ENDO IMAGING

1. Adrenal Imaging
Most adrenal masses are innocuous
First adrenal published finding- Addison (1855) describes how
adrenal glands can cause bronzing of skin
Nonfunctioning benign tumors- MC finding in general population
Most are cortical adenomas
Infectious/infiltrative lesions are more common in developing
world
Features on imaging
Benign myelolipoma- visible fat on imaging
Adrenal cysts- smooth walled water density lesions
Necrotic metastases- look cystic, but arent cysts
Malignant lesions- large, irregular
Necrosis is also unique to malignancy
Always compare new studies to old images to look for changes
Benign lesions rarely get bigger
Benign lesions show low density on CT, malignant lesions dont
Physiologic CT washout- contrast dye washes out quickly in
benign lesions, but sticks around for longer in malignant lesions
Pheochromocytoma- most specific diagnosis is MIBG
Lower sensitivity though
10% of tumors detected incidentally at imaging
10% bilateral/extra adrenal
RULE OF TENS
ACC- rare, potentially fatal tumor of adrenal gland
Endocrinologistss nemesis
Formal recommendation for patient without any
significant underlying history and an incidental lesion
6 months, 1 year, 2 year, 3 year follow ups to rule
out ACC
Diagnostic percutaneous biopsy rarely necessary

2. Parathyroid Imaging
Primary hyperparathyroidism- endocrine disorder caused by
overproduction of PTH by either single gland (more commonly-
85%) or multiple glands (less common- 15%)
Superior parathyroid glands- less variable in location
80% are located at posterior to mid portion of thyroid
lobe at cricothyroid junction
More than 2 glands present in 2-9% of individuals
Usually bean shaped, but can be elongated or multilobed
 Primary hyperparathyroidism- common (affects 1-4 per 1000)
Most cases asymptomatic
Secondary hyperparathyroidism- elevation of PTH in response to
metabolic derangements of chronic kidney disease
Tertiary hyperparathyroidism- continued physiologic stimulation
of secondary hyperparathyroidism causes autonomous function
of PTH tissue
Ultrasound techniques/findings
Color and power doppler exam of suspected parathyroid
gland should be used to evaluate vascularity and look for
feeding artery
Parathyroid adenomas- discrete oval nodules that are
homogeneously hypoechoic relative to thyroid gland
Can also be bilobed or multilobed, but thats less
common
Normal parathyroid glands arent seen on ultrasound
Parathyroid scintigraphy
MC tracer is technetium 99m
MC imaging for parathyroid
CT
Increased enhancement of lesions is a bad sign
SPECT CT- scintingraphy PLUS CT

3. Pituitary imaging
Pituitary gland- anterior and posterior lobes
IMPORTANT. Jk
Sits within sella turcica
Indications for imaging- patient presents with s/s of
excess or deficiency of pituitary hormone
Prolactinoma- excess prolactin
s/s- galactorrhea, menstrual irregularities
Acromegaly- overproduction of growth hormone
Cushing syndrome- caused by too many glucocorticoids
Central obesity, hirsutism, cervical fat pad, purple striae,
acne
Imaging modalities
MRI- mainstay image for this part
Better soft tissue resolution than CT, no artifacts from
surrounding structures
Summary- know the anatomy and take a good history to help
with imaging interpretation

4. Thyroid cancer imaging

 Differentiated thyroid cancer (DCT) = papillary & follicular
carcinomas
3x F > M
Tx: surgery, iodine ablation
Low mortality, high recurrence
Rates are increasing
Staging factors: age, size, nodal involvement, mets
Under 45 = Stage 1
Under 45 w/ mets = Stage II
Lungs & skeleton MC mets
Imaging modalities: cervical sonography, whole body
scintigraphy (WBS), PET/CT, FDG-PET
Biopsy w/ FNA
Nodal mets = round, no fatty hilum, hyperechogenicity, cystic
change, microcalcifications

5. Thyroid Ultrasound
US is primary imaging for thyroid
Penetration up to 5cm
Decreased echogenicity due to histology of autoimmune dz.
Surrounded by thin echogenic capsule
Parenchyma = homogenous, medium/high speckle echogenicity
Darker than adipose tissue, brighter than neck muscles
Size is dependent on a lot of things cirrhosis, renal failiure,
parity, iodine, BMI, TSH, gender, age, smoking
Adults: 4-6 cm long; 1.3-6 mm thick
Enlarged if AP 2cm
Use axial & sagittal planes
Compression helps you see cysts, microcalcifications
Autoimmune dz. is MC (Graves & Hashimoto)
Thyroiditis = inflammation of thyroid
Transient thyrotoxicosis hyperthyroid normal if
destroyed quickly

6. Thyroid Ultrasound Part 2: Nodules

Nodule = pathological condition of the thyroid
Cystic & solid
Most nodules are benign
Cysts can be colloid, hemorrhagic
Most are partial cysts
 Solid neoplasms: Hashimoto, hyperplasia, follicular & Hurthle cell
adenomas/carcinomas, papillary, medullary, anaplastic
carcinomas, lymphomas, mets
41% of pop on US
Increases w/ age
Due to benign hyperplasia (MC), MEN, radiation exposure, iodine
deficiency, thyroiditis
Do NOT FNA cystic, echogenic foci, spongiform, large & mostly
cystic, innumerable & tiny
FNA
Solid hypoechogenic w/ coarse echogenic foci
Solid homogeneous nodules w/ thin capsules
Solid nodules w/ refractive edge shadows
Larger nodules