Gray Scale Ultrasonography of Adrenal Neoplasms

MICHAEL E. BERNARDINO,’ HARVEY M. GOLDSTEIN, AND BARRY GREEN

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Ultrasonic characteristics of 21 adrenal neoplasms (19 pa- shape with smooth contours. One primary lesion had a
tients) examined by gray scale ultrasonography are reviewed. tonguelike projection anterior to the kidney (fig. 3).
The significance of the adrenal-renal cleavage plane is dls- Another patient with metastatic lung carcinoma demon-
cussed. In our experience the cleavage plane only has defl- strated acoustical shadowing behind the mass related to
nite localization value when it separates the adrenal gland
calcifications within the lesion (fig. 4).
from the kidney on all uftrasonographic sections. Compres-
An echogenic cleavage plane through the entire adre-
slon of the posterior wall and/or anterior displacement of the
inferior vena cava was seen In about two-thirds of the right
nal-renal interface was definable in nine lesions (fig. 3).
adrenal tumors. The difficulty in examining left adrenal The cleavage plane was partial in four and not demon-
masses is emphasized. Ultrasonography has proved to be an strated in eight (fig. 5). In nine right adrenal masses, a
excellent screening procedure for adrenal tumors. similar echogenic interface was noted between the liver
and adrenal lesion (figs. 2 and 3). The interface was
Although ultrasonography of the adrenal gland is used partial in one and not observed in three masses.
for evaluation of clinically suspected adrenal masses [1- Nine of the 13 right adrenal masses demonstrated
6], only a few reports have documented its effectiveness either anterior bowing of the inferior vena cava and/or
with gray scale equipment [7, 8]. We review our expeni- impression upon the posterior wall of the inferior vena
ence with 21 adrenal neoplasms, stressing the ultrason- cava (figs. 4 and 6). The inferior vena cava was not
ographic features which have proved most helpful as observed in three patients and appeared normal in one
well as the diagnostic pitfalls. adrenal lesion.

Case Material Discussion

The series included 19 individuals with 21 proven The adrenal glands lie cephalad, anterior, and some-
adrenal neoplasms. The 11 males and eight females what medial to both kidneys. The right adrenal has a
ranged in age from 7 months to 70 years. Histologic triangular shape and the left is slightly cnescentic. Nei-
proof was available by percutaneous biopsy, surgery, or thor is usually greater than 3 cm in any dimension. The
autopsy in seven patients. In the other 12, at least two of right gland is posterior to the inferior vena cava while
the following modalities were used for diagnostic conf in- the left adrenal is located to the left of the aorta; these
mation : intravenous urography, angiography, radionu- features prove to be valuable landmarks on cross-sec-
clide adrenal imaging, and computed tomography. There tional imaging. With standard scanning techniques and
were 13 right adrenal masses and eight on the left. Of presently available equipment, only lesions of 3 cm or
the 19 patients, three had primary adrenal carcinoma, larger can be reliably imaged, although normal adrenal
four had neuroblastoma, and 12 had metastases. In the
patients with metastases, the primary tumors were lung
carcinoma in six, breast carcinoma in four, and mela-
noma in two.
All patients were examined by gray scale technique
utilizing progressive generations of a commercially avail-
able scanner. A 2.25 or 3.5 MHz internally focused
transducer was used, depending on patient size. In the
majority, recording was accomplished with a 70 mm
camera. Scans were obtained at 1 cm intervals or less in
both the longitudinal and transverse supine positions.
Slightly oblique planes were frequently used to optimally
visualize adrenal-renal interfaces. Nine patients were
also examined in the prone position as indicated. ...

Ultrasonographlc Features

Tumors ranged in size from 4-25 cm (figs. 1 and 2),

and all displayed solid echo characteristics with no focal Fig. 1.-Supine oblique longitudinal scan through 4 x 2 cm right
cystic areas. The massestended to have a round to ovoid adrenal neuroblastoma (arrowheads). L = liver, K = right kidney.

Received October 18, 1977; accepted after revision January 5, 1978.

All authors: Department of Diagnostic
I Radiology. University of Texas System Cancer Center, M. D. Andsreon Hospital and Tumor InstItute,
Houston, Texas 77030. Address reprint requests to M. E. Bernardino.

Am J Ro.ntg.nol 130:741-744, AprIl 1978 741 0361 -803X/78/0400 - 0741 $02.00

© 1978 American Roentgen Ray Society
 742 BERNARDINO ET AL.
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,. _.et.#{149} !1
Fig. 4.-Calcified right adrenal metastases from lung carcinoma.
Supine longitudinal sonogram demonstrates mass (M) indenting poste-
nor vena cava. Note several sharp bands of acoustical shadowing behind
Fig. 2.-Right adrenal
metastatic lesion from lung primary tumor.
small calcifications.
Supine longitudinal scan
through largest mass (M) in series. Mass is
sharply margmnated . contains internal echoes, and is clearly separated
from liver (L) and kidney (K).

Fig. 5.-Supine longitudinal scan through left adrenal neuroblastoma

(M). There is no cleavage plane between mass and left kidney.

Fig. 3.-Supine longitudinal sonogram through primary right adrenal

carcinoma (M). Note cleavage plane between undersurface of liver (L)
and upper pole of kidney (K).

glands have been visualized by the decubitus oblique

method described by Sample [9].
The importance of cleavage planes to determine the
anatomic origin of a supranenal mass has been stressed
[7, 8]. This may be an echogenic interface between the
adrenal and kidney or adrenal and liver. In our series
using gray scale ultrasound, an adrenal-renal interface
through the entire mass was seen in less than half the
lesions. In our experience, a cleavage plane only has
definite localization value when it separates the adrenal
Fig. 6.-Supine longitudinal sonogram, 2 cm to right of midline,
gland from the kidney on all ultrasonographic sections. showing solid right adrenal mass (M) representing metastasis from lung
If an echogenic interface is not seen on all sections, carcinoma. Mass is compressing and anteriorly bowing inferior vena
cava.
accurate differentiation of an adrenal from an upper pole
renal mass is more difficult (fig. 7). Similarly, a cleavage
between the adrenal mass and liver was observed in tumor. Thus, even though a mass may appear anatomi-
about two-thirds of our right adrenal lesions. However, cally discrete from adjacent structures by virtue of an
despite its presence, we are aware that at least one of echo interface, focal invasion of adjacent organs may be
these cases had local invasion of the liver by the adrenal present.
 GRAY SCALE ULTRASONOGRAPHY OF ADRENAL NEOPLASMS 743
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Fig. 7.-Supine longitudinal sonograms on two patients with masses (M) in right suprarenal region. Both demonstrate poor “renal-mass” interface.
A, Adrenal metastasis. B, Renal cell carcinoma.

!
Fig. 8.-Prone longitudinal sonogram, 6 cm to left of midline, showing Fig. 9.-Prone longitudinal scan demonstrating hypoechoic “mass”
left adrenal mass (M) containing internal echoes. Mass was not apparent anterior to upper pole of left kidney. This represents prominent median
with supine scanning. K = kidney. lower pole of normal spleen (5). a finding confirmed by computed
tomography. K = kidney.

Compression of the posterior wall and/or anterior

displacement of the inferior vena cava was seen in about Lesions of the left adrenal gland may be difficult to
two-thirds of our right adrenal tumors. To our knowl- evaluate in the supine position because of interfering
edge, this observation has not been documented previ- gas within the overlying stomach and bowel and the lack
ously. This finding might be expected since the right of an acoustical window such as the liven. As a result,
adrenal gland is located posterior to the inferior vena such masses are often seen best with prone and oblique
cava. Depending on the size of the mass, the inferior views (fig. 8). Other anatomic structures or pathologic
vena cava may be arched anteriorly or just indented processes are sometimes visualized in the region of the
without significant displacement. A variable amount of left adrenal gland and can be easily mistaken for adrenal
luminal obstruction may be present. Slight indentation masses. In particular, the spleen and lesions of the
of the posterior wall of the inferior vena cava was even pancreatic tail may be confused with left adrenal masses
seen in our smallest mass, a 4 x 2 cm neuroblastoma. [10]. The splenic “pseudomass” usually is a hypoechoic
When the inferior vena cava is anteriorly bowed or structure located cephalad and slightly anterior to the
posteriorly indented, a careful examination of the right superior pole of the kidney on prone scans. This finding
adrenal area should ensue. However, the sign is nonspe- can be seen with both normal and enlarged spleens (fig.
cific and may be seen with renal, lymph node, and other 9). When necessary, oblique views and computed to-
retropenitoneal masses. mography are of benefit in differentiating the spleen
 744 BERNARDINO ET AL.

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