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respirations 14/min. Electrocardiography demon- tion and plasma levels of cortisol, ACTH, DEA-
strated atrial fibrillation with no signs of is- S, 4-androstenedione, plasma renin activity
chemia. Chest X-ray did not demonstrate pul- (PRA) and aldosterone were all within usual lim-
monary congestion. Arterial blood gases were as its (Table I). Based on these findings, we diag-
follows: pH 7.41, PO2 90, PCO2 20.1 and HCO3 nosed a non-functional right adrenal hemorrhagic
19.2. Laboratory data were notable for anemia mass. Elective surgery was planned to prevent
(Hb 9.1 g/dl) and high ESR (105 mm/h) (Table further pain and for the high size of the adrenal
I). Gastrointestinal treat bleeding had been ex- lesion (an adrenal mass 6 cm carries an in-
cluded by negative of occult blood stool, and sec- creased risk of adrenal malignancy). Based on a
ondary by pancolonscopy. The patients under- multidisciplinary approach, we decided on open
went to abdominal CT, which showed a right surgery to remove the right adrenal mass. Our
suprarenal mass (18 14 cm), appearing hypo- surgery colleagues performed exploratory la-
dense, mild peripheral enhancement of the thick- paratomy via a midline celiotomy under general
ened capsule while the most part of it was inho- anesthesia in elective conditions with appropriate
mogenously hypodense with some peripheral cal- therapy. Exploration of the abdomen revealed a
cification (Figure 1). The day after, since the pa- 18 14 cm dark lesion originating from the right
tient accused a worsening of the lumbar pain he retro-peritoneal region. The lesion was adherent
was then submitted to a CEUS. The baseline ul- to the right adrenal gland and received its blood
trasonography evaluation showed a 18 cm of supply from all adrenal arteries. The adrenal
maximum diameter mass with regular margins. mass was completely excised with a right adrena-
This lesion was locate in the right kidney, with- lectomy (Figure 3). Histopathological examina-
out infiltrative effect. The mass showed inho- tion of the mass showed an oval massive hemor-
mogenous iso-hypoechogenecity, within sclerotic rhagic adrenal lesion, measuring 191412 cm
and fluid-particle areas. After contrast injection of diameter, containing mostly coagulated blood
CEUS evaluation showed that the lesion did not with fibrosclerotic wall. A diagnosis of an hem-
enhance during the whole examination but only orrhagic adrenal pseudocyst was made. The pa-
some tiny vessels disposed peripherally were en- tients post-operative course was uneventful and
countered. CEUS showed features suggestive for he was discharged 9 days after the operation.
hemorrhagic adrenal pseudocyst (Figure 2). Follow-up demonstrated that the patient remains
Hormonal levels, including 24-hours urinary well and asymptomatic 3 months after surgery,
metanephrines, aldosterone, free cortisol excre- with good laboratory data (Table I).
After surgery
At diagnosis (3 months) Normal value
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V. Cantisani, L. Petramala, P. Ricci, A. Porfiri, C. Marinelli, G. Panzironi, A. Ciardi, G. De Toma, C. Letizia
A B
Figure 1. Computer tomography scan showing a large adrenal hemorraghic lesion (A), which after contrast administration
shows only mild peripheral enhancement (B).
A B
Figure 2. A, Color-Doppler ultrasonography (US) shows the presence of large inhomogenous adrenal lesion without any
clear vascular signs. B, At CEUS the lesion does not show any signs of enhancement.
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A giant hemorragic adrenal pseudocyst
A B
Figure 3. A, A 19X14X12 cm adrenal mass with massive hemorrhage. B, Containing centrally coagulated blood with fi-
brosclerotic wall.
encountered in the daily work-up of the patients in not reliable for differentiating the various
order to obtain a better characterization of lesions histopathologic non-adenomatous lesions from
to start soon the prompt treatment. Different stud- one another. Conversely, Dietrich et al19, recently
ies have shown that benign and malignant adrenal showed that CEUS may allow to visualize the
masses can be differentiated at CT with a sensitiv- vascularization and perfusion even in small
ity of 85-100% and a specify of 95-100%15. adrenal masses, but it cannot be applied to differ-
MRI is also an accurate method for studying entiate reliably between malignant and benign le-
adrenal mass and in particular is important in the sions. However, they did studied only solid le-
case of indeterminate adrenal mass after CT15. sions. We report the CEUS features of a non-
These techniques, although represent gold stan- completely determinate case at CT of hemor-
dard in the adrenal lesion diagnosis, present some rhagic adrenal pseudocyst. A complex pseudo-
limits: high cost, patients with claustrophobia or cyst may be difficult to differentiate from metas-
refusing to the examination, possible adverse reac- tasis and other necrotic tumor or abscess5. Under-
tion of contrast medium , still limited availability lying, carcinoma should be suspected in patients
on the territory for MRI, while adverse reaction, with a high, erythrocyte sedimentation rate
scan radiation exposure for CT scan. (ESR), mixed echoes, an US and stippled calcifi-
As a consequence of these limitations, US cation20. In fact, in our patient CT scan showed
plays an increasingly important role as first-line an heterogeneous, mildly hyperdense extensive
examination for the adrenal masses evaluation. lesion before contrast agent administration. The
However, the sensitivity of US for the detection lesion after contrast medium administration
of adrenal lesions varies from 66.7%10 to more showed enhancement of the capsule, with in-
than 90% of all-even small-adrenal gland crease of the Hounsfield Unit (HU). The features
lesion16. Recently, CEUS which is nowadays a were interpreted as suggestive of probably ag-
well-established imaging modality indifferent gressive adrenal hemorrhagic lesion; because of
fields such as liver17, vascular imaging18, so on the lack of any story of trauma when the exami-
was also used in adrenal pathology evaluation15. nation was performed, and because of the size of
However, the results showed by the two studies the lesion, the patient was submitted then to
present in literature were contradictory. In fact, surgery. It should be taken in account that an ex-
Friedrich- Rust et al15 reported that CEUS was act diagnosis in clinically important because an
able to differentiate adenomas and non-adenomas adrenal cyst 6 cm carries an increased risk of
lesions with a sensitivity comparable to CT and malignancy. In fact, the incidence of malignancy
MRI; contrast-enhanced sonography, however, is in adrenal cystic lesions is approximately 7%.
2549
V. Cantisani, L. Petramala, P. Ricci, A. Porfiri, C. Marinelli, G. Panzironi, A. Ciardi, G. De Toma, C. Letizia
2550