Diagnostic ultrasound ( PDFDrive )

426 PART II Abdominal and Pelvic Sonography
ater adenomas. 53 In an autopsy series involving 464 patients
with adrenal metastases over a 30-year period, Lam and Lo found
that 90% of the lesions were carcinoma, of which 56% were
adenocarcinomas. he most common primary tumor site was
the lung at 35%. 51 Adrenal metastases can also be secondary to
malignancies of breast, hepatocellular, thyroid, renal, pancreatic,
gastrointestinal, or melanoma origins. Direct invasion of the
adrenal gland can also be seen in some cases of renal cell and
hepatocellular carcinomas. In these cases, the aggressive tumors
disrupt fascial planes and invade the adrenal gland.
FIG. 11.11 Large Adrenocortical Carcinoma. Sagittal sonogram
of the left lank shows a large heterogeneous solid mass anterior to
the left kidney.
FIG. 11.12 Adrenocortical Carcinoma. Transverse sonogram shows
a heterogeneous large lobulated right adrenal mass (calipers).
Sonographic Features
Metastatic lesions are variable in size, oten with ill-deined
borders and inhomogeneously hypoechoic features (Fig. 11.13).
Bilateral lesions are seen in 40% of cases and oten occur in
patients with metastatic disease elsewhere. Many metastatic lesions
are large, greater than 4 cm in size, with irregular shape and
features of cystic necrosis. In some cases, metastases can appear
small and homogeneously hypoechoic and thus be mistaken for
benign adenomas on sonography. herefore when adrenal lesions
are identiied in patients with known malignancy, further CT
or MRI characterization should be pursued to determine if the
lesion meets the criteria for an adenoma. 54 In cases of direct
invasion of the adrenal gland by adjacent primary malignancy,
it may be diicult to distinguish the adrenal gland from the
primary tumor on ultrasound (Fig. 11.14).
Lymphoma
Adrenal involvement in lymphoma is most commonly seen as
secondary involvement from lymphomatous disease elsewhere,
with an estimated prevalence of 5% and up to 35% in autopsy
cases. 53,55 Primary adrenal lymphoma is rare, with fewer than
200 cases reported in literature. 56,57 Primary adrenal lymphoma
is most commonly seen in older men, with a mean age of 65
years. 47 Non-Hodgkin lymphoma is more common than Hodgkin
lymphoma, of which the difuse large B-cell subtype is most
common. 58 he most common clinical manifestation of adrenal
lymphoma is adrenal insuiciency, which can be seen in up to
two-thirds of cases. Patients can also present with hypoglycemia,
hyponatremia, or Addisonian crisis. 59 Some patients may also
have nonspeciic symptoms of pain and fever. Hepatosplenomegaly,
lymphadenopathy, and bone marrow involvement are
A B C
FIG. 11.13 Adrenal Metastasis in Three Different Patients. (A)-(C) Sagittal sonograms show heterogenous adrenal mass.