DAVID SUTTON PICTURES THE ADRENAL GLANDS ONLY FOR STUDY PURPOSE

1. 27
THE ADRENAL GLANDS
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 27.1 Arterial supply of the adrenals. I.P. =
inferior phrenic artery; a = superior phrenic
artery; b = middle adrenal artery; c = inferior
adrenal artery.

4. • Fig. 27.2 Venous drainage of the adrenal
gland. R.A.V. = right adrenal vein; L.A.V. = left
adrenal vein; L.R. = left renal vein; LV.C. =
inferior vena cava; R.R. = right renal vein.

5. Fig. 27.3 Tracing from a photograph of neonatal
kidneys and adrenals; the latter are relatively
large compared with adult adrenals, being
one-third the size of the kidneys.

6. • Fig. 27.4 Normal adrenals as shown by CT (see text). (A) Section
just above right kidney. In this example the right adrenal has well-
marked lateral and medial limbs. The top of the left adrenal is also
shown behind the pancreas, although frequently it is not seen at
this level (L43, W512). (B) Section including top of left kidney. The
left adrenal resembling an arrowhead is well seen, as is the right
adrenal, although the limbs now appear shorter (L43, W572). (C)
Section at slightly lower level, including tops of both kidneys (L43,
W572). Note that the adrenals are separated from the kidneys by
fatty aerials tissue.

7. • Fig. 27.4 Normal adrenals as shown by CT (see text). (A) Section just
above right kidney. In this example the right adrenal has well-marked
lateral and medial limbs. The top of the left adrenal is also shown behind
the pancreas, although frequently it is not seen at this level (L43, W512).
(B) Section including top of left kidney. The left adrenal resembling an
arrowhead is well seen, as is the right adrenal, although the limbs now
appear shorter (L43, W572). (C) Section at slightly lower level, including
tops of both kidneys (L43, W572). Note that the adrenals are separated
from the kidneys by fatty aerials tissue.

8. • Fig. 27.5 Calcified adrenals in a child. These
were a chance finding, the IVP being
performed for urinary infection.

9. • Fig. 27.6 Adrenal calcification (arrows) from
tuberculosis on CT scan. (Courtesy of Dr J. P.
R. J enkins.)

10. • Fig. 27.7 Ultrasound scan showing echogenic
suprarenal neuroblastoma (arrows). (Courtesy
of Dr C. Dicks-Mireaux.)

11. • Fig. 27.8 Normal adrenal glands shown by
MRI (T,-weighted). (Courtesy of Professor
Graham Cherryman.)

12. • Fig. 27.9 Low-density rounded mass in left-
adrenal of a 26-year-old woman with a clinical
suspicion of a phaeochromocytoma (arrow) on a
coronal T,-weighted spin-echo (SE 560/25) image.
Note the clinically unsuspected bilateral renal
cysts (c)-von Hippel-Lindau disease. (Courtesy of
Dr R. W. Whitehouse.)

13. • Fig. 27.10 Needle biopsy of right adrenal
tumour under CT control with patient prone.
Histology: adenocarcinoma from bowel (L36,
W256).

14. • Fig. 27.11 Cushing's disease.
Seleno-nor-cholesterol scintigraphy showed
bilaterally symmetrical adrenal activity confirming
pituitary-driven hyperplasia. CT had shown a
unilateral adrenal nodule which proved to be
non-functioning. L= liver; C = activity in colon.

15. • Fig. 27.12 Conn's syndrome. (A) Right-sided
nodule shown at CT. (B) Seleno-nor-
cholesterol scintigraphy showed a
corresponding unilateral functioning adenoma
(posterior view, day 7). (C) DMSA scintigraphy
was used to confirm the anatomical location
of the abnormal focus (posterior view, day 7).

16. • Fig. 27.13 Conn's syndrome. (A) CT revealed a
left unilateral nodule. (B) Seleno-nor-cholesterol
scintigraphy showed bilateral symmetrical activity
(posterior view, day 7). Diagnosis: nodular
hyperplasia of the adrenals. (C) DMSA
scintigraphy was used to confirm the anatomical
location of the adrenals (posterior view, day 7).

17. • Fig. 27.14 Phaeochromocytoma. (A)
Heterogeneous mass shown on MRI (arrows).
(B) This was confirmed to be a highly active
functioning tumour on mlBG scintigraphy.

18. • Fig. 27.15 Cystic phaeochromocytoma. (A) An
atypical tumour shown on CT as a loculated
cystic mass, and (B) confirmed on posterior
view mIBG scintigraphy as an actively
functioning tumour of the adrenal medulla.

19. • Fig. 27.16 Malignant phaeochromocytoma.
(A) Non-specific appearance of liver
metastases on CT, and (B) shown on mIBG
scintigraphy to be functioning adrenal
metastases.

20. • Fig. 27.17 Neuroblastoma. Posterior view
mIBG appearances in two cases showing
intense uptake in the tumours. (Courtesy of
Dr. I. Driver).

21. • Fig. 27.18 Paraganglioma. (A) CT showed a
non-specific tumour anterior to the aorta
which was found to be intensely active on (B)
mIBG scintigraphy.

22. • Fig. 27.19 (A) MR T2-weighted axial section shows a large heterogeneous
mass above the left kidney. Neuroblastoma. Sagittal (C) and coronal (B) T 1
-weighted spin-echo (TR/TE 400/15 ms) images showing multiple
ganglioneuromas. (C) A large right dumb-bell shaped paravertebral mass
extends across to the left. In (B) the mass is seen to extend anterior to the
spine with displacement of the aorta, and it also extends posteriorly into
the spinal canal. There is destruction and collapse of the body of one of
the lower thoracic vertebra. Another ganglioneuroma is present in the left
intercostal region and is well shown in (C). (Courtesy of Dr C. Dicks-
Mireaux.)

23. • Fig. 27.19 (A) MR T2-weighted axial section shows a large heterogeneous mass
above the left kidney. Neuroblastoma. Sagittal (C) and coronal (B) T 1 -weighted
spin-echo (TR/TE 400/15 ms) images showing multiple ganglioneuromas. (C) A
large right dumb-bell shaped paravertebral mass extends across to the left. In (B)
the mass is seen to extend anterior to the spine with displacement of the aorta,
and it also extends posteriorly into the spinal canal. There is destruction and
collapse of the body of one of the lower thoracic vertebra. Another
ganglioneuroma is present in the left intercostal region and is well shown in (C).
(Courtesy of Dr C. Dicks-Mireaux.)

24. • Fig. 27.20 Contiguous
postcontrast CT scans
showing a small right
adrenal adenoma (a).
Note this small
adenoma is only
visible on one of the
adjacent scans.
Normal left adrenal
gland. (Courtesy of Dr
J. P. R. Jenkins.)

25. • Fig. 27.21 (A) Ultrasound scan shows a large
irregular mass (arrows) above the right kidney.
Adrenal carcinoma. K = kidney. (B) CT shows the
mass extending anteriorly and invading muscle
posteriorly. Ao = aorta. (Courtesy of Dr Janet
Murfitt.) (C) MR T 2 -weighted coronal sections
show a large, mainly low-density mass above the
left kidney. Carcinoma of left adrenal.

26. • Fig. 27.21 (A) Ultrasound scan shows a large irregular
mass (arrows) above the right kidney. Adrenal
carcinoma. K = kidney. (B) CT shows the mass
extending anteriorly and invading muscle posteriorly.
Ao = aorta. (Courtesy of Dr Janet Murfitt.) (C) MR T 2 -
weighted coronal sections show a large, mainly low-
density mass above the left kidney. Carcinoma of left
adrenal.

27. • Fig. 27.22 Adrenal carcinoma (m) surrounding
the left adrenal vein (arrow), abutting onto the
abdominal aorta (A) and infiltrating the psoas
muscle (p) on a postcontrast CT scan. (Courtesy of
Dr J. P. R. Jenkins.)

28. • Fig. 27.23 (A) Large mass in left adrenal. Note
the nodular calcification in the tumour and low-
density areas in the liver. Adrenal carcinoma
presenting with Cushing's syndrome (L36, W256).
(B) Coronal reconstruction of tumour (L38,
W128).

29. • Fig. 27.24 (A) Same patient as Fig. 27.23,
showing deposits in liver at narrow window
(L63, W64). (B) Six months later, and
following removal of adrenal tumour,
deposits have increased in size (L50, W64).

30. • Fig. 27.25 (A) Large metastasis in right
adrenal (L36, W256). (B) Bilateral metastases
(arrows) in the adrenals from bronchial
carcinoma (L45, W256).

31. • Fig. 27.26 CT scan of bilateral enlarged
adrenal glands (m) from lymphomatous
infiltration. (Courtesy of Dr J. P. R. Jenkins.)

32. • Fig. 27.27 Coronal MRI
scan (T 2 -weighted)
shows bilateral
adrenal metastases
(arrows) as high-signal
masses. Primary lung
carcinoma with
collapse of right upper
lobe is also well shown.
(Courtesy of Dr Gordon
Thomson and Bristol
MRI Centre.)

33. • Fig. 27.28 (A,B) Right adrenal lipoma (arrow).
Coronal reconstruction of and show a diagnostic
bright hyperechoic appearance. low-density mass
(-67 HU) ([46, 41024).

34. • Fig. 27.29 Adrenal cyst (c) measuring 11 HU
on a postcontrast CT scan. Normal enhancing
left adrenal gland. (Courtesy of Dr J. P. R.
Jenkins.)

35. • Fig. 27.30 (A) Bilateral adrenal hyperplasia
(L36, W512). (B,C) Hypertrophied right and
left adrenals in another patient (L36, W51 2).

36. • Fig. 27.30 (A) Bilateral adrenal hyperplasia
(L36, W512). (B,C) Hypertrophied right and
left adrenals in another patient (L36, W51 2).

37. • Fig. 27.31 (A) Left adrenal phlebogram
showing small Conn's tumour (arrow). (B)
Right adrenal phlebogram showing Conn's
tumour.

38. • Fig. 27.32 MR study. T 2 -weighted image
shows a small 1 cm adenoma (arrow) behind
the IVC. Right-sided Conn's tumour.

39. • Fig. 27.33 Left-sided Conn's tumour
measuring 1.2 cm in diameter.

40. • Fig. 27.34 Right-sided Conn's tumour 1.9 cm
in diameter. Normal left adrenal also well
shown (L36, W256).

41. • Fig. 27.35 Small left Conn's tumour 0.8 cm in
diameter and marked by white dot. (Density
20 HU-L43, W512).

42. • Fig. 27.36 Right-sided Conn's tumour shown
by scintigraphy 7 days post injection.

43. • Fig. 27.37 Inferior vena
cavography in a patient
with a large
phaeochromocytoma
lying posterior and medial
to the inferior vena cava.

44. • Fig. 27.38 Left ventricular angiocardiogram. This
patient presented with mitral incompetence. (A)
There is evidence of marked mitral incompetence. (B,
C) Pathological vessels are shown arising from the
aorta to supply a large vascular mass above the left
atrium. Phaeochromocytoma removed by surgery.

45. • Fig. 27.39 Ultrasound scan shows large
rounded tumour (arrows) above upper pole
of right kidney (Same case as Fig. 27.46.)

46. • Fig. 27.40 (A) Giant bilateral cystic
phaeochromocytoma displacing the kidneys
downward and liver upward ([36, W128). (B)
Coronal reconstruction through tumours and
downward-displaced kidneys (L36, W64).

47. • Fig. 27.41 MR T2 - weighted image shows
bilobed high-signal tumour above the right
kidney. (A) Coronal, (B,C) Axial sections. The
posteromedial segment of the tumour lay behind
the crus of the diaphragm and would have been
missed at surgery without forewarning. (Courtesy
of Dr R. Whitehouse.)

48. • Fig. 27.41 MR T2 - weighted image shows
bilobed high-signal tumour above the right
kidney. (A) Coronal, (B,C) Axial sections. The
posteromedial segment of the tumour lay behind
the crus of the diaphragm and would have been
missed at surgery without forewarning. (Courtesy
of Dr R. Whitehouse.)

49. • Fig. 27.42 Small phaeochromocytoma (arrow)
(3 cm diameter) anterior to upper pole of
right kidney (L45, W51 2).

50. • Fig. 27.43 Phaeochromocytoma (5 x 3.5 cm)
in left adrenal (arrow) L41,W256

51. • Fig. 27.44 Large phaeochromocytoma (7 x 8
cm) in right adrenal and displacing liver (L36,
W256).

52. • Fig. 27.45 Ectopic small phaeochromocytoma
(arrow) (3 cm diameter) anterior to left hilum
(L36, W256).

53. • Fig. 27.46 (A) Scintiscan using mlBG shows large
right phaeochromocytoma (12th rib marked). (B)
CT of same patient confirms a large
phaeochromocytoma (7 cm) (L45, W512). The
tumour was also shown by ultrasound (Fig.
27.39).

54. • Fig. 27.47 MR T2 -weighted (A,B) coronal sections through
kidneys and anterior to kidneys; (C) axial section. High-
signal highly vascular tumour mass lying anterior to the
hilum of the left kidney. Large drainage veins seen in (B)
phaeochromocytoma. (Courtesy of Dr Philip Gishan.)

55. • Fig. 27.47 MR T2 -weighted (A,B) coronal sections
through kidneys and anterior to kidneys; (C) axial
section. High-signal highly vascular tumour mass lying
anterior to the hilum of the left kidney. Large drainage
veins seen in (B) phaeochromocytoma. (Courtesy of Dr
Philip Gishan.)

56. • Fig. 27.48 (A) Deposits in liver (L36, W128).
(B) Glandular masses around the aorta (L36,
W256). The patient had a malignant
phaeochromocytoma removed 6 months
previously.

57. • Fig. 27.49 Sclerotic bone deposits in same
patient as Fig. 27.48.

58. • Fig. 27.50 Intrathoracic paravertebral tumour in a 12-
year-old boy shown to right of lower spine (arrow).
Further intra-abdominal tumours were shown. There
was a familial history. (Courtesy of Dr F. Starer.)