Incidentally Discovered Adrenal Mass Radio Clin N Am 49 ( 2011) 361-368 Danilo Fausto
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Transcript of Incidentally Discovered Adrenal Mass Radio Clin N Am 49 ( 2011) 361-368 Danilo Fausto
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IncidentallyDiscovered AdrenalMass
Radio Clin N Am 49 ( 2011) 361-368
Danilo Fausto
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Adrenal –> adjacente aos rins ( ad-renal)
Composição
Cortical
Medular(catecolaminas)
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•Formato Y invertido , T ou V
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•Formato Y invertido , T ou V
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Incidentalomas Adrenais
•Definição (≥ 1cm, assintomáticas) •Prevalência 4% a 5%•A grande maioria das massas são benignas (adenomas mais comuns).• Sítio de metástases e neoplasias primárias
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Incidentaloma?
Benigno Metástase Maligno
Responder de maneira confiável , rápida e menor custo.
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Características
Massa
Tamanho da lesão/
crescimento
Contexto (neoplasia conhecida)
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“Certas lesões adrenais tem características benignas de imagem (específicas) que são diagnósticas à detecção e não justificam mais investigação”
“Estudos de imagem prévios são extremamente importantes pois estabilidade implica benignidade…”
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Características
Malignas
•Necrose central•Atenuação heterogênea•Margens irregulares• História de malignidade
Benignas
•Realce homogêneo•Densidade baixa•Margens bem definidas•Tamanho
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Figure 2: Axial contrast-enhanced CT scan demonstrates 5.8-cm irregular heterogeneous right adrenal metastasis (arrow) that invades adjacent liver in 51-year-old. woman with lung cancer.
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Myelolipoma in 46-year-old woman. (a) Axial contrast-enhanced CT scan shows 3.5-cm right adrenal mass composed primarily of fat anteriorly (long arrow) and mixed elements posteriorly (short arrow)
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Mielolipoma em uma mulher de 74 anos de idade. Tomografia computadorizada axial com contraste mostra um a adrenal à direita com 9 cm que contém uma grande quantidade de gordura e um pequena componente de partes moles, com diagnóstico de um mielolipoma.
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Tipos de tumores
Tumores primários da cortical•Adenoma•Carcinoma adreno-cortical•Mielolipomas*
Tumores da medular •Feocromocitoma•Neuroblastoma
Outros tumores primários•Leiomiomas
•Linfomas•Metastases
Outras lesões•Cistos•Hiperplasia adrenal
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Massas adrenais maiores que 4 cm serão ressecadas, exceto nos casos de lesões com etiologia bem definidas ( cistos, sangramento, mielolipomas, adenomas).
História de malignidade é o dado mais importante na propedêutica dos incidentalomas adrenais.
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Metástases•Importância
•Estadiamento
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Avaliação da massa
TC RNM PET*
BIÓPSIA
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• Adenomas quantidade variável de gordura.
•70% dos adenomas possuem lipídios intracitoplasmáticos e podem ser diagnosticados na TC sem contraste.
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Lipid-rich adenoma in 47-year-old man. Axial unenhanced CT image shows a well-defined 1.8-cm left adrenal mass with attenuation of 2 HU.
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CISTO ADRENAL
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•Outros parâmetros de avaliação dos adenomas à TC.•Histograma de Pixels
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•Outros parametros de avaliação dos adenomas à TC.•Histograma de Pixels
*Hoje em dia não é usado rotineiramente devido a diferentes resultados nos estudos de acompanhamento ( follow-up).
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•Outros parâmetros usados para diferenciar o adenomas de lesões não adenomatosas
•Características no wash-out.
•Depois de realce com contraste intravenoso, osadenomas perdem contraste mais rapidamente, enquanto a lavagem das metástases é mais prolongada.
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APW ( porcentagem absoluta de wash-out)RPW ( porcentagem relativa de wash-out)
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APW > 60%RPW > 40%
Diagnósticos de Adenoma
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APW = 50 – 12,5/ 50 – 4 X 100
82%
RPW = 50-12,5 / 50 X 100
75%
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Axial CT scans of right adrenal metastasis in 71-year-old man with lung cancer. (a) Unenhanced scan shows 4.2-cm heterogeneous mass (arrow) withattenuation of 44 HU. (b) On dynamic contrast-enhanced scan, mass has attenuation of 73 HU. (c) On 15-minute delayed scan, mass has attenuation of 69 HU. APW andRPW are 14% and 5%, respectively, consistent with nonadenoma.
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RM Técnica – Chemical Shift ( CS )
Depende da presença de lipídios intra-citoplasmáticos
Queda de sinal ( parâmetro – baço)
Diferenciar adenomas de metástases
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1.5-cm right adrenal adenoma in 67-year-old man. (A) T1-weighted in-phase MR image shows a rightadrenal mass that is mildly hyperintense relative to the spleen. (B) T1-weighted opposed-phase MR image showsmarked signal intensity loss relative to the spleen, diagnostic of an adenoma.
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TC X RM
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PET
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Adrenal metastasis in 82-year-old man with non-small cell lung cancer. (A) Axial unenhanced CT image shows a 5-cm right adrenal mass. (B) Axial CT and PET coregistered image shows markedly increased FDG uptakein the right adrenal metastasis.
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Biópsia Adrenal*•Número diminuindo
•Casos inconclusivos
•Crescimento anormais
*Dosar metanefrinas antes
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•Conseguiu caracterizar como benigno – encerrado. •Massas < 4 cm e estáveis no ultimo ano – não é necessário mais exames de imagem.
•Se crescer : biópsia ou ressecção.
•Pacientes sem história de câncer e sem exames anteriores para comparação com características totalmente benignas – repetir TC ou RM após 12 meses.
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Conclusão
•Incidentalomas adrenais são mais comuns
•Ter parâmetros criteriosos para indicar exames de imagem.