ENDOCRINE DISEASES

1. IMAGING OF ENDOCRINE DISEASES
Presented By :
Dr. Seham Adam

3. The pituitary gland (or hypophysis cerebri), together with its
connections to the hypothalamus, acts as the main endocrine
interface between the central nervous system and the rest of
the body.
Gross anatomy
The pituitary gland sits atop the base of the skull in a
concavity within the sphenoid bone called the sella turcica
(pituitary fossa), immediately below the hypothalamus and
optic chiasm.
The pituitary is usually divided (in practice) into anterior and
posterior parts

4. ANATOMY OF PITUTARY GLAND
OPTIC CHIASMA
INFUNDIBULUM
PITUTARY GLAND
CAVERNOUS SINUS

5. ANATOMY OF PITUTARY GLAND

6. ANATOMY OF PITUTARY GLAND

7. ANATOMY OF PITUTARY GLAND

9. ANATOMY OF PITUTARY GLAND

11. Normal Pituitary

12. IMAGING TECHNIQUES
High resolution (2 to 3mm thick slices)
• Sagittal T1-WI pre & post Gadolinium
• Coronal T1-WI pre & post Gadolinium
• Axial T2-WI
•Dynamic Gadolinium enhanced coronal T1-WI for small microadenoma.

13. MRI OF PITUITARY GLAND
IMAGING SEQUENCES

14. Pituitary Microadenomas are a minority of all pituitary
adenomas.
By definition, a microadenoma is less than 10 mm in size.
If the same tumor is greater than 10 mm in size, it is then
considered a pituitary macroadenoma. Differences in
presentation and imaging merely represent a difference in
size rather than any fundamental difference in biology.

15. MRI OF PITUITARY GLAND
IMAGE INTERPRETATION

16. Pituitary Macroadenomas are the most common
suprasellar mass in adults, They are defined as pituitary
adenomas greater than 10 mm in size and are
approximately twice as common as pituitary
microadenomas.
On imaging, they usually present as a solid tumor with
attenuation similar to the brain (30-40 HU) and demonstrate
moderate contrast enhancement. The same is observed on
MRI, where they are isointense to the grey matter both on T1-
and T2-weighted images. However, attenuation and signal
characteristics can significantly vary depending on tumor
components such as hemorrhage, cystic transformation, or
necrosis

17. MRI OF PITUITARY GLAND
IMAGE INTERPRETATION

18. Pituitary Adenoma

19. PITUITARY GLAND
DISEASES
Prolactinoma (high secretion of prolactin).
Acromegaly (high secretion of G.H. after 18 yrs).
Cushing Syndrome (high secretion of ACTH).

20. PITUITARY HYPOPLASIA
Failure of hypothalamic axons & surrounding
Venous plexus to connect with (anterior lobe ) adenohypophysis
• Global adenohypophyseal dysfunction.
• Preserved (posterior lobe )neurohypophyseal function
Imaging Findings:
• Small shallow sella turcica
• Small adenohypophysis.
• Ectopic Neurohypophysis.
• Midline facial & cranial anomalies

21. PITUITARY ADENOMAS:
Clinical Presentation
►Hormone hypersecretion
Acromegaly
Cushing’s Disease
Amenorrhea / Galactorrhea
►Symptoms from mass effect
Headaches
Vision loss
Pituitary gland dysfunction

22. Pituitary Adenoma

23. Prolactinoma
High serum Prolactin
1.Pregnancy
2.Stress
3.Lactation
4.Wet nursing reflex
1.Prolactinoma
2.Pituitary tumor
3.Polycystic ovaries
4.Primary hypothyroidism
5.Post herpes zoster

24. Prolactinoma
Clinical presentaion
Most Common Functional Pituitary adenoma (30-40%)
 Female : Male Prevalence-10:1, median age of diagnosis-34 yrs

25. Prolactinoma
Serum Prolactin level (ng/ml)

26. Acromegaly
• Most commonly due to pituitary adenoma
• Clinical Presentation
• enlargement of the hands, feet, nose, tongue, lips and ears
• general thickening of the skin with moist hands
• Organomegaly (especially thyroid, heart and liver)
• Characteristic thick, deep voice and slowing of speech
• Mandible: prognathism with gaping teeth

27. Acromegaly
Pituitary MRI-macroadenomas are detected in >80% of acromegaly.

28. Cushing`s
Disease
• pituitary Adenoma 60%(Cushing’s Disease)
• Ectopic source 15% (ACTH/CRH tumors)
ACTH-Dependent
75%
• Adrenal Adenomas
• Adrenal Carcinoma
• Nodular Hyperplasia (micro or macro)
ACTH-Independent
25%

29. Cushing’s Syndrome

31. Symptom of mass effect
• Headache
• Vision loss
• Pituitary hormone dysfunction
• Cranial Nerve Abnormality.

32.  Lipoma
 Pars intermedia cyst (Rathk’s Cleft cyst )
 Meningioma
 Craniopharyngioma
 Arachnoid cyst
 Apoplexy
 Sheehans` syndrome
 Aneurysm
Differential Diagnosis

33. Lipoma

34. Meningioma

35. Rathk`s Cleft Cyst
•A benign growth found on the pituitary gland in the brain, specifically a
fluid-filled cyst in the posterior portion of the anterior pituitary gland. It
occurs when the Rathke's pouch does not develop properly

36. Cranio-pharyngioma

37. Arachnoid Cyst

38. Apoplexy
acute clinical syndrome caused by either
hemorrhagic or non-hemorrhagic necrosis
of the pituitary gland. Although variable, it
typically comprises headache, visual
deficits, ophthalmoplegia, and altered
mental status. An existing pituitary
macroadenoma is usually present (60-
90%), but it has occurred with healthy
glands in a few isolated cases.

39. Sheehan’s Syndrome
Sheehan syndrome is a rare cause of pituitary
apoplexy and hypopituitarism. It only occurs in
postpartum females who experience large volume
hemorrhage and hypovolemic shock during
delivery
Clinical presentation
pituitary failure
may be silent and present with delayed hypopituitarism
• agalactorrhoea
• amenorrhea
• oligomenorrhea
• adrenal insufficiency
• hyponatremia (diabetes insipidus) in the acute setting
of extreme hypovolemia
• hypothyroidism
• growth hormone deficiency
• optic chiasm compression
• visual field loss
• headache
• ophthalmoplegia

40. Aneurysm

42. The Thyroid Gland

43. Thyrotoxicosis
Graves disease

44. Normal Ultrasound Appearance of the Thyroid
Gland
Ultrasound Appearance of Diffuse Thyroid
Enlargement (Goiter)

45. Thyrotoxicosis
Graves disease

48. Hypothyroidism
Thyroiditis

49. Ultrasound appearance of thyroid Ultrasound appearance of thyroiditis

50. Thyroid nodules
Suspicious sonographic features :
 Hypoechoic
 Micro calcification
 Infiltrative margin
 Taller than wider
 Abnormal cervical lymph node.

52. The radioactive iodine uptake test
The thyroid uptake is performed to evaluate the function of the
gland.
Low uptake suggests thyroiditis while high uptake suggests Graves
disease
Radionuclide imaging is unreliable in excluding or confirming the
presence of cancer.

53. The Parathyroid Gland

54. Parathyroid Imaging
1.Sonography
2.99mTc-sestamibi Scintigraphy
are the dominant imaging techniques for
preoperative location of parathyroid adenomas
Numerous studies comparing these techniques suggest
similar sensitivities and specificities for solitary adenoma
detection.
Localization accuracy is also improved when both
studies are obtained preoperatively

55. Ultrasound
Ultrasound is one of the most commonly used initial imaging modalities.
Greyscale
most nodules need to be >1 cm to be confidently seen on ultrasound
parathyroid adenomas tend to be homogeneously hypoechoic vs the overlying thyroid gland
an echogenic thyroid capsule separating the thyroid from the parathyroid may be seen
Doppler ultrasound
Can commonly show a characteristic extrathyroidal feeding vessel (typically a branch off the
inferior thyroidal artery 1,6), which enters the parathyroid gland at one of the poles. Internal
vascularity is also commonly seen in a peripheral distribution. This feeding artery tends to
branch around the periphery of the gland before penetration. This feature can give a
characteristic arc or rim of vascularity. The overlying thyroid gland may also show an area of
asymmetric hypervascularity that may help to locate an underlying adenoma

56. Parathyroid Adenoma

57. Parathyroid Adenoma

59. 99mTc-sestamibi Scintigraphy
Is used to localize parathyroid adenoma that cannot be localized
with other imaging modalities as ultrasound or MRI. Localization of
parathyroid
adenoma allows the surgeon to use a minimally
invasive surgical approach

60. Adrenal gland

61. Adrenal Gland
 The adrenal gland is named for it is location adjacent to the kidney : ad-renal .
 Also known as supra adrenal glands.
 Characteristic inverted Y,V or T shape.
 Situated on the posterior abdominal wall over the upper pole of the kidneys behind
the peritoneum.
 Each gland is enclosed in the peri-renal fascia and have body and two limbs.

63. Histology
Adrenal cortex-90% of adrenal composed of three
zones.
1.zona glomerulosa –outermost secretes
mineralocorticoids(aldosterone)
2.zona fasciculate- 80%-secretes cortisol.
3. zona reticulate-5-10%-secretes androgens.

64. Histology
Adrenal medulla- 10% of adrenal made up of
chromaffin cells , secretes- epinephrine or nor
-epinephrine
Part of sympathetic autonomic nervous
system

65. Normal Gland / CT , MRI

66. Anatomical landmarks:
 Right Adrenal Gland :
Superior to right kidney , medial to right lobe of liver lateral to crus of right
hemidiaphragm , posterior to IVC.
 Left Adrenal Gland :
Superior to upper pole of left kidney in triangle formed by left lateral margin of aorta,
posterior surface of body and tail of pancreas and upper pole of left kidney.

67. Imaging Modalities
Ultrasound .
Computed tomography.
Magnetic resonance imaging.
Nuclear medicine imaging.

68. Adrenal Adenoma
• most common adrenal mass lesion and are often found incidentally during abdominal imaging
• The most common disease states caused by functioning adenomas are Cushing syndrome (due
to excess cortisol production), Conn syndrome (due to excess aldosterone production)

69. Thus, tissues containing lipid and water have signal loss (i.e.,
appear darker) on out-of phase images.
Thus, on out-of phase images, the adenoma appears darker than
on in-phase images.

70. CT in Differentiating Benign from Malignant Adrenal Masses
certain imaging findings are helpful in differentiating benign from
malignant lesions.
•Larger lesions
•Change in lesion size
•The shape .
•Intracellular lipid content of the adrenal mass
represents the histologic difference between adenomas and metastases
•Differences in vascular enhancement patterns represent the physiologic
difference.
•Adenomas vigorously enhance and exhibit early washout of contrast
material compared with metastases

73. out-of phase images in-phase images
Benign lesion
Malignant lesion
in-phase images
out-of phase images

74. Adrenal Hyperplasia
nonmalignant growth (enlargement) of the adrenal glands and is a rare
cause of ACTH-independent Cushing syndrome, with unilateral adrenal
cortical adenomas being the commonest

75. Adrenal Hyperplasia
 enlarged limbs of one or both adrenal glands >10 mm thick
 normal adrenal morphology maintained

76. Adrenal Hemorrhage
Causes
 Anticoagulant therapy
 Stress
 Sepsis ( waterhouse friderichsen)
 Surgery
 Tumor
 Blunt abdominal trauma

77. Adrenal Hemorrhage

78. Adrenal Cyst

79. Adrenal Myelolipomas
 Rare benign and usually asymptomatic tumors of the adrenal gland characterized by predominant
amount of fat.
 The amount of fatty component according to soft tissue is variable

80. Adrenal Myelolipomas
The CT appearance is usually characteristic. The typical adrenal myelo-
lipoma appears as an adrenal lesion with fat-containing components with
soft tissue and punctate calcification.

81. Pheochromocytoma
• ~ 10% are extra-adrenal
• ~10% are bilateral
• ~10% are malignant
• ~10% are found in children
• ~10% are familial
• ~10% are not associated with
hypertension
• ~10% contain calcification

82. Polycystic ovaries
• Hairsutism - 70%
• Secondary Amenorrhea - 50%
• Obesity - 40%
• Abnormal uterine bleeding - 30%
• Normal menstruation - 20%
• Risk of DM2, breast and endometrial Ca
• Infertility