Showing posts with label Genitourinary. Show all posts
Showing posts with label Genitourinary. Show all posts

August 21, 2014

Renal Artery Variants in Patients with Normal Renal Function


3D volume rendered CT image shows a 2nd right renal artery (arrows) arising from the right common iliac artery

Facts

  • "Normal" renal arterial arrangement = single bilateral renal arteries with hilar segmental branching. This occurred in 46% of cases in a landmark angiographic report published in 1978
  • Normally, no intrarenal arterial anastomoses are present. Each artery represents an end artery -- interruption results in infarction of that segment
  • Variations include double renal arteries, triple renal arteries, pre-hilar segmental branching, fetal lobulation and exaggerated size difference (greater than 2 cm). 
  • Most common variations are multiple renal arteries followed by pre-hilar segmental branching


Knowledge of Renal Vascular Variations is Important For:

  • Renal transplantation
  • Renovascular hypertension
  • Vascular reconstruction for congenital and acquired lesions
  • Reconstructive surgery for abdominal aortic aneurysms
Our case: Double right renal artery with the smaller branch originating from the common iliac artery

Reference:
- Harrison, Jr., et al. Incidence of anatomical variants in renal vasculature in the presence of normal renal function. Ann Surg 1978;188:83-89.
- Ozkan U, et al. Renal artery origins and variations: angiographic evaluation of 855 consecutive patients. Diagn Interv Radiol 2006;12:183-6.

July 11, 2014

Focal Urinary Bladder Wall Thickening


Axial and sagittal-reformatted CT images show focal thickening of the posterior wall of the urinary bladder (arrows) with increased enhancement relative to normal bladder wall. 

Differential Diagnosis

  • Tumor (benign, malignant, metastasis)
  • Adherent clot
  • Infection/inflammation (TB, cystitis cystica/glandularis, malakoplakia, schistosomiasis)
  • Trauma (mural hematoma)
  • Extravesical pathologies (spread of extravesical inflammation or tumor, endometriosis)
Facts
  • Transitional cell carcinoma accounts for most focal bladder masses
  • Most of the time it is impossible to distinguish tumor from other causes of focal wall abnormality and cystoscopy is necessary
Our case: Transitional cell carcinoma in a 73-year-old female

Reference

Patel U. Imaging And Urodynamics Of The Lower Urinary Tract. Springer 2010.
Bhargava. Ultrasound Differential Diagnosis. Jaypee Brothers Publishers, 2005.

July 1, 2014

Krukenberg Tumors


Axial and coronal-reformatted CT images of a 41-year-old woman shows an enlarged, solid-appearing right ovarian mass (arrows). The left ovary (not shown) is normal. 

Facts:
  • Metastatic tumor to the ovary that contains mucin-secreting, signet ring cells
  • Usually originate from primary tumors of GI tract (most common = colon and stomach)
  • 10% of all ovarian tumors
  • Occur in reproductive age
Imaging:
  • Nonspecific appearance. Can be solid or mixed solid/cystic
  • High suspicion for ovarian metastasis if:
    • Bilateral 
    • Complex-appearing ovarian masses
    • Known GI tract tumor (esp. colon and stomach)
    • MRI showing T1/T2 hyper intensity due to mucin
Our case: Ovarian metastasis from primary gastric cancer.

Reference:
Jung SE, et al. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics 2002; 22:1305.

February 11, 2014

Color Doppler Twinkling Artifact


Longitudinal images of the left kidney show a stone (arrow) in the lower pole with posterior acoustic shadowing and the color Doppler twinkling artifact (short arrows).

Facts:

  • Rapidly alternating red and blue signal behind a highly reflective structure on color Doppler US
  • Useful diagnostic signs especially for urinary calculi detection and improved diagnostic confidence
  • Can also be seen in calcifications in various tissues, biliary stones, encrusted indwelling urinary stents, gallbladder adenomyomatosis and bile duct hamartomas
  • Two proposed mechanisms:
    • Phase jitter - intrinsic machine noise causing random fluctuation of acoustic waves
    • Acoustic waves hitting a rough interface producing complex beam pattern with multiple reflections

Reference
Kim HC, et al. Color Doppler twinkling artifacts in various conditions during abdominal and pelvic sonography. J Ultrasound Med 2010; 29:621.

February 1, 2014

Emphysematous Cystitis


Sagittal-plane ultrasound image of the bladder shows a linear hyperechoic structure with posterior "dirty shadowing" in the anterior aspect of the urinary bladder. There is no recent bladder catheterization. Upon decubitus positioning, this abnormality is immobile, suggesting extraluminal location. 
Axial non-contrast CT of the same patient demonstrates gas within the anterior and posterior walls of the urinary bladder (arrows).

Facts:

  • Rare bladder inflammation with gas in bladder wall and surrounding tissues
  • Generally caused by E.coli, K.pneumoniae or anaerobic gas-forming organisms
  • Pathology: numerous gas filled intramural cysts on mucosal surface
  • Risk factors: diabetes, immunocompromised state, urinary tract obstruction
  • Most patients have mild forms of disease and respond well to antibiotics. Some have severe inflammation, gangrene and sepsis
Imaging:
  • X-ray and CT usually is diagnostic with gas in the bladder wall, surrounding tissues and in the lumen in the absence of prior catheterization
  • Ultrasound may show gas in the wall as hyperechoic lesions with posterior dirty shadowing. Visualization of posterior wall of urinary bladder may be limited if gas is present in the anterior aspect of the bladder. Decubitus scan helps localizing gas, whether inside the bladder lumen or in the wall
  • CT helps detecting complications such as perforation or emphysematous pyelonephritis
Reference
Gillenwater JY, et al. Adult and pediatric urology, volume 1, 2002.
Petersen RO, et al. Urologic pathology, 2009.

August 31, 2012

ESWL-induced Perinephric Hematoma

Ultrasound image of the kidney shows a crescentic heterogeneous hypoechoic lesion in the perinephric space (arrows). The kidney is marked by the calipers. 
Axial unenhanced CT images confirm a thick left perinephric hematoma (stars) and several fragmented stones in the lower pole of the left kidney.
Facts
  • ESWL (Extracorporeal Shock Wave Lithotrypsy) is a common and standard treatment for renal/proximal ureteric calculi in majority of patients
  • Most common complication = microscopic hematuria
  • Perinephric hematoma and infection (including pyelonephritis) can occur
  • Incidence of hematoma varies depending on method of diagnosis. By US, incidence is about 0.1-0.6%. By CT/MRI, incidence rises to 20-25% of cases. 
  • No clear correlation between number of shockwaves or intensity given and incidence of hematoma
  • Most perinephric hematoma resolves spontaneously within 2 years and the renal function is preserved. They are mostly treated conservatively
Imaging: US and CT
  • Crescent-shaped collection surrounding the affected kidney
  • Hypoechoic on US, hyperattenuating on non-contrast CT and no enhancement after IV contrast
  • Displacement or compression of adjacent renal parenchyma
  • Differentiate from subcapsular hematoma by appearance and pressure effect to underlying kidney.
  • "Page" kidney occurs when (usually) subcapsular hematoma causes chronic renal parenchymal compromise and then hypertension

Reference:
Labanaris AP, Kuhn R, Schott GE, Zugor V. Perirenal hematomas induced by extracorporeal shock wave lithotripsy (ESWL). Therapeutic management. TheScientificWorldJOURNAL 2007;7:1563-1566.

July 21, 2012

Pyonephrosis

 Longitudinal ultrasound image of the right kidney shows moderate right hydroureteronephrosis (arrows) with internal debris.

Longitudinal image of the right ureter (arrows) shows a stone (arrowhead) in the distal ureter causing proximal hydroureter. 

Facts:

  • Bacterial infection of urine associated with ureteral obstruction, AKA infected hydronephrosis. Accumulation of pus in the renal pelvis and calices of the kidney
  • Common causes are ureteric obstruction by stone and ureteropelvic junction (UPJ) obstruction
  • Septic patients with high fever, flank pain and tenderness
  • Any febrile patients with hydronephrosis should be suspected of having pyonephrosis
  • Ultrasound: echogenic urine and debris in the hydronephrotic kidney
  • Prompt drainage essential 
Reference:
Hodler J, Von Schulthess GK, Zollikofer ChL. Diseases of the abdomen and pelvis 2010-2013

December 11, 2011

Scrotal Pyocele

Gray-scale and color Doppler US images of the testicle shows a complex fluid collection (stars) around the testicle and marked scrotal skin thickening. The epididymis is edematous with increased flow (image not shown).

Facts: Scrotal Pyocele
  • Also known as scrotal abscess
  • Can be superficial (from infected hair follicles, wound) or intrascrotal
  • Causes: epididymitis, TB, instrumentation, neurogenic bladder, chronic catheter indwelling, spread from intraabdominal infection (i.e., appendicitis)
  • Intrascrotal abscess requires surgical drainage
Imaging
  • US is the modality of choice
  • Complex-appearing fluid around the testicle
  • Scrotal skin thickening with hyperemia
  • Evidence of causes such as epididymitis or others
  • Based on imaging, it is difficult to distinguish pyocele from hematocele
References
1. Siegel MJ. Pediatric Sonography, 2010.
2. Resnick MI, Novick AC. Urology Secrets, 3rd ed, 2003.

November 21, 2011

Renal Scarring

A longitudinal ultrasound image of the kidney shows a focal depression of the lower pole cortex (arrows) with focal parenchymal thinning and a caliceal stone (between calipers).

Facts:
  • Renal scar is a common incidental finding during imaging of the GU tract
  • It can occur both with and without episodes of infundibular obstruction
  • Reflux is considered a major contributor in development of non-obstructive scarring, particularly in children with vesicoureteric reflux (VUR)
  • In adults, renal scarring is more associated with renal stone disease, either with stone or history of stone
Imaging
  • Focal cortical thinning and depression of the cortex, overlying the pyramid on any imaging modalities (IVU, US, CT, MR)
  • Hyperechoic band is seen over the parenchymal thinning on US
  • Mimic = normal renal lobulation. Lobulation will span the pyramids with echogenic lobular junctions into renal columns
Reference:
Newhouse JH, Amis, Jr, ES. The relationship between renal scarring and stone disease. AJR 1988; 151:1153-1156.

July 1, 2011

Obstructing Ureteric Stone on Ultrasound

Figure 1: A gray-scale ultrasound image of the right kidney shows right hydronephrosis and hydropelvis.
Figure 2: The scan in the right pelvis demonstrates an echogenic focus (arrow) with posterior acoustic shadowing (arrowheads) at the site where the ureter abruptly changes its caliber.

Facts:
  • Imaging in patients presenting with renal colic is performed to 1) confirm the suspected renal colic, 2) diagnose cause and level of obstruction, 3) detect or rule out complications of renal colic (obstruction, infection), 4) detect alternative diagnoses
  • Non-contrast CT is current gold standard for diagnosis of urinary tract stone disease
  • Ultrasound may be an initial imaging done although its sensitivity is limited (37% - 64%) for detecting renal calculus (lower for ureteric calculus) and acute obstruction (74% - 85%)
Imaging Appearance
  • Stone (brightly echogenic focus with posterior acoustic shadowing). For renal stone less than 5 mm, ultrasound is of limited accuracy. Ureteric stone is uncommonly appreciated on US.
  • Hydronephrosis
  • Twinkling artifact behind the stone, and absent ureteral jet on color Doppler imaging
Reference:
Scott LM, Sawyers SR, Bokhari J, Hamper UM. Ultrasound evaluation of the acute abdomen. Ultrasound Clin 2007;2:493-523.

December 30, 2010

Steinstrasse

Plain abdominal radiograph shows multiple tiny stones (arrows) lined in the distal right ureter. The patient has had a recent extracorporeal lithotripsy.

Facts: Steinstrasse
  • Steinstrasse is a German word, meaning "stone street" or "street of stones" first coined by the German pioneer of lithotripsy
  • After lithotripsy, tiny stones line up in the ureter producing an appearance resembling a cobbled street on plain radiograph
  • Steinstrasse can develop in 1 day to 3 months after stone fragmentation. It can develop after the first ESWL, or after several sessions.
  • Incidence increases with stone size
  • Most common location = distal ureter, followed up upper ureter
  • It often passes by itself. 25% of patients, however, may experience obstruction at the ureteral level. If obstructed, percutaneous drainage or ureteral stent placement may be needed to manage ureteral obstruction until the fragments become dislodged and pass
Imaging
  • Steinstrasse best detected with plain radiography
  • Ultrasound is the most appropriate imaging mean to detect associated obstruction (hydronephrosis)

References:
1. Zagoria RJ. Genitourinary Radiology The Requisites, 2nd edition.
2. Sayed MA, El-Taher AM, Aboul-Ella HA, Shaker SE. Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJUI 2001; 88:675-678.

September 9, 2010

Krukenberg Metastasis

Fig. 1: Axial CT image shows circumferential thickening of the gastric antrum.
Fig. 2: Axial CT image of the pelvis shows bilateral, predominantly solid, less than 10 cm, ovarian masses (stars). There is small ascites.


Facts: Krukenberg Metastasis
  • Originally described by Dr. Krukenberg in reference to a rare form of malignant ovarian signet-ring tumor that distinction between primary and metastatic signet-ring tumors from the stomach was difficult
  • Differentiation between Krukenberg metastatic signet-ring ovarian tumors vs. primary has implication for management and prognosis. Primary signet-ring ovarian tumors can be treated with resection if found early. Krukenberg tumors are indicative of late-stage disease
  • Primarily from gastrointestinal adenocarcinoma (stomach, colon)
Imaging Findings
  • Distinction between primary and metastatic ovarian tumors can be difficult on imaging. There is no reliable, consistent feature that is accurate enough to differentiate the two
  • Radiologist may suggest possible Krukenberg metastasis if ovarian lesions are solid, less than 10 cm, involve both ovaries and present late.
Our case: Signet-ring adenocarcinoma of the stomach with bilateral ovarian metastases (Krukenberg metastasis)

References
1. Brown DL, Zou KH, Tempany CMC, et al. Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the radiology diagnostic oncology group study. Radiology 2001;219:213-218.
2. Zagoria RJ, Mayo-Smith WW, Fielding JR. Genitourinary imaging case review series, 2nd edition, 2008.

August 18, 2010

Ovarian Hyperstimulation Syndrome



Ultrasound images show enlarged ovaries with multiple cysts in a woman who had received assisted reproduction procedure. Ascites is also present but not shown on these images.

Facts: Ovarian Hyperstimulation Syndrome (OHSS)
  • Complication related to exogenous administration of human chorionic gonadotropin (HCG) for assisted reproduction
  • Believed to be due to increased capillary permeability, resulting in fluid shift from intravascular to extravascular compartments
  • Broad clinical spectrum, ranging from mild, moderate to severe, but can be life threatening
  • Common in mid- to late-luteal phase
  • Early signs: abdominal heaviness, tension and pain (due to bilateral ovarian enlargement with multiple cysts)
  • Risk factors: young patient (less than 30 years old), underlying polycystic ovaries, high number of follicles and estradiol levels at the time of HCG injection, protocols that utilize GnRH
  • Golan classification describes 5 grades of OHSS based on ovarian size, symptoms (abdominal distention, nausea, vomiting, dyspnea), signs (ascites, pleural effusion, hemoconcentration, hypovolemia, oliguria).
Imaging
  • Ultrasound most appropriate imaging to confirm clinical suspicion
  • Enlarged ovaries with several cysts
  • Ascites, pleural effusion
  • Necklace sign (string of ovarian follicles close to the surface of the ovary) may indicate an increased risk of developing this syndrome
Reference:
1. Gianaroli L, Ferraretti AP, Fiorentino A. The ovarian hyperstimulation syndrome. Reproductive Med Rev 1996;5:169-184.
2. Golan A, Ron-El R, Herman A, et al. Ovarian hyperstimulation syndrome: an update review. Obstet Gyncol Surv 1989;44:430-440.

July 30, 2010

Acute Tubular Necrosis

Tc-99m MAG3 renal scan of a renal transplant recipient, day 1 after transplant with oliguria, shows delayed excretion of tracer from the transplant kidney. Images in vascular phase (not shown) are normal (normal perfusion and uptake).

Facts
  • May occur immediately or after an initial short period of allograft function
  • Related to both donor and recipient factors
  • More common in cadaveric kidneys of older donors who sustained warm ischemia time or prolonged hypotensive periods
  • Presented with oliguria or anuria early after transplant
  • Diagnosis made by exclusion of other factors. Traditional signs (tubular casts, low urine osmolality) not reliable if patients with native partially functioning kidneys
  • Treatment: supportive, return to dialysis if anuric (expected recovery of renal function usually within 3 weeks)
Renal Scan
  • Normal perfusion, variable uptake but no (or delayed) excretion
  • Serial scans helpful in determining viability of oliguric kidneys, predicting recovery or deterioration
Reference:

Resnick MI, Older RA. Diagnosis of Genitourinary Disease, 2nd edition, 1997

July 18, 2010

Brenner Tumor of the Ovary

Ultrasound image of the right ovary shows a well-circumscribed complex mass (arrows) with cystic and solid components (arrowheads) in a 66-year-old woman with abnormality seen on CT scan.

Facts: Complex Ovarian Mass
  • Long list of potential causes, encompassing tumor (primary and neoplastic), inflammation and infection in a postmenopausal woman
  • Potential tumors: serous and mucinous cystadenoma/cystadenocarcinoma, teratoma, clear cell carcinoma, endometrioid carcinoma, necrotic primary or metastatic tumors
  • Most of these (if we think it is neoplasm) would need to be diagnosed histologically because imaging findings are nonspecific and malignancy cannot be excluded
Facts: Brenner Tumor
  • Uncommon ovarian neoplasm, usually incidentally found
  • Women in 5th to 7th decade of life
  • Predominantly solid, but can be complex with cystic components when associated with serous and mucinous cystadenomas (seen in up to 30% of cases)
  • Can be benign, borderline or malignant
Our case: Brenner tumor with struma ovarii on histology.

Reference:

Green GE, Mortele KJ, Glickman JN, Benson CB. Brenner tumors of the ovary sonographic and computed tomographic imaging features. J Ultrasound Med 2006;25:1245-1251.

June 27, 2010

Helical CT for Urolithiasis

A coronal-reformatted CT image (without IV contrast) shows an obstructing right ureterovesical junction (UVJ) stone (arrow), causing hydroureteronephrosis. There is enlargement of the right kidney with perinephric stranding (arrowheads) as a result.

Facts:
  • Urolithiasis incidence in the U.S. and Europe approximately 0.1% - 0.4% of population
  • Male to female ratio = 3:1
  • Peak age during third to fifth decade of life
  • Recurrence rate about 75% during 20 years
Detection Rates by Various Imaging Methods
  • Conventional radiography 50-70%
  • Intravenous urography (IVU) 70-90%
  • Ultrasound 50-60%
  • Normal-dose CT: sensitivity 94-100%, specificity 97%
  • Low-dose CT: sensitivity 95%, specificity 95%
Advantages of CT over IVU
  • Shorter examination time
  • Avoid cost and complications of IV contrast
  • Greater sensitivity for stone detection
  • Higher potential for detection of abnormalities unrelated to stone disease
  • Study directly compared low-dose (<>
  • Meta-analysis of 7 studies of low-dose CT in 1061 patients showing 95% sensitivity and specificity for stone diagnosis
References
1. Liu W, Esler SJ, Kenny BJ, et al. Low-dose nonenhanced helical CT of renal colic: assessment of ureteric stone detection and measurement of effective dose equivalent. Radiology 2000;215:51-54.
2. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR 2008;191:396-401.

June 21, 2010

Adrenal Cortical Carcinoma

Axial CT image shows a 5-cm heterogeneous left adrenal mass (arrows) with ill-defined border anterolaterally, and a liver mass (arrowhead).

Facts: Adrenal Cortical Carcinoma (ACC)
  • Rare tumor, 0.5 to 2 cases per million population
  • Bimodal age peak - young children, and adults in 4th to 5th decades
  • Male = female
  • Tumor arises from adrenal cortex; 50% produces hormones (cortisol, androgens)
  • Most common site of metastasis: liver and lung
Adrenal Masses: Size Matters
  • Mass less than 2 cm: incidence of malignancy 1%
  • 2-4 cm: 3% - 8%
  • 4-6 cm: 8% - 25%
  • Greater than 6 cm: 40% - 80%
Imaging Features
  • CT or MRI can suggest the diagnosis if there is malignant feature: venous invasion and/or capsular invasion, metastasis to lymph nodes or other organs.
  • Mass usually is large, 70% of ACC are larger than 6 cm on imaging
  • Usually heterogeneous after contrast administration
  • 30% are calcified (usually central)
  • Enlarged lymph nodes seen in 1/3 of cases (usually at high para-aortic or paracaval)
  • MRI may be used as an adjunct to CT for delineation of IVC invasion and extension
Our case: adrenal cortical carcinoma

References:
1. DeVita VT, et al. DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, 8th edition, 2008

2. Husband JE, Reznek RH. Imaging in Oncology, Volume 1, 2nd edition, 2004.


May 21, 2010

Renal Oncocytoma


Sagittal contrast-enhanced CT image shows a well defined, enhancing mass in the right kidney of a 67-year-old man presenting with hematuria.

Facts: Renal Oncocytoma
  • 5% of all adult primary renal epithelial neoplasm in surgical series
  • Believed to originate from or differentiate toward type A intercalated cells of the cortical collecting duct
  • Men more common than women
  • Frequently seen in 7th decade
Imaging Features
  • Solitary, well defined mass of renal cortex
  • Stellate fibrotic scar can be seen with large tumors
  • Spoke-wheel pattern of feeding arteries seen on catheter angiography
  • Cannot be differentiated from renal cell carcinoma, and can be associated with RCCs either as hybrid tumors or collision tumors
Our case: Oncocytoma proven by histology. On imaging, this mass cannot be differentiated from RCC and should be investigated as possible RCC until proven otherwise.


Reference:
Prasad SR, Surabhi VR, Menias CO, et al. Benign renal neoplasms in adults: cross-sectional imaging findings. AJR 2008;190:158-164

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May 18, 2010

Hematosalpinx

Fig.1: Sagittal US image of the pelvis of a 13-year-old girl presenting with acute pelvic pain shows multiple cystic lesions (arrows) behind the uterus (U). These cystic structures have peculiar frondlike structures internally suggesting that they represent a dilated fallopian tube.
Fig. 2: Sagittal T2W MR image confirms the presence of dilated fallopian tube with fluid-fluid levels, suggesting hematosalpinx.


Facts: What Causes Hematosalpinx?
  • Tubal pregnancy (most common)
  • Endometriosis
  • Fallopian tube cancer
  • Obstructed vagina resulting in menstrual blood backflow into fallopian tubes
Facts: Isolated Tubal Torsion
  • Very rare entity causing lower abdominal pain
  • Usually occurs in reproductive age
  • Diagnosis rarely made preoperatively
  • Imaging findings are adnexal cystic mass, hydrosalpinx, hematosalpinx
  • Twisted fallopian tube, if visualized, is a specific sign for tubal torsion. If the ovary is also torsed, the ipsilateral ovary becomes enlarged.
Our case: isolated fallopian tube torsion causing hematosalpinx.

Reference:
1. Park BK, Kim CK, Kim B. Isolated tubal torsion: specific signs on preoperative computed tomography and magnetic resonance imaging. Acta Radiologica 2008;49:233-235.
2. Wikipedia: hematosalpinx

April 21, 2010

Extraadrenal Pheochromocytoma: MRI

Fig. 1: Axial T2-weighted MR image with fat suppression shows a well circumscribed retroperitoneal soft tissue mass below the aortic bifurcation with heterogeneous high T2 signal intensity.
Fig. 2: Post contrast MR image shows heterogeneous enhancement of the mass.


Facts: Extraadrenal Pheochromocytoma
  • 10% of all pheochromocytoma
  • Most in the abdomen (98%)
  • Along prevertebral and paravertebral ganglia, including the organ of Zuckerkandl (which is the only macroscopic extraadrenal sympathetic paraganglia located at the origin of inferior mesenteric artery)
  • Benign or malignant difficult to determine by histology. If there is local invasion or metastasis to non-chromaffin tissues --> malignant
  • Extraadrenal pheochromocytoma metastasizes more often than adrenal counterpart
MR Imaging Appearance
  • High T2 signal intensity, classic "salt-and-pepper" pattern on T2WI
  • Enhancing, usually heterogeneous
  • No lipid content (lack of signal dropout on opposed-phase images)
Our case - extraadrenal pheochromocytoma below the aortic bifurcation incidentally found on MRI, confirmed with I-123 MIBG and serum catecholamines. It should be noted that half of all pheochromocytomas are now discovered incidentally on imaging.

Reference:
Elsayes KM, Narra VR, Leyendecker JR, et al. MRI of adrenal and extraadrenal pheochromocytoma. AJR 2005;184:860-867.


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