An Algorithmic Approach

Dr Muhammad Shoyab
Resident in Radiology
Bangabandhu Sheikh Mujib Medical University (BSMMU)
Dhaka, Bangladesh
Algorithmic Checklist
1. H/O Hyperfunction or Hypo?
2. Density / Intensity on Plain Film
3. Glands enlarged or atrophied?
4. Unilateral / Bilateral? Bilaterally symmetrical?
5. Contrast enhancement
 1. Hormonal Status
HYPER HYPO
CUSHING’S Stress
ACTH-dependent (Aldosterone ↑, Cortisol ↑, ACTH (surgery, shock, disseminated /
↑) : 80% due to hyperplasia, 20% adenoma, 5% opportunistic / atypical
CA infection)

ACTH-independent (Aldosterone ↑, Cortisol ↑, ACTH Neoplasm

OK) : PPNAH, PPNAD, AIMAH
CONN’S (Aldosterone ↑, Cortisol OK, ACTH OK) :
20% hyperplasia, 80% adenoma, CA rare
PHEO : HTN, ↑VMA
(CA, mets, lymphoma)
Autoimmunity (80% of cases in
developed countries, F>M)
Granuloma (most common
cause in underdev countries)
(SNAG = deficiency, insufficiency)
 2. Density / Intensity on Plain
 Macroscopic fat density (< -30 HU) : Myelolipoma
 2. Density / Intensity on Plain
 Macroscopic fat density (< -30 HU) : Myelolipoma
 <15 HU : Adenoma
 2. Density / Intensity on Plain
 Macroscopic fat density (< -30 HU) : Myelolipoma
 <15 HU : Adenoma
 Homogeneous fluid density : Cyst
 2. Density / Intensity on Plain
 Macroscopic fat density (< -30 HU) : Myelolipoma
 <15 HU : Adenoma
 Homogeneous fluid density : Cyst
 Varies with age in haemorrhage
 3. Enlarged or Atrophied?
MAY BE ENLARGED Limbs > 5 mm : Hyperplasia
ENLARGED Any size : Granuloma (bilaterally symmetrical); Cyst,
Lymphoma (retroperitoneal L/N)

<5 cm
Adenoma : rapid washout of contrast
Pheo : 3-5 cm, intense C+
Mets (small) : prolonged washout of contrast

>5 cm
Myelolipoma : macroscopic fat density
CA (non-func >10) : invasive
Mets (large) : no invasion, thick rim C+, het C+
AIMAH : massive size, limbs > 30 mm
ATROPHIED Autoimmunity
Chronic granuloma
 4. Bilateral Symmetry

BILATERALLY SYMMETRICAL
Granuloma (enlarged / atrophied in chronic)
Autoimmune (atrophied)
Hyperplasia (often)
 5. Contrast Enhancement Pattern

Homogeneous C+ Rim C+
Adenoma : no rim C+, rapid Granuloma (Bilat symm enlarged,
washout hypofunc)

Lymphoma : Retroperitoneal ± other Cystic degen of neopl

L/N
Mets (Thick rim, prolonged washout, het
Hyperplasia (Nodular C+) C+, no local invasion)
Heterogeneous C+ Intense C+ C—
Mets (prolonged washout, thick rim, Pheo (het) Myelolipoma
no local invasion) AIMAH (nodules) Hge
Cyst (Rim C+ in
CA : invasion degen neopl cyst)
Some Adrenal Pathologies
• Granuloma
• Hyperplasia
• Haemorrhage
• Cyst
• Adenoma
• Myelolipoma
• Pheochromocytoma
• Carcinoma
• Metastases
• Lymphoma
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged (atrophied & calcified in chronic)
4. Bilaterally symmetrical (unilateral unusual)
5. Rim C+ on CT. Little C+ on MRI
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged (atrophied & calcified in chronic)
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged (atrophied & calcified in chronic)
4. Bilaterally symmetrical
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged (atrophied & calcified in chronic)
4. Bilaterally symmetrical (unilateral unusual)
 Granuloma (TB / Fungal)
1. Hypofunction
2. Calcification, Necrosis, L/N ±
3. Enlarged (atrophied & calcified in chronic)
4. Bilaterally symmetrical (unilateral unusual)
5. Rim C+ on CT. Little C+ on MRI
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
3. Often bilaterally symmetrical
4. Homogeneous C+ (intense in AIMAH)
Outline : may be multinodular

Nuclear Imaging : NP-59 uptake

Normal : Adrenals visualised on 5th day or later
If <5 days : adenoma (unilateral), hyperplasia (bilat)
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
3. Often bilaterally symmetrical
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
3. Often bilaterally symmetrical
4. Homogeneous C+ (intense in AIMAH)
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
3. Often bilaterally symmetrical
4. Homogeneous C+ (intense in AIMAH)
Outline : may be multinodular
 Hyperplasia
1. Hyperfunction (Cushing’s / Conn’s / AIMAH)
2. Limbs > 10 mm (>30 mm in AIMAH). Glands may be
enlarged (massively enlarged in AIMAH)
3. Often bilaterally symmetrical
4. Homogeneous C+ (intense in AIMAH)
Outline : may be multinodular

Nuclear Imaging : NP-59 uptake

Normal : Adrenals visualised on 5th day or later
If <5 days : adenoma (unilateral), hyperplasia (bilat)
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
USG : Acute – hyper; chronic – anechoic, calcification.
Doppler : no vascularity
ROUNDED, distorted, with fat stranding
3. Gland size : any
4. Uni / Bilateral (trauma R>L), usually asymmetric
5. Contrast / Doppler : -ve
History & Signs of trauma / other causes [stress (surgery, shock, infection),
coagulopathy, tumour]
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
USG : Acute – hyper; chronic – anechoic, calcification.
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
USG : Acute – hyper; chronic – anechoic, calcification.
Doppler : no vascularity
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
USG : Acute – hyper; chronic – anechoic, calcification.
Doppler : no vascularity
ROUNDED, distorted, with fat stranding
 Haemorrhage
1. Hormone status : any (hypo if 90% destruction)
2. SIZE & DENSITY / INTENSITY VARY WITH AGE OF HGE
CT / MRI : Blood-blood level
USG : Acute – hyper; chronic – anechoic, calcification.
Doppler : no vascularity
ROUNDED, distorted, with fat stranding
3. Gland size : any
4. Uni / Bilateral (trauma R>L), usually asymmetric
5. Contrast / Doppler : -ve
History & Signs of trauma / other causes [stress (surgery, shock, infection),
coagulopathy, tumour]
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
3. Gland size : enlarged (50% <5 cm, can be upto 20 cm)
4. Bilateral symmetry : may be
5. Contrast : no uptake (wall C+ in degen neopl cyst)
Thick wall (upto 3 mm) & septations in complex cysts
(>3 mm wall is not degen neopl cyst but necrotic SOL)
 Simple cyst (40%)

 Pseudocyst / haemorrhagic (40%) : complex cyst, C-

 Degen neopl cyst (15%) : complex cyst, wall/septa C+

 Hydatid cyst (5%)

 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
3. Gland size : enlarged (50% <5 cm, can be upto 20 cm)
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
3. Gland size : enlarged (50% <5 cm, can be upto 20 cm)
4. Bilateral symmetry : may be
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
3. Gland size : enlarged (50% <5 cm, can be upto 20 cm)
4. Bilateral symmetry : may be
5. Contrast : no uptake (wall C+ in degen neopl cyst)
 Cyst
1. Hormone status : any
2. Homogeneous water density / intensity on plain
Calcification ±
3. Gland size : enlarged (50% <5 cm, can be upto 20 cm)
4. Bilateral symmetry : may be
5. Contrast : no uptake (wall C+ in degen neopl cyst)
Thick wall (upto 3 mm) & septations in complex cysts
(>3 mm wall is not degen neopl cyst but necrotic SOL)
 Simple cyst (40%)

 Pseudocyst / haemorrhagic (40%) : complex cyst, C-

 Degen neopl cyst (15%) : complex cyst, wall/septa C+

 Hydatid cyst (5%)

 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT
signal loss on antiphase MRI.
Rarely contain macroscopic amounts fat ( myelo/lipoma)
3. Gland size : enlarged (<2 cm in Conn’s, 2-5 cm in Cushing’s)
4. 90% unilateral
5. Contrast : homogeneous uptake (but no wall C+)
Rapid washout : >50% in 10 min (on both CT & MRI)
First D/D of asymp adrenal mass, even with known CA elsewhere.
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT,
signal loss on antiphase MRI.
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT,
signal loss on antiphase MRI.
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT,
signal loss on antiphase MRI.
Rarely contain macroscopic amounts fat ( myelo/lipoma)
3. Gland size : enlarged (<2 cm in Conn’s, 2-5 cm in Cushing’s)
4. 90% unilateral
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT,
signal loss on antiphase MRI.
Rarely contain macroscopic amounts fat ( myelo/lipoma)
3. Gland size : enlarged (<2 cm in Conn’s, 2-5 cm in Cushing’s)
4. 90% unilateral
5. Contrast : homogeneous uptake (but no wall C+)
Rapid washout : >50% in 10 min (on both CT & MRI)
 Adenoma
1. Hormone status : Normal in most cases
Hyper : 80% of Conn’s & 20% of Cushing’s are due to adenoma
2. 90% are lipid-rich : <15 HU on NECT,
signal loss on antiphase MRI.
Rarely contain macroscopic amounts fat ( myelo/lipoma)
3. Gland size : enlarged (<2 cm in Conn’s, 2-5 cm in Cushing’s)
4. 90% unilateral
5. Contrast : homogeneous uptake (but no wall C+)
Rapid washout : >50% in 10 min (on both CT & MRI)
First D/D of asymp adrenal mass, even with known CA elsewhere.
 Adenoma

Mets
Atypical Adenoma

<50% washout
Unilateral,
Hypodense <37 HU >50% washout
Adrenal Mass

>37 HU
Contrast Delayed Film (10 min)
 Myelolipoma
1. Hormone status : normal (non-func tumor, asymp pt)
2. Density : Heterogeneous (FAT + marrow ± calcification ±
soft tissue)
MACROSCOPIC FAT DENSITY (-30 HU and lower) mass
can be confidently diagnosed as myelolipoma
(Adenoma contains microscopic fat : <15 HU)
3. Gland size : enlarged (rarely >10 cm)
4. Unilateral (very rarely bilateral)
5. Contrast : no uptake
 Myelolipoma
1. Hormone status : normal (non-func tumor, asymp pt)
2. Density : Heterogeneous (FAT + marrow ± calcification ±
soft tissue)
 Myelolipoma
1. Hormone status : normal (non-func tumor, asymp pt)
2. Density : Heterogeneous (FAT + marrow ± calcification ±
soft tissue)
MACROSCOPIC FAT DENSITY (-30 HU and lower) mass
can be confidently diagnosed as myelolipoma
 Myelolipoma
1. Hormone status : normal (non-func tumor, asymp pt)
2. Density : Heterogeneous (FAT + marrow ± calcification ±
soft tissue)
MACROSCOPIC FAT DENSITY (-30 HU and lower) mass
can be confidently diagnosed as myelolipoma
(Adenoma contains microscopic fat : <15 HU)
 Myelolipoma
1. Hormone status : normal (non-func tumor, asymp pt)
2. Density : Heterogeneous (FAT + marrow ± calcification ±
soft tissue)
MACROSCOPIC FAT DENSITY (-30 HU and lower) mass
can be confidently diagnosed as myelolipoma
(Adenoma contains microscopic fat : <15 HU)
3. Gland size : enlarged (rarely >10 cm)
4. Unilateral (very rarely bilateral)
5. Contrast : no uptake
 Pheochromocytoma
1. Hormone status : HTN, High urinary VMA
2. Density : Homogeneous ± hge ± necrosis ± calcification
3. Gland size : enlarged, usu >3 cm (3-5 cm)
4. 90% Unilateral
5. Contrast : INTENSE HETEROGENEOUS

MRI : T1-hypo, T2-very hyper, C++ (salt-n-pepper pattern)

Nuclear Medicine : MIBG uptake — ↑uptake after 24-72 hrs
indicates recurrence / ectopic / mets
 Pheochromocytoma
1. Hormone status : HTN, High urinary VMA
2. Density : Homogeneous ± hge ± necrosis ± calcification
3. Gland size : enlarged, usu >3 cm (3-5 cm)
4. 90% Unilateral
5. Contrast : INTENSE HETEROGENEOUS
 Pheochromocytoma
1. Hormone status : HTN, High urinary VMA
2. Density : Homogeneous ± hge ± necrosis ± calcification
3. Gland size : enlarged, usu >3 cm (3-5 cm)
4. 90% Unilateral
5. Contrast : INTENSE HETEROGENEOUS

MRI : T1-hypo, T2-very hyper, C++ (salt-n-pepper pattern)

Nuclear Medicine : MIBG uptake — ↑uptake after 24-72 hrs
indicates recurrence / ectopic / mets
 Pheochromocytoma : Rule of 10’s

 10% extra-adrenal (aortic bifurcation & UB commonest)

 10% extra-abdominal
Associated with :
 10% bilateral VHL
NF-1
 10% in children MEN-2A, 2B

 10% autosomal dominant

 10% familial (multiple, <3 cm)
 10% malignant (difficult to differentiate; mets is a clue)
 10% normotensive
 Carcinoma
1. Hormone status : 50% func (=hyper), 50% non-func (=normal)
2. Density : Solid homogeneous ± hge ± necrosis ± calcification ± L/N ±
mets
3. Gland size : Enlarged (Func >5 cm, non-func >10 cm)
4. 90% Unilateral (L>R)
5. Contrast : Heterogeneous
invasive margin ± IVC ± L/N ± other invasion
(IVC invasion best seen on sagittal)

Angiogram : Enlarged adrenal arteries, minimal neovascularity (predominant

neovascularisation in RCC – upper pole confused with adrenal)
PET : ↑ FDG uptake
 Carcinoma
1. Hormone status : 50% func (=hyper), 50% non-func (=normal)
2. Density : Solid homogeneous ± hge ± necrosis ± calcification ± L/N ±
mets
3. Gland size : Enlarged (Func >5 cm, non-func >10 cm)
4. 90% Unilateral (L>R)
5. Contrast : Heterogeneous
 Carcinoma
1. Hormone status : 50% func (=hyper), 50% non-func (=normal)
2. Density : Solid homogeneous ± hge ± necrosis ± calcification ± L/N ±
mets
3. Gland size : Enlarged (Func >5 cm, non-func >10 cm)
4. 90% Unilateral (L>R)
5. Contrast : Heterogeneous
invasive margin ± IVC ± L/N ± other invasion
(IVC invasion best seen on sagittal)

Angiogram : Enlarged adrenal arteries, minimal neovascularity (predominant

neovascularisation in RCC – upper pole confused with adrenal)
PET : ↑ FDG uptake
 Metastases
1. Hormone status : any
2. Density : Small - homogeneous; Large - het (± necrosis,
hge, calcification)
3. Gland size : Small (<5 cm) / Large (>5 cm – usu from
melanoma) . Discrete (most) / diffuse
4. Unilateral / Bilateral; usu asymmetric
5. Contrast : het C+, prolonged washout, thick rim C+
LOCAL INVASION UNCOMMON
Outline : Small - regular; Large - lobulated / distorted
Adrenal mets indicates advanced disease
 Metastases
1. Hormone status : any
2. Density : Small - homogeneous; Large - het (± necrosis,
hge, calcification)
3. Gland size : Small (<5 cm) / Large (>5 cm – usu from
melanoma) . Discrete (most) / diffuse
4. Unilateral / Bilateral; usu asymmetric
5. Contrast : het C+, prolonged washout, thick rim C+
 Metastases
1. Hormone status : any
2. Density : Small - homogeneous; Large - het (± necrosis,
hge, calcification)
3. Gland size : Small (<5 cm) / Large (>5 cm – usu from
melanoma) . Discrete (most) / diffuse
4. Unilateral / Bilateral; usu asymmetric
5. Contrast : het C+, prolonged washout, thick rim C+
LOCAL INVASION UNCOMMON
Outline : Small - regular; Large - lobulated / distorted
Adrenal mets indicates advanced disease
 Lymphoma
1. Hormone status : any
2. Density : Homogeneous (Necrosis uncommon without Rx /
rapid growth)
3. Gland size : Enlarged
4. Unilateral / Bilateral : 50/50; usu asymmetrical
5. Contrast : Moderate C+
Uncommon. Indicates advanced stage. 2°>1°. NHL>HL.
Usu associated with RETROPERITONEAL ± other L/N.
 Lymphoma
1. Hormone status : any
2. Density : Homogeneous (Necrosis uncommon without Rx /
rapid growth)
3. Gland size : Enlarged
 Lymphoma
1. Hormone status : any
2. Density : Homogeneous (Necrosis uncommon without Rx /
rapid growth)
3. Gland size : Enlarged
4. Unilateral / Bilateral : 50/50
 Lymphoma
1. Hormone status : any
2. Density : Homogeneous (Necrosis uncommon without Rx /
rapid growth)
3. Gland size : Enlarged
4. Unilateral / Bilateral : 50/50; usu asymmetrical
5. Contrast : Moderate C+
 Lymphoma
1. Hormone status : any
2. Density : Homogeneous (Necrosis uncommon without Rx /
rapid growth)
3. Gland size : Enlarged
4. Unilateral / Bilateral : 50/50; usu asymmetrical
5. Contrast : Moderate C+
Uncommon. Indicates advanced stage. 2°>1°. NHL>HL.
Usu associated with RETROPERITONEAL ± other L/N.