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Adrenocortical adenoma

Case contributed by Mohamed Abdel-Tawab Mohamed
Diagnosis certain

Presentation

Uncontrolled diabetes and hypertension, weight gain mainly in the abdomen with moon face, polyphagia, hair loss, bone pain and loss of teeth.

Patient Data

Age: 30 years
Gender: Female
ct
  • left suprarenal mass lesion is seen measuring 4.7 x 3.6 x 4.2 cm. It shows homogeneous postcontrast enhancement with clear fat planes around.
  • it shows enhancement as follows:
    • unenhanced phase = 37 HU.
    • enhanced phase = 71 HU.
    • delayed phase = 45 HU.
    • absolute washout = 76 %
  • liver: mildly enlarged with marked diffuse fatty infiltration

Histopathology:

  • nature of specimen : left adrenalectomy
  • gross : adrenalectomy specimen measured 7 x 5 x 4 cm and weighing 50 rims, surrounded by normal looking fatty tissue measured 0.5 cm at maximum thickness serialing showed nodule with orange yellow colourr measured 5 x 4 x 3 cm (capsule was inked black).
  • microscopic:  sections examined from the specimen received revealed a circumscribed mass formed of groups of adrenocortical cells, mostly arranged in an acinar and trabecular pattern with clear or eosinophilic cytoplasm and central rounded nuclei. There is moderate vascularity. There are focal cystic changes. No nuclear atypia. No necrosis. No malignancy.

Case Discussion

  • pathologically proven left adrenocortical adenoma, presented as a functioning adenoma with the manifestation of Cushing disease.
  • CT protocol in such cases is CT washout which has two types; absolute and relative. The absolute one can only be calculated when you have a non-contrast phase where CT washout = (Enhanced CT - Delayed CT) / (Enhanced CT - unenhanced CT) x 100%.
  • relative washout (non-contrast is not done) = (Enhanced CT - Delayed CT) / (Enhanced CT) x 100%.
  • the enhanced phase is acquired at 60 sec while the delayed phase is at 15 minutes.
  • to diagnose adrenal adenoma according to the above mentioned CT washout rate, we need:
  • in our case, the absolute washout was 76%, diagnostic of adrenal adenoma.
  • the essential step in obtaining accurate CT washout after adjusting the CT phases is to fix the level and size of ROI (region of interest). To fix the level of measurement, scanning should start from the same level in all phases in order to obtain measurements in the same numbered slice, otherwise, you should adjust the level manually considering the respiratory movement of abdominal organs. The other point is to fix the size of ROI by propagating or duplicating it in the other phases. 
  • the made fatty infiltration of the liver is attributed to manifestations of Cushing disease.

 

Thanks to Dr. Mostafa Ahmed Sayed Hamada

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