Adrenal and other retroperitoneal masses

ADRENAL AND OTHER
RETROPERITONEAL MASSES
Modified lecture presented at ESUR fall meeting 2014 in Lisbon
Philipp Steiger, Dr. med.
Oberarzt
Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie
Inselspital Bern, Schweiz
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Adrenal Mass
Normal adrenal Adrenal mass
1 2
Adrenals play a roll in imaging in 2 situations
a) adrenal mass is detected on cross-sectional
imaging (rarely on ultrasound)
a) known biochemical abnormality
1. http://radiopaedia.org/articles/adrenal-gland
2. http://radiopaedia.org/cases/adrenal-mass
ADRENAL AND OTHER RETROPERITONEAL MASSES P. Steiger 2

Adrenal Mass
a) incidental adrenal mass is detected on cross-sectional
known neoplasm no known neoplasm

Adrenal Mass

Adrenal Mass
✓ Neoplasm confirmed

Adrenal Mass
Problem: metastasis and adenomas are common
 Metastasis yes or no? or something different?

Adrenal Mass
Problem: metastasis and adenomas are common
Most common adrenal metastasis:
Lung, breast, stomach, kidney cancer, melanoma, lymphoma
Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Lam KY et al. Clin Endocrinol (Oxf). 2002 Jan;56(1):95-101

Adrenal Mass
Look carefully:
• Rule in: Other metastasis? Older images? De novo? PET?
• Rule out: Benign imaging characteristics (washout,
chemical shift)?

Adrenal Mass
Look carefully:
• Rule in: Other metastasis? Older images? De novo? PET?
• Rule out: Benign imaging characteristics (washout,
chemical shift)?
 Biopsy

Adrenal Mass
 Biopsy

Adrenal Mass
 Biopsy
Does it alter treatment? Rule out pheochromocytoma!

Adrenal Mass
 Biopsy
Does it alter treatment? Rule out pheochromocytoma!
FNA? Core needle biopsy? CT vs. US vs. MR guided

Adrenal Mass
Complications of biopsies:
• adrenal hematoma
• abdominal pain
• hematuria
• pancreatitis
• pneumothorax
• formation of an adrenal abscess
• tumor recurrence along the needle track
Clinical practice. The incidentally discovered adrenal mass. Young WF Jr. N Engl J Med. 2007 Feb 8;356(6):601-10.

Adrenal Mass
Benign imaging characteristics:
1
2
3

Adrenal Mass
1 Cyst
1
2
1. Image due to legal reasons not shown
3

Adrenal Mass
1 Cyst
2 Myelolipoma
1
2
1. Giant adrenal endothelial cyst associated with acute and chronic morbidity in a young female: a case report. Muhammad Rizwan Khan. Cases J.
2009; 2: 8841.
2. http://radiopaedia.org/articles/adrenal-myelolipoma Case 3
3

Adrenal Mass
1 Cyst
2 Myelolipoma
3 Lipid rich adenoma (<10 HU)
1
2
2. http://radiopaedia.org/articles/adrenal-myelolipoma Case 3
3. http://radiopaedia.org/cases/ctadenoma
3

Adrenal Mass
1 Cyst
2 Myelolipoma
3 Lipid poor adenoma (>10 HU)???

Adrenal Mass
1 Cyst
2 Myelolipoma
3 Lipid poor adenoma (>10 HU)???
washout

Adrenal Mass
imaging (rarely on ultrasound); ✓ Neoplasm confirmed
Diagnosis of an adenoma (CT washout)
Absolute Percentage Washout (APW)
100 x venous HU – delayed HU
venous HU – precontrast HU
Relative Percentage Washout (RPW)
venous HU
Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.

Adrenal Mass
Diagnosis of an adenoma (CT washout)
Absolute Percentage Washout (APW)
venous HU – precontrast HU
 > 60% adenoma
Relative Percentage Washout (RPW)
venous HU
 > 40% adenoma
Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls Johnson PT, Radiographics. 2009 Sep-Oct;29(5):1333-51.

Image
see below
Drawing shows the enhancement pattern of a lipid-poor adenoma.
RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.295095027
Published in: Pamela T. Johnson; Karen M. Horton; Elliot K. Fishman; RadioGraphics 2009, 29, 1333-1351.
DOI: 10.1148/rg.295095027 © RSNA, 2009
APW: 100%
(> 60% adenoma )
RPW: 52%
(> 40% adenoma )

Google search for “Adrenal wash out”
http://www.radiologytutor.com/index.php/cases/endocrine/107-
adrenalcalc
http://www-hsc.usc.edu/~phillimc/calc/adrenal_ct.html
http://www.chestx-ray.com/index.php/calculators/adrenal-characterization
http://www.radreport.org/template/0000281
http://www.braegelmann.com/bernd/scripts/adrenalgland.html

Adrenal Mass
Diagnosis of an adenoma with MR

Adrenal Mass
Diagnosis of an adenoma with MR
in/out-of-phase

Adrenal Mass
Diagnosis of an adenoma (MR signal in/opp)
Adrenal-to-spleen CSI ratio
lesion SIOP / spleen SIOP
lesion SIIP / spleen SIIP
Adrenal signal intensity index
100 x lesion SIIP / lesion SIOP
lesion SIIP
 < 0.71 adenoma
 > 16.5% adenoma
Comparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. Israel GM et al. AJR 2004; 183:215-219
Characterization of adrenal tumors by chemical shift fast low-angle shot MR imaging: comparison of four methods of quantitative evaluation. Fujiyoshi F. AJR 2002; 180

Adrenal Mass
Diagnosis of an adenoma
MR vs CT

• 15-DECT: 478 adrenal masses in 453 patients
• CSMR: 235 adrenal masses in 217 patients
RPW calculated from 15-DECT showed the highest diagnostic
performance for characterising hyperattenuating adrenal masses
regardless of underlying malignancy, and the sensitivity,
specificity and accuracy were 91.7 %, 74.8 % and 88.1 %,
respectively in all patients.
Conclusions: 15-DECT was more accurate than CSMR in
characterising hyperattenuating adrenal masses regardless of
underlying malignancy.
The value of 15-minute delayed contrast-enhanced CT to differentiate hyperattenuating adrenal massescompared with chemical shift MR imaging.
Koo HJ et al.
Eur Radiol. 2014 Jun;24(6):1410-20. Epub 2014 Mar 20.

Adrenal Mass
What else is new?

Adrenal Mass
What else is new?
• Shorter protocols (10min vs. 15min)
• Histogram analysis
• Dixon sequences (quantification of absolute fat
content)

10min vs 15min
323 adrenal lesions (213 left, 110 right)
307 adenomas and 16 nonadenomas
RPW test washout of 40%
• Sensitivity 76.9% (83%)
• Specificity 93.7% (93%)
• Accuracy 77.7% (85%)
APW test washout of 60%
• Sensitivity 52.1% (88%)
• Specificity 93.3% (86%)
• Accuracy 54.0% (88%)
„In conclusion the 10 minute delayed adrenal enhancement washout tests have reduced
sensitivity for the detection of adenomas compared with results from prior studies, and the
test sensitivity appears to be clinically suboptimal. This finding might be explained by
insufficient time for the intravenous contrast material to wash out from benign
lesions.“
Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging
protocol revisited in a large patient cohort
Sangwaiya MJ et al
Radiology. 2010 Aug;256(2):504-10

2
Computed Tomographic Histogram Analysis in the
Diagnosis of Lipid-Poor Adenomas: Comparison to
Adrenal Washout Computed Tomography.
Jhaveri, Kartik; Lad, Shilpa; Haider, Masoom; MD,
FRCPC
Journal of Computer Assisted Tomography. 31(4):513-
518, July/August 2007.
Digital Object Identifier:
10.1097/01.rct.0000250105.93423.a2
FIGURE 1 . CT histogram analysis: an ROI drawn on
adrenal nodule (left) distributes pixels on a bar graph
based on pixel attenuation (right) with pixel
attenuation on horizontal axis and number of pixels on
vertical axis. Number of pixels with negative
attenuation (negative pixels) can be obtained by
summing number of pixels with attenuation less than
zero HU (left of dotted line).
Histogram analysis
Image
see right

Histogram analysis
24 lipid-poor adenomas more than 60% absolute enhancement washout
Threshold of more than 5% negative pixels CT histogram analysis
Sensitivity 91.6%
Specificity 100%
Threshold of more than 10% negative pixels CT histogram analysis
Sensitivity 70.8%
Specificity 100%
CONCLUSIONS: Computed tomographic histogram analysis has good
potential in the diagnosis of lipid-poor adenoma and can reduce the
need to perform adrenal washout CT.
Computed tomographic histogram analysis in the diagnosis of lipid-poor adenomas: comparison to adrenalwashout computed tomography.
Jhaveri KS
J Comput Assist Tomogr. 2007 Jul-Aug;31(4):513-8.

Dixon sequence
Dixon sequence (MR spectroscopic imaging) allows discriminating between lipid
and water and further allows calculating the absolut content of fat.
20 patients with 22 adrenal tumors larger than 15 mm
15 Adenomas: Mean percentage of lipid 13.4% (SD 8%)
7 Carcinomas: Mean percentage of lipid 3.5% (SD 2%)
Only one lesion would have been misclassified on the basis of in vivo
measurements of lipid content.
„In vivoMR spectroscopic imaging of adrenal tumors appears to be useful
for differentiating between adrenal carcinomas and adenomas.“
In vivo MR spectroscopic imaging of the adrenal glands: distinction between adenomas and carcinomas larger than 15 mm based on
lipid content.
Leroy-Willig A et al.
AJR Am J Roentgenol. 1989 Oct;153(4):771-3.

Adrenal Mass
Guidelines recommend:
washout

Adrenal Mass

Adrenal Mass
✓ No known neoplasm (CT is performed for other reasons e.g. vascular, trauma)
 Incidentaloma
Medical and surgical evaluation and treatment of adrenal incidentalomas. Zeiger MA. J Clin Endocrinol Metab. 2011 Jul;96(7):2004-15.

Adrenal Mass
 Incidentaloma
Definition: Newly detected adrenal mass > 1cm
(exclude patient with cancer workup and staging)
Incidence: Up to 8.7%, correlates with number in autopsy

Adrenal Mass
 Incidentaloma
- Adenoma 41%
- Metastases 19 %
- Adrenocorctical carcinoma 10%
- Pheochromocytoma 8%
- myelolipoma✓ < -10 HU 9%
- cysts✓ and others 13%
The clinically inapparent adrenal mass: update in
diagnosis and management. Mansmann G et al.
Endocr Rev. 2004 Apr;25(2):309-40.

The clinically inapparent
adrenal mass: update in
diagnosis and management.
Mansmann G. Endocr Rev.
2004 Apr;25(2):309-40.
Image
see below

Adrenal Mass
b) : incidental adrenal mass is detected on cross-sectional imaging (rarely on
ultrasound); ✓No known neoplasm
Guidelines
• American Association of Clinical Endocrinologists and American Association of
Endocrine Surgeons Medical Guidelines for the Management of Adrenal
Incidentaloma 2009
• NIH state-of-the-science statement on management of the clinically inapparent
adrenal mass ( incidentaloma ) 2002
• Guidelines for the management of the incidentally discovered adrenal mass;
Kapoor et al., Can Urol Assoc J. Aug 2011

American Association of Clinical
Endocrinologists and American
Association of Endocrine Surgeons
Medical Guidelines for the
Management of Adrenal
Incidentaloma AACE/AAES
Adrenal Incidentaloma Guidelines,
Endocr Pract. 2009;15(Suppl 1)
Image
Algorithm for the evaluation and management of an
adrenal incidentaloma

Image
see below
Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee. Berland LL et al. JACR 2010 7, 754-773

Adrenal Mass
 Incidentaloma
Imaging can not distinguish between functioning
and nonfunctioning adrenal mass

Adrenal Mass
 Incidentaloma
Imaging can not distinguish between functioning
and nonfunctioning adrenal mass
 Endocrine tests

What happens to our reports?
Adrenal incidentalomas are common and guidelines recommend testing to exclude
functioning lesions and malignancy.
Despite guidance, actual clinical practice appears to differ among centres.
2.4 - 51% (Northern Ireland)
CT scans Adenomas Newly
identified
Seen by an
endocrinologist
2011 690 17 (2.46%) 7 (1.01%) 5 (29.4%)
2012 1264 26 (2.01%) 12 (0.95%) 4 (15.4%)
Only a few patients had been tested to exclude a functional lesion and there was
inconsistent terminology in reporting adrenal lesions. Therefore, we support
comprehensive reporting of AIs and a selective testing strategy.
Radiology reporting of adrenal incidentalomas - who requires further testing?
Paterson F
Clin Med. 2014 Feb;14(1):16-21.

Adrenal Mass
Normal adrenal Adrenal mass
Adrenals play a roll in imaging in 2 situations
a) adrenal mass is detected on cross-sectional imaging
(rarely on ultrasound)

Adrenal Mass
b) known biochemical abnormality
Clinicians tell you: “We performed blood and urine tests and found the following
biochemical abnormalities. We have a patient with…”
1) with primary hyperaldosteronism (Conn syndrome)
2) with elevated cortisol levels in urine or blood plasma (Cushing syndrome)
3) with suspicion of hyperandrogenism
4) with elevated catecholamines in urine or blood plasma

Adrenal Mass
b) known biochemical abnormality
Adrenal cortex is producing either aldosterone, glucocorticoids or androgens
and the adrenal medulla is producing catecholamines.

Mineralcorticoids (Aldosterone)
Glucocorticoids (Cortisol)
Glucocorticoids, Androgens,
Estrogens
Adrenaline, Noradrenaline
Grey‘s Anatomy

Adrenal Mass
Clinicians ask you:

Adrenal Mass
Clinicians ask you:
Is there an adrenal mass or extraadrenal mass?

Adrenal Mass
Clinicians ask you:
Is there an adrenal mass or extraadrenal mass?
Which imaging modality do we use best?

Adrenal Mass
1) with primary hyperaldosteronism.
Which imaging modality do we use?
Clinical symptoms: Drug resistance, refractory
hypertension, muscle cramping and weakness
 Screening: Plasma renin activity to plasma
aldosterone concentration
 Confirmation: Lack of suppression of
aldosterone levels after salt loading
American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of
Adrenal Incidentaloma AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15(Suppl 1)

Adrenal Mass
Primary hyperaldosteronism

Adrenal Mass
Primary hyperaldosteronism ✓ confirmed

Adrenal Mass
Imaging modality?

Adrenal Mass
Imaging modality?
MR vs. CT?

Aldosterone-producing adenoma CT vs. MR
34 Patients: CT (n=30) and MR (n=24)
Observer 1
CT
Observer 2
CT
Observer 1
MR
Observer 2
MR
Sensitivity 87% 85% 83% 92%
Specificity 93% 82% 83% 92%
interobserver agreement CT (k=0.71) and MR (k=0.67)
In conclusion, we have demonstrated comparable sensitivity and
specificity on CT and MR imaging for the detection of aldosterone-producing
adenoma in primary hyperaldosteronism. We therefore
suggest that the use of CT or MR imaging be based on the
radiologist’s experience or confidence in detecting aldosterone-producing
adenomas on these modalities.
Diagnostic performance of CT versus MR in detecting aldosterone-producing adenoma in primary hyperaldosteronism (Conn's
syndrome)
Lingam RK et al.
Eur Radiol. 2004 Oct;14(10):1787-92. Epub 2004 Jul 6.

Adrenal Mass
• Primary hyperaldosteronism

Adrenal Mass
• Primary hyperaldosteronism ✓confirmed

Adrenal Mass
• Imaging modality: MR or CT

Adrenal Mass
• Imaging modality: MR or CT ✓clear

Adrenal Mass
Adrenal mass ✓

Adrenal Mass
• Adrenal mass ✓
 problem solved?

Adrenal Mass
Clinicians ask you now:
1. Is the nodule on your scan the aldosterone
producing adenoma?
2. Idiopathic primary adrenal hyperplasia?

Adrenal Mass
What could you offer?

Adrenal Mass
What could you offer?
Adrenal venous sampling

Image
Due to legal reasons not shown
American Association of Clinical
Endocrinologists and American Association of
Endocrine Surgeons Medical Guidelines for
the Management of Adrenal Incidentaloma
AACE/AAES Adrenal Incidentaloma
Guidelines, Endocr Pract. 2009;15(Suppl 1)
Image
Algorithm for confirmation of primary aldosteronism

Adrenal venous sampling
• 203 patients with primary aldosteronism
• prospectively selected for AVS and CT findings
• 194 patients both adrenal veins were catheterized
• 110 patients unilateral aldosterone hypersecretion
N= CT findings unilateral aldosterone hypersecretion
58 normal 24 (41.4%)
47 unilateral micronodule (< or =10 mm) 24 (51.1%), 7 from the contralateral adrenal
32 unilateral macronodule (>10 mm) 21 (65.6%), 1 from the contralateral adrenal)
CONCLUSIONS:
On the basis of CT findings alone, 42 patients (21.7%) would have been
incorrectly excluded as candidates for adrenalectomy, and 48 (24.7%)
might have had unnecessary or inappropriate adrenalectomy. AVS is an
essential diagnostic step in most patients to distinguish between unilateral
and bilateral adrenal aldosterone hypersecretion.
Role for adrenal venous sampling in primary aldosteronism.
Young WF
Surgery. 2004 Dec;136(6):1227-35.

Adrenal Mass
2) with elevated cortisol levels in urine or blood plasma (Cushing
Syndrom, subclinical cushing syndrom)
Clinical Symptoms
Rapid weight gain, Moodiness, irritability, or depression Muscle and bone weakness, Memory and
attention dysfunction, Osteoporosis, Diabetes mellitus, Hypertension, Immune suppression, Sleep
disturbances, Menstrual disorders such as amenorrhea in women, Decreased fertility in men,
Hirsutism, Baldness, Hypercholesterolemia

Adrenal Mass
Screening & diagnosis:
• Late-night salivary cortisol
• Overnight 1mg dexamethasone suppression test
• 24-hour urine free cortisol

Adrenal Mass
Biochemical diagnosis

Adrenal Mass
Biochemical diagnosis
Imaging still needed or what clinicians want to know ?

Adrenal Mass

Adrenal Mass
Unilateral disease (adenoma, adenoma within a myelolipoma, adenoma of
uncertain malignant potential, carcinoma)
Bilateral disease (including primary pigmented nodular adrenal dysplasia
(PPNAD)
(ACTH-independent macronodular hyperplasia (AIMAH))

Adrenal Mass
3) with suspicion hyperandrogenism, hyperestrogenism

Adrenal Mass
3) with suspicion hyperandrogenism, hyperestrogenism
Condition which is rarely caused by a primary
adrenal mass
Imaging is not the main diagnostic workup

Adrenal Mass

Adrenal Mass
Clinical symptoms
Skin sensations. Flank pain. Elevated heart rate. Elevated blood pressure, including paroxysmal (sporadic, episodic)
high blood pressure. Orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in
diastolic blood pressure greater than 10 mmHg upon standing) Palpitations. Anxiety, often resembling that of a panic
attack- Diaphoresis (excessive sweating) Headaches – most common symptom: Pallor. Weight loss. Localized
amyloid deposits found microscopically. Elevated blood glucose levels.
http://en.wikipedia.org/wiki/Pheochromocytoma

Adrenal Mass
Clinical symptoms
Skin sensations. Flank pain. Elevated heart rate. Elevated blood pressure, including paroxysmal (sporadic, episodic)
high blood pressure. Orthostatic hypotension (a fall in systolic blood pressure greater than 20 mmHg or a fall in
diastolic blood pressure greater than 10 mmHg upon standing) Palpitations. Anxiety, often resembling that of a panic
attack- Diaphoresis (excessive sweating) Headaches – most common symptom: Pallor. Weight loss. Localized
amyloid deposits found microscopically. Elevated blood glucose level
 Suspicion of pheochromocytoma
http://en.wikipedia.org/wiki/Pheochromocytoma

Adrenal Mass
Diagnosis
American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal
Incidentaloma AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15(Suppl 1)

Adrenal Mass
Diagnosis
a) 24 hour urine collection
for catecholamines
for total or fractionated metanephrine

Adrenal Mass
Diagnosis
for catecholamines
b) More recently plasma free metanephrine and normetanephrine

Adrenal Mass
Diagnosis
for catecholamines
Why imaging?

Adrenal Mass
Diagnosis
for catecholamines
Why imaging?
 Localisation DD Paraganglioma

Adrenal Mass
Recommendations:
Endocrine Society: Suggest CT rather than MRI as the first-choice imaging
modality because of its excellent spatial resolution for thorax, abdomen, and pelvis
American Association of Clinical Endocrinologists and American Association
of Endocrine Surgeons Medical Guidelines for the Management of Adrenal
Incidentaloma: Either may be used as the definitive imaging study, depending on
availability, cost, and patient preference., MIBI not mentioned
The North American Neuroendocrine Tumor Society Consensus Guideline for
the Diagnosis and Management of Neuroendocrine Tumors (NANTES) Either
computed tomography (CT) or magnetic resonance imaging (MRI) is recommended
for initial tumor localization, with MRI preferred in children and pregnant or lactating
women because of concerns regarding radiation exposure.

Pheochromocytoma
1. http://radiopaedia.org/cases/pheochromocytoma
1

Pheochromocytoma
“First, adenomas usually are more enhancing in the venous
than in the arterial phase or have equivalent enhancement
across phases. Second, a mass that is greater than 110-HU
enhancing in the arterial phase, particularly with higher
enhancement in the arterial phase, is most likely a
pheochromocytoma. Third a pheochromocytoma are more
likely to be heterogeneous than are adenomas.”
MDCT of Adrenal Masses: Can Dual-Phase Enhancement Patterns Be Used to Differentiate Adenoma and Pheochromocytoma-
Northcutt BG et al.
AJR 2013; 201:834-839

Pheochromocytoma
~ 10% extra-adrenal
~ 10% bilateral
~ 10% malignant
~ 10% found in children
~ 10% familial
~ 10 % not associated with hypertension

Other retroperitoneal masses:

Image
see below
Figure 1 Drawing of the anatomy of the retroperitoneal spaces at the level of the kidneys. The anterior pararenal space (APRS) is located between the
parietal peritoneum (PP) and the anterior renal fascia (ARF) and contains the pancreas (Pan), the ascending colon (AC), and the descending colon
(DC). The posterior pararenal space (PPRS) is located between the posterior renal fascia (PRF) and the transversalis fascia (TF). The perirenal space
(PRS) is located between the anterior renal fascia and the posterior renal fascia. Ao = aorta, IVC = inferior vena cava, LCF = lateroconal fascia.
RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.314095132
Published in: Prabhakar Rajiah; Rakesh Sinha; Carlos Cuevas; Theodore J. Dubinsky; William H. Bush Jr; Orpheus Kolokythas; RadioGraphics 2011,
31, 949-976. DOI: 10.1148/rg.314095132 © RSNA, 2011

RadioGraphics,
http://pubs.rsna.org/doi/abs/10.1148/
rg.314095132
Published in: Prabhakar Rajiah;
Rakesh Sinha; Carlos Cuevas;
Theodore J. Dubinsky; William H.
Bush Jr; Orpheus Kolokythas;
RadioGraphics 2011, 31, 949-976.
DOI: 10.1148/rg.314095132 ©
RSNA, 2011
Image
see below

Other retroperitoneal masses:
• MR vs. CT?
• Complications: Infiltration / Mass effect on adjacent organs
• Orphan disease! Evidence?
• Core needle biopsy
• Referral to a more specialised centre

Take home message
• Adenoma and metastasis are common
know how to differentiate them
• Other adrenal lesion are rare
use the right imaging technique
• Other retroperitoneal masses
biopsy

Adrenal and other retroperitoneal masses

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