A Crucial Step Adjunct to CT Attenuation Values In Characterizing Adrenal Masses A Prospective Observational Study At Our Institute.

Aim: To characterize incidentally detected adrenal masses by CT attenuation values and 15 minutes wash out characteristics at contrast-enhanced CT. Method : Prospective observational study from March 2012 -2013 was done, with all the abdominal scan evaluated for adrenal masses. Departmental protocol was followed with15 minutes delayed scan added. CT attenuation values at different phases were used to calculate absolute percentage washout (APW) and relative percentage washout (RPW). The masses with attenuation value <10HU on unenhanced scans were diagnosed as lipid rich adenomas and masses with attenuation values >10 on plain scan with APW of >60% and RPW>40% were diagnosed as lipid poor adenomas; rest being nonadenomas, metastasis if there was known malignancy. The masses were evaluated in terms of their sizes, site of involment, stastical significance (p<0.05) in attenuation values at different phases and washout studies. Results: 96 lesions were detected in 84 patients from March 2012 -2013.M:F ratios of 1.7:1, mean age being 46 years. Lipid poor adenomas (LPA) were the commonest mass followed by metastasis. 64% of patients with malignancy had adrenal metastasis while 36% had adenomas. There was no significant difference in size(p=0.23) between LPA and non-adenomas (NA) whereas statistical difference was noted in mean attenuation values on unenhanced, delayed, wash-in and wash-out values(p <0.05).There was no significant difference on enhanced scan (p=0.95),but absolute percentage washout (APW) and relative percentage washout (RPW) was statistically significant between LPA and NA (p<0.05).Conclusion: CT attenuation values, absolute and relative percentage washout values characterize the adrenal masses.

Mainly Adrenal Gland Involving NK/T-Cell Nasal Type Lymphoma Diagnosed with Delay due to Mimicking Adrenal Hemorrhage

A 29-yr-old man, presented with abdominal pain and fever, had an initial computed tomography (CT) scan revealing low attenuation of both adrenal glands. The initial concern was for tuberculous adrenalitis or autoimmune adrenalitis combined with adrenal hemorrhage. The patient started empirical anti-tuberculous medication, but there was no improvement. Enlargement of cervical lymph nodes were developed after that and excisional biopsy of cervical lymph nodes was performed. Pathological finding of excised lymph nodes was compatible to NK/T-cell lymphoma. The patient died due to the progression of the disease even after undergoing therapeutic trials including chemotherapy. Lymphoma mainly involving adrenal gland in the early stage of the disease is rare and the vast majority of cases that have been reported were of B-cell origin. From this case it is suggested that extra-nodal NK/T-cell lymphoma should be considered as a cause of bilateral adrenal masses although it is rare.

Bilateral Adrenal Histoplasmosis: Endoscopic Ultrasound – guided Fine Needle Aspiration as a Method of Diagnosis and Assessment

We report a case of a healthy 78 -year- old indonesian man who presented with chronic weight loss, poor appetite and lethargy. CT abdomen showed bilateral adrenal masses. EUS – guided FNA was performed on the left adrenal gland. Histopathology report was Histoplasma Capsulatum. He recovered well with antifungal treatment without any complication. In this case, we found that the role of EUS – guided FNA was not only limited to diagnosis but also helped in the prognosis of the disease since the method was able to assess the general anatomy of the adrenal gland better than other imaging modalities due to its close proximity and direct visualization.