells (F) and hematopoietic (bone marrow) cells (H), which make up a large part of the myelolipoma. A higher-power photomicrograph of the same lesion (original magnification, x200; H-E stain) (right) demonstrates a vacuolated fat cell (F) surrounded by markedly hyperchromatic hematopoietic cells.

View larger version (153K): [in a new window]   Figure 4e. Adenoma associated with a myelolipoma in a 64-year-old woman with Cushing syndrome. (a) Axial unenhanced CT scan shows a large left adrenal mass with multiple low-attenuation areas centrally (horizontal arrow) that represent pockets of fat. A speck of calcification (vertical arrow) is also noted adjacent to the fatty component. (b) Contrast-enhanced arterial-phase CT scan shows mild enhancement of the mass. (c) Axial spin-echo T1-weighted MR image (500/16) shows the mass with small central foci of high signal intensity (arrow) that correspond to the foci of fat seen at CT. (d) Axial fast spin-echo T2-weighted MR image (6,000/102) shows the mass with mixed signal intensity. Multiple high-signal-intensity foci of varying size are seen within the mass and correspond to the hematopoietic component of a myelolipoma, which in this case forms a large part of the mass (cf e). (e) Photomicrograph (original magnification, x100; H-E stain) (left) shows a myelolipoma with a capsule (C) superior to adrenocortical tissue (A), the hyperfunctioning part of the lesion. More inferiorly, there is a mixture of vacuolated fat cells (F) and hematopoietic (bone marrow) cells (H), which make up a large part of the myelolipoma. A higher-power photomicrograph of the same lesion (original magnification, x200; H-E stain) (right) demonstrates a vacuolated fat cell (F) surrounded by markedly hyperchromatic hematopoietic cells.

View larger version (104K): [in a new window]   Figure 5a. Adenoma of uncertain malignant potential in a 73-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows a large (6.5-cm) mass in the left adrenal gland (arrow). There was neither hemorrhage nor necrosis within the mass, nor metastases at presentation. (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) demonstrates no significant signal dropout (arrow). (c) On an axial fast spin-echo T2-weighted MR image (7,500/105), the mass (arrow) is isointense relative to the spleen.

View larger version (110K): [in a new window]   Figure 5b. Adenoma of uncertain malignant potential in a 73-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows a large (6.5-cm) mass in the left adrenal gland (arrow). There was neither hemorrhage nor necrosis within the mass, nor metastases at presentation. (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) demonstrates no significant signal dropout (arrow). (c) On an axial fast spin-echo T2-weighted MR image (7,500/105), the mass (arrow) is isointense relative to the spleen.

View larger version (100K): [in a new window]   Figure 5c. Adenoma of uncertain malignant potential in a 73-year-old woman. (a) Axial in-phase FMPSPGR T1-weighted MR image (150/4.2, flip angle = 90°) shows a large (6.5-cm) mass in the left adrenal gland (arrow). There was neither hemorrhage nor necrosis within the mass, nor metastases at presentation. (b) Axial out-of-phase FMPSPGR T1-weighted MR image (150/1.8, flip angle = 90°) demonstrates no significant signal dropout (arrow). (c) On an axial fast spin-echo T2-weighted MR image (7,500/105), the mass (arrow) is isointense relative to the spleen.

View larger version (104K): [in a new window]   Figure 6a. Adrenal carcinoma in a 32-year-old woman with Cushing syndrome. (a) Unenhanced CT scan demonstrates a large, low-attenuation suprarenal mass (short arrows) containing areas of high attenuation (long arrows) that are consistent with hemorrhage. (b) Contrast-enhanced CT scan demonstrates the mass with heterogeneous enhancement. Large areas of necrosis are also seen (*). Note the anterior displacement and compression of the inferior vena cava (IVC) (arrow). (c) Axial T1-weighted MR image (500/14) demonstrates high-signal-intensity areas within the mass (arrow), a finding that is consistent with hemorrhage. (d) Axial fast spin-echo T2-weighted MR image (7,500/100) also demonstrates extensive high-signal-intensity areas within the mass (arrow), a finding that is consistent with necrosis. (e) Photomicrograph (original magnification, x100; H-E stain) demonstrates amorphous necrosis (arrows), a finding that is seen in the majority of adrenal carcinomas.

View larger version (134K): [in a new window]   Figure 6b. Adrenal carcinoma in a 32-year-old woman with Cushing syndrome. (a) Unenhanced CT scan demonstrates a large, low-attenuation suprarenal mass (short arrows) containing areas of high attenuation (long arrows) that are consistent with hemorrhage. (b) Contrast-enhanced CT scan demonstrates the mass with heterogeneous enhancement. Large areas of necrosis are also seen (*). Note the anterior displacement and compression of the inferior vena cava (IVC) (arrow). (c) Axial T1-weighted MR image (500/14) demonstrates high-signal-intensity areas within the mass (arrow), a finding that is consistent with hemorrhage. (d) Axial fast spin-echo T2-weighted MR image (7,500/100) also demonstrates extensive high-signal-intensity areas within the mass (arrow), a finding that is consistent with necrosis. (e) Photomicrograph (original magnification, x100; H-E stain) demonstrates amorphous necrosis (arrows), a finding that is seen in the majority of adrenal carcinomas.

View larger version (116K): [in a new window]   Figure 6c. Adrenal carcinoma in a 32-year-old woman with Cushing syndrome. (a) Unenhanced CT scan demonstrates a large, low-attenuation suprarenal mass (short arrows) containing areas of high attenuation (long arrows) that are consistent with hemorrhage. (b) Contrast-enhanced CT scan demonstrates the mass with heterogeneous enhancement. Large areas of necrosis are also seen (*). Note the anterior displacement and compression of the inferior vena cava (IVC) (arrow). (c) Axial T1-weighted MR image (500/14) demonstrates high-signal-intensity areas within the mass (arrow), a finding that is consistent with hemorrhage. (d) Axial fast spin-echo T2-weighted MR image (7,500/100) also demonstrates extensive high-signal-intensity areas within the mass (arrow), a finding that is consistent with necrosis. (e) Photomicrograph (original magnification, x100; H-E stain) demonstrates amorphous necrosis (arrows), a finding that is seen in the majority of adrenal carcinomas.

View larger version (132K): [in a new window]   Figure 6d. Adrenal carcinoma in a 32-year-old woman with Cushing syndrome. (a) Unenhanced CT scan demonstrates a large, low-attenuation suprarenal mass (short arrows) containing areas of high attenuation (long arrows) that are consistent with hemorrhage. (b) Contrast-enhanced CT scan demonstrates the mass with heterogeneous enhancement. Large areas of necrosis are also seen (*). Note the anterior displacement and compression of the inferior vena cava (IVC) (arrow). (c) Axial T1-weighted MR image (500/14) demonstrates high-signal-intensity areas within the mass (arrow), a finding that is consistent with hemorrhage. (d) Axial fast spin-echo T2-weighted MR image (7,500/100) also demonstrates extensive high-signal-intensity areas within the mass (arrow), a finding that is consistent with necrosis. (e) Photomicrograph (original magnification, x100; H-E stain) demonstrates amorphous necrosis (arrows), a finding that is seen in the majority of adrenal carcinomas.

View larger version (65K): [in a new window]   Figure 6e. Adrenal carcinoma in a 32-year-old woman with Cushing syndrome. (a) Unenhanced CT scan demonstrates a large, low-attenuation suprarenal mass (short arrows) containing areas of high attenuation (long arrows) that are consistent with hemorrhage. (b) Contrast-enhanced CT scan demonstrates the mass with heterogeneous enhancement. Large areas of necrosis are also seen (*). Note the anterior displacement and compression of the inferior vena cava (IVC) (arrow). (c) Axial T1-weighted MR image (500/14) demonstrates high-signal-intensity areas within the mass (arrow), a finding that is consistent with hemorrhage. (d) Axial fast spin-echo T2-weighted MR image (7,500/100) also demonstrates extensive high-signal-intensity areas within the mass (arrow), a finding that is consistent with necrosis. (e) Photomicrograph (original magnification, x100; H-E stain) demonstrates amorphous necrosis (arrows), a finding that is seen in the majority of adrenal carcinomas.

View larger version (135K): [in a new window]   Figure 7a. Adrenal carcinoma in an 11-year-old girl with Cushing syndrome and virilization. (a) Axial fast spin-echo T2-weighted MR image (5,000/105) shows a large, left-sided adrenocortical carcinoma (black arrow) and a liver metastasis (white arrow). (b) Chest CT scan shows extensive lung metastases.

View larger version (117K): [in a new window]   Figure 7b. Adrenal carcinoma in an 11-year-old girl with Cushing syndrome and virilization. (a) Axial fast spin-echo T2-weighted MR image (5,000/105) shows a large, left-sided adrenocortical carcinoma (black arrow) and a liver metastasis (white arrow). (b) Chest CT scan shows extensive lung metastases.

View larger version (132K): [in a new window]   Figure 8a. Adrenocortical carcinoma in a 45-year-old woman with a history of hypertension. (a) Contrast-enhanced CT scan demonstrates a large, heterogeneously enhancing mass in the right suprarenal region (arrow) with extension into the IVC (*). (b) Sagittal thin-section reformatted image elegantly demonstrates tumor extension into the IVC and right atrium (arrow).

View larger version (143K): [in a new window]   Figure 8b. Adrenocortical carcinoma in a 45-year-old woman with a history of hypertension. (a) Contrast-enhanced CT scan demonstrates a large, heterogeneously enhancing mass in the right suprarenal region (arrow) with extension into the IVC (*). (b) Sagittal thin-section reformatted image elegantly demonstrates tumor extension into the IVC and right atrium (arrow).

View larger version (108K): [in a new window]   Figure 9a. PPNAD in a 28-year-old man. (a, b) Delayed contrast-enhanced CT scans show small nodules in the left (a) and right (b) adrenal glands (arrows). The remaining portions of the glands do not appear hyperplastic. (c) Photomicrograph (original magnification, x200; H-E stain) (left) shows nodules of enlarged and hyperchromatic cells (hyperplastic adrenocortical cells) (arrowhead) alternating with normal adrenocortical parenchyma (A). Photomicrograph (original magnification, x200; H-E stain) (right) reveals deeply eosinophilic cells with an abundance of lipofuscin pigment (arrows) and a focal cluster of hyperchromatic cells with dark blue staining (H). The latter are hematopoietic cells and are commonly seen incidentally in normal adrenal tissue. These findings indicate the presence of PPNAD, also known as micronodular hyperplasia.

View larger version (112K): [in a new window]   Figure 9b. PPNAD in a 28-year-old man. (a, b) Delayed contrast-enhanced CT scans show small nodules in the left (a) and right (b) adrenal glands (arrows). The remaining portions of the glands do not appear hyperplastic. (c) Photomicrograph (original magnification, x200; H-E stain) (left) shows nodules of enlarged and hyperchromatic cells (hyperplastic adrenocortical cells) (arrowhead) alternating with normal adrenocortical parenchyma (A). Photomicrograph (original magnification, x200; H-E stain) (right) reveals deeply eosinophilic cells with an abundance of lipofuscin pigment (arrows) and a focal cluster of hyperchromatic cells with dark blue staining (H). The latter are hematopoietic cells and are commonly seen incidentally in normal adrenal tissue. These findings indicate the presence of PPNAD, also known as micronodular hyperplasia.

View larger version (174K): [in a new window]   Figure 9c. PPNAD in a 28-year-old man. (a, b) Delayed contrast-enhanced CT scans show small nodules in the left (a) and right (b) adrenal glands (arrows). The remaining portions of the glands do not appear hyperplastic. (c) Photomicrograph (original magnification, x200; H-E stain) (left) shows nodules of enlarged and hyperchromatic cells (hyperplastic adrenocortical cells) (arrowhead) alternating with normal adrenocortical parenchyma (A). Photomicrograph (original magnification, x200; H-E stain) (right) reveals deeply eosinophilic cells with an abundance of lipofuscin pigment (arrows) and a focal cluster of hyperchromatic cells with dark blue staining (H). The latter are hematopoietic cells and are commonly seen incidentally in normal adrenal tissue. These findings indicate the presence of PPNAD, also known as micronodular hyperplasia.

View larger version (127K): [in a new window]   Figure 10a. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (108K): [in a new window]   Figure 10b. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (108K): [in a new window]   Figure 10c. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (105K): [in a new window]   Figure 10d. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (102K): [in a new window]   Figure 10e. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (97K): [in a new window]   Figure 10f. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.

View larger version (205K): [in a new window]   Figure 10g. AIMAH in a 50-year-old man with Cushing syndrome. (a) Contrast-enhanced CT scan shows massive hyperplasia of both adrenal glands (arrows), which still retain their adreniform contour. (b, c) Axial unenhanced (b) and contrast-enhanced (c) fat-saturated spin-echo T1-weighted MR images (500/16) show intense homogeneous enhancement of the hyperplastic nodular glands. (d, e) Axial in-phase (150/4.2) (d) and out-of-phase (150/2.3) (e) FMPSPGR T1-weighted MR images (flip angle = 90°) demonstrate 42% signal dropout within the glands with the out-of-phase sequence, a finding that indicates the presence of intracellular lipid. (f) Sectioned gross resected specimen of the left adrenal gland shows marked cortical expansion with multiple nodules (arrows). (g) Photomicrograph (original magnification, x200; H-E stain) reveals sheets of largely fascicular zone cells and areas of glomerular zone cells, which have a more compact trabecular pattern. No malignant or pigmented cells are seen.