Slideshow
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Slide 1
A 63-year-old man with history of a pT2N0M0 Stage II Grade 3 clear cell renal cell carcinoma who had undergone a laparoscopic left radical nephrectomy 18 months ago is found to have a new right adrenal mass.
The mass measures 3 cm in diameter and demonstrates an attenuation of 25 HU on non-contrast computed tomography (CT) scan.
A CT 15-minute adrenal washout study is performed and demonstrates 65% absolute washout characteristics.
Submit your diagnosis to see full explanation.
Classically, adrenal masses that “washout,” or lose more than 40%-60% of contrast enhancement 15 minutes after the contrast bolus, are managed as adenomas, since the specificity of an adrenal washout study is extremely high.1-9
Recent data, however, reveal that RCC (and hepatocellular carcinoma) metastases can exhibit washout characteristics identical to lipid-poor adenomas.10 These new findings have important clinical implications.
Answer: Given washout characteristics, the lesion is not a metastasis
This case was prepared by Alexander Kutikov, MD, of Fox Chase Cancer Center in Philadelphia.
References
- Grumbach MM, Biller BMK, Braunstein GD, et al. Management of the clinically inapparent adrenal mass (“incidentaloma”). Ann Intern Med 2003;138:424-429.
- Szolar DH, Korobki M, Reittner P, et al. Adrenocortical carcinomas and adrenal pheochromocytomas: Mass and enhancement loss evaluation at delayed contrast-enhanced CT. Radiology 2005;234:479-485.
- Korobkin M, Brodeur FJ, Francis IR, et al. CT time-attenuation washout curves of adrenal adenomas and nonadenomas. Am J Roentgenol 1998;170:747-752.
- Pena CS, Boland GW, Hahn PF, et al. Characterization of indeterminate (lipid-poor) adrenal masses: Use of washout characteristics at contrast-enhanced CT. Radiology 2000;217:798-802.
- Israel GM, Korobkin M, Wang C, et al. Comparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. Am J Roentgenol 2004;183:215-219.
- Haider MA, Ghai S, Jhaveri K, et al. Chemical shift MR imaging of hyperattenuating (>10 HU) adrenal masses: does it still have a role? Radiology 2004;231:711-716.
- Boland GW, Blake MA, Hahn PF, et al. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology 2008;249:756-775.
- Hussain HK, Korobkin M. MR imaging of the adrenal glands. Magn Reson Imaging Clin N Am 2004;12:515-544.
- Kutikov A, Crispen PL, Uzzo RG. Pathophysiology, evaluation, and medical management of adrenal disorders. In: Campbell-Walsh Urology, 10th ed. Edited by Wein AJ, Kavoussi LR, Partin AW, et al. Philadelphia: Elsevier, p. in press, 2011
- Choi YA, Kim CK, Park BK, Kim B. Evaluation of adrenal metastases from renal cell carcinoma and hepatocellular carcinoma: use of delayed contrast-enhanced CT. Radiology 2013;266:514-520.
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