case_images: PMC11784626_01
case_images: Bilateral adrenal adenomas. (A) Axial noncontrast CT image demonstrates bilateral adrenal nodules (arrows) with homogenous low density <10 HU, highly specific for benign lipid-rich adenoma. (B) Axial T2 -weighted image in the same patient shows homogenous low-signal intensity signal of the adrenal lesions (arrows) comparable to the liver. (C, D) Chemical shift MRI images (C in-phase, D opposed-phase) showing signal drop on opposed-phase images (arrows in D) where the lesions are now much darker than in C, consistent with intralesional fat, classic of lipid-rich adenomas. CT = computed tomography; MRI = magnetic resonance imaging.
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case_images: Imaging characteristics favor these masses to be benign, lipid rich adenomas (Fig. 1).
case_images: PMC11784626_02
case_images: Bilateral macronodular adrenal hyperplasia in McCune-Albright Syndrome. Coronal noncontrast CT image demonstrates diffuse nodular enlargement of the adrenal glands bilaterally with homogeneous low-density lesions (arrows) consistent with bilateral nodular adenomatous hyperplasia in the setting of McCune-Albright Syndrome. Note diffuse bone abnormalities in keeping with multiple areas of fibrous dysplasia, with bone expansion and ground glass appearance (dashed arrow), variable rib spacing, and a vertebral compression deformity (arrowhead). CT = computed tomography.
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case_images: A surveillance CT abdomen showed bilateral macronodular adrenal hyperplasia (Fig. 2).
case_images: PMC11784626_03
case_images: Bilateral pheochromocytomas in Von-Hippel Lindau syndrome. (A-C) Coronal adrenal-protocol CT before contrast (A), in the 75-second-delay phase (B), and in the 15-minute-delay phase (C) demonstrate bilateral heterogeneously hyperenhancing adrenal masses, right greater than left (white arrows) consistent with bilateral pheochromocytomas in the setting of Von-Hippel Lindau syndrome. (D-F) Coronal T2 image (D) demonstrate bilateral heterogeneously hyperintense T2 lesions, in keeping with classic light-bulb sign on T2 for pheochromocytomas (circles). Axial in-phase (E) and opposed-phase (F) images demonstrate no change in signal, in contrast to adenomas in Fig. 1. CT = computed tomography.
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case_images: PMC11784626_04
case_images: Bilateral pheochromocytomas in Von-Hippel Lindau syndrome. (A-C) Coronal adrenal-protocol CT before contrast (A), in the 75-second-delay phase (B), and in the 15-minute-delay phase (C) demonstrate bilateral heterogeneously hyperenhancing adrenal masses, right greater than left (white arrows) consistent with bilateral pheochromocytomas in the setting of Von-Hippel Lindau syndrome. (D-F) Coronal T2 image (D) demonstrate bilateral heterogeneously hyperintense T2 lesions, in keeping with classic light-bulb sign on T2 for pheochromocytomas (circles). Axial in-phase (E) and opposed-phase (F) images demonstrate no change in signal, in contrast to adenomas in Fig. 1. CT = computed tomography.
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case_images: PMC11784626_05
case_images: Bilateral adrenal hemorrhage due to malignancy. (A) Axial T1-weighted MR image showing bilateral adrenal lesions (arrows) with intrinsic T1 hyperintensity consistent with hemorrhagic lesions. (B) Axial subtracted MRI post contrast image showing only small areas of peripheral enhancement (arrowhead) with much of the lesion without enhancement. Findings consistent with bilateral metastatic disease with hemorrhage. (C) Axial fused FDG PET/CT image in the same patient showing the bilateral lesions with minimal focal peripheral increased FDG uptake correlating to the areas of enhancement seen on the MRI, related to viable tumor with adjacent hemorrhage. CT = computed tomography; FDG PET = fluorodeoxyglucose positron emission tomography; MRI = magnetic resonance imaging.
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case_images: In retrospect, the largest focus of FDG avidity corresponded to a region of enhancement demonstrated on initial MRI (Fig. 4).
case_images: PMC11784626_06
case_images: Bilateral adrenal myelolipomas in congenital adrenal hyperplasia. Coronal (A), sagittal (B), and axial (C) contrast-enhanced CT images on the 75 s delayed phase show bilateral large adrenal masses (arrows) with macroscopic fat and a few coarse calcifications (arrowheads) consistent with bilateral myelolipomas. Note this male patient has a uterus as they were assigned female at birth (dashed arrow). CT = computed tomography.
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case_images: The right adrenal mass measured 21 cm and the left adrenal mass measured 33 cm (Fig. 5).
case_images: PMC11784626_07
case_images: Bilateral adrenocortical neoplasms in multiple endocrine neoplasia type 1. (A) Axial T2 MRI image showing bilateral lesions with T2 intermediate signal, mildly above that of the adjacent liver (dashed arrow). (B) Axial post contrast image demonstrates heterogenous enhancement. (C-D) Axial in-phase (C) and opposed-phase (D) MRI images do not show any signal loss. Findings are not typical of adenomas. CT = computed tomography; MRI = magnetic resonance imaging.
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case_images: She was also found to have bilateral adrenal masses - the left mass was large, > 4 cm, with complex features; the right mass was considered to be a smaller (< 4 cm) lipid-poor adenoma (Fig. 6).
case_images: PMC11784626_08
case_images: Bilateral adrenal hemorrhage due to trauma. Axial contrast-enhanced CT in the portal venous phase (A) demonstrates bilateral adrenal hyperattenuating lesions (arrows) that were new from a prior CT scan done 9 months ago. These enlarged on subsequent CT performed 12 days later (B), consistent with bilateral adrenal hemorrhage. Initial CT additionally shows active bleeding from a splenic laceration (arrowhead), with splenic artery embolization coils noted on subsequent CT (dashed arrow). CT = computed tomography.
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case_images: In addition to hemodynamic support, she received urgent splenic artery embolization; she was found to have bilateral adrenal hemorrhage (Fig. 7).
case_images: PMC11784626_09
case_images: Bilateral adrenal metastases from melanoma. (A) Axial CT image with contrast showing bilateral adrenal lesions with heterogenous enhancement in a patient with known metastatic melanoma. (B) Axial CT with contrast 6 months later shows increase in size of the bilateral lesions, consistent with progressive metastatic disease. CT = computed tomography.
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case_images: Follow-up CT scans at 6- and 9-month intervals demonstrated progressive bilateral enlargement to up to 7 cm on the right and 5.2 cm on the left, favoring metastatic disease (Fig. 8).
case_images: PMC11784626_10
case_images: Bilateral adrenocortical neoplasms in suspected Li-Fraumeni syndrome. Coronal post contrast CT image showing bilateral adrenal lesions (arrows). The right adrenal lesion demonstrates heterogenous enhancement and was consistent with an adrenocortical carcinoma. The left adrenal lesion is heterogenous with foci of fat and calcifications (arrowhead) corresponding to sites of myelolipomatous change within this atypical adenoma. CT = computed tomography.
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case_images: She was initially found to have bilateral adrenal masses, which were initially stable on annual surveillance imaging, though the right adrenal mass slowly enlarged over the course of 6-7 years (Fig. 9).
case_images: PMC11784626_11
case_images: Bilateral adrenal lymphoma. (A) Axial CT image with contrast demonstrates large bilateral adrenal masses in a patient with diffuse large B cell lymphoma. (B) Fused coronal FDG PET/CT image demonstrates marked FDG uptake. (C) Follow-up fused coronal PET/CT image after treatment demonstrates interval decrease in size and FDG uptake of the bilateral lesions (arrow heads) in keeping with favorable treatment response. CT = computed tomography; FDG PET = fluorodeoxyglucose positron emission tomography.
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case_images: Patient received combination cytotoxic chemotherapy with rituximab and prednisone with good partial response to therapy (Fig. 10).