Preoperative Imaging and Suspicion of Malignancy

In addition to distant metastases and tumor size, imaging studies can provide information suggestive of malignancy. Imaging findings suggestive of malignancy include the following: CT

Stippled calcifications

A poorly delineated, rugged, somewhat square-shaped tumor, with the periodic appearance of prominent buds, very different from the round adenoma (Fig. 69-3) Areas of necrosis Aortocaval adenopathies

Evidence of local invasion; note that CT is known to overestimate the extent of liver and caval invasion

Heterogeneously increased early T2-weighted signal Weak and late enhancement after injection of gadolinium

FIGURE 69-3. Computed tomography scan showing a budding tumor in a patient with Cushing's syndrome and an adrenocortical carcinoma.

Finding of an intravascular signal identical to the tumor signal is of paramount importance and diagnostic of malignancy

131I-6P-iodomethylnorcholesterol (NP-59) scintigraphy Lack of or very weak uptake in the presence of a normal contralateral uptake22 However, 18 cases of adrenocortical carcinomas exhibiting clear uptake of NP-59 have been described.23 Virtually all of them were highly differentiated carcinomas with overt clinical hypersecretion. Bone scintigraphy—Tc 99m

Should be performed routinely in all patients with a suspicion of adrenocortical carcinoma When disseminated metastases are seen a palliative treatment rather than surgical resection is indicated As mentioned, needle biopsy should not be used because of its lack of sensitivity and risk of a capsular tear with tumor spillage, except in some patients for diagnosis of probable metastatic tumors to the adrenal.

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