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0:23

Today we are honored to welcome Dr.

0:25

Deborah Baumgarten for a case-based review

0:28

of adrenal lesions.

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Dr. Baumgarten completed medical school

0:32

and all of her radiology training at Emory University.

0:35

She was on staff at Emory for over 25 years

0:37

before moving to the Mayo Clinic in Jacksonville, Florida

0:41

where she specializes in abdominal imaging

0:44

with a special interest in ultrasound and GU imaging.

0:48

At the end of the lecture, please join Dr.

0:50

Baumgarten in a q

0:51

and a session where she will address questions you

0:53

may have on today's topic.

0:55

Please remember to use the q

0:56

and a feature to submit your questions so we can get to

0:59

as many as we can before our time is up.

1:02

With that, we are ready to begin today's lecture. Dr.

1:04

Baumgarten, please take it from here.

1:08

Excellent. Alright, so I'm gonna be talking today

1:11

about adrenal lesions.

1:12

Um, I have some disclosures first.

1:14

First on the um, on the advisory board

1:16

of Voyager Pharmaceuticals, which is a

1:19

contrast material company I invest in Cultivate MD,

1:22

which uh, deals with medical startups.

1:24

I am a section editor for UpToDate

1:26

and I'm on a couple of editorial boards,

1:28

but none of them are really relevant to this talk.

1:31

So my objectives, uh, for this next hour

1:34

or so is to understand the guidelines that we use every day

1:38

that are published in the radiology literature for dealing

1:41

with predominantly incidental adrenal masses.

1:44

But we're going to be approaching lesions

1:46

that are also not so incidental.

1:50

I'm gonna use cases to illustrate the various adrenal

1:52

pathologies that we can encounter on a day-to-day.

1:55

And I'm gonna try to have you see some differences

1:57

between benign and malignant lesions so

2:00

that you can streamline your approach

2:01

to the differential diagnosis.

2:04

And then I've come across a few mimics

2:06

of adrenal lesions in my practice

2:07

and I'll show a few of those.

2:10

So what first is an incidentaloma, it's an adrenal lesion

2:14

and importantly it's an adrenal lesion

2:16

that's greater than a centimeter that we discovered

2:18

during imaging for some other reason.

2:21

So this is not a study that is looking

2:23

for adrenal pathology, it's for something else.

2:27

Now in our literature we've discussed

2:29

and will show that nodules less than a centimeter do not

2:32

require further investigation.

2:34

And in fact a lot of people should just not even mention

2:36

them in their reports or don't mention them at

2:39

all, kind of ignore them.

2:41

Now, in terms of the true prevalence

2:43

of adrenal incidentalomas,

2:45

it really depends on how they're discovered.

2:47

In autopsy series, the median discovery is about 3%

2:51

of all autopsy autopsy series that have been published

2:54

between 1941 and 1999.

2:57

And it's a little bit less than

2:58

that when you look at imaging about 2% in series published

3:01

from 1982 to 2019.

3:05

So for example, here's a nodule

3:07

that one would ignore if incidentally discovered

3:11

this is a patient who was being, um, worked up for hematuria

3:15

and there's a seven millimeter nodule here.

3:18

So we should not even probably mention this nodule.

3:22

You could probably bury it in the report if you wanted to

3:25

and say less than one centimeter does not need

3:27

to be followed, that sort of thing.

3:29

But keep in mind that if this were discovered

3:31

and then you later found out

3:32

that this patient had some symptoms

3:34

of a hormonally active adrenal nodule,

3:37

this wouldn't really be an incidental finding.

3:39

It would actually explain the symptom the patient was having

3:42

and might be a functioning adenoma

3:44

and would require further investigation

3:46

and possibly resection.

3:48

And I'm talking about things like cortisol,

3:50

hyper production, or uh, androgen hyper production

3:54

that might be from the adrenal.

3:57

But these are the guidelines that we tend

3:59

to follow the ACR 2017 guidelines,

4:02

and you can't really read this,

4:03

but what we're gonna do is look at various arms

4:05

of this chart as we go through various adrenal pathology.

4:10

And these guidelines are for incidental,

4:12

asymptomatic adrenal masses.

4:13

And again, look at this greater than

4:15

or equal to one centimeter that we detect on imaging.

4:20

So here for example, is this case

4:23

and if you wanna put something in the chat about

4:25

what you think you're seeing here, I would be happy to uh,

4:28

have that happen and I will try to keep up with the chat

4:31

or if you put it in the q

4:33

and a section, not sure I can open that one

4:37

uh, as easily here.

4:39

Let's see Q and a. Yeah, I can,

4:41

there's no open questions right now,

4:42

but if you all want to, so somebody put in lipoma a

4:45

ML Myla lipoma.

4:46

Great. So what you're basically telling me is that you see

4:49

that this lesion is very similar to the fat around it.

4:54

So this is a lesion that's composed of fat

4:56

and we have several choices when, when we're in this region.

5:00

But what you need to note in this particular case is

5:02

that the limbs of the adrenal gland are here being splayed.

5:06

That's almost like a beak sign that we talk about

5:08

with various organs telling us

5:10

where the origin of this lesion is.

5:12

So we have a fat containing lesion origin from the adrenal

5:16

and this is a myelo lipoma.

5:19

So this would fit into this particular part of the chart

5:22

that we just looked at.

5:24

This is a myelo lipoma and it's benign

5:26

and does not require any follow-up.

5:29

So here's our next case and I'm gonna show you two patients.

5:34

Actually this particular patient has no cancer history

5:37

and I think we can also see all, see

5:40

that there's a quite large right adrenal mass here

5:43

and I have it on several different uh,

5:46

phases here without contrast.

5:48

A relatively portal phase and a little bit delayed.

5:51

So again, keep in mind this patient has no cancer history.

5:56

This is the same patient underwent an MRI.

5:59

Looking at this lesion, it shows some a little bit

6:02

of bright T two, it enhances.

6:06

Now this is a similar patient, similar type

6:09

of lesion in the same location,

6:11

but this patient has a cancer history.

6:12

This patient has lung cancer

6:14

and we can see that this lesion has a little bit

6:17

of central necrosis here, an area

6:18

that is not enhancing very well.

6:22

So these are both lesions that are greater than

6:24

or equal to four centimeters.

6:26

And in this first patient with no cancer history,

6:30

our guidelines tell us to consider resection

6:32

of these lesions for any adrenal lesion found

6:35

that's greater than four centimeters.

6:36

Again, incidental and this patient did have this resected

6:41

and it's what you would probably think

6:42

adrenal cortical carcinoma.

6:44

And a few of you wrote that in there.

6:47

In this patient with a cancer history,

6:50

we would fall into this arm.

6:52

So we would consider a biopsy of this lesion

6:54

or a pet CT to try

6:55

to figure out whether it was indeed a metastasis.

6:59

And this patient underwent a a biopsy

7:01

and did indeed have a lung cancer metastasis.

7:04

And it would not necessarily be prudent

7:08

to just take this out If this patient has metastatic

7:10

disease from lung cancer.

7:12

Treatment is not usually resection of an adrenal mass

7:15

unless perhaps it is the only area of metastasis.

7:19

So we wouldn't just jump to taking this out,

7:21

we'd wanna biopsy it so

7:22

that the patient could go on appropriate chemotherapy.

7:26

But here's another patient.

7:28

This is a patient who has prostate cancer

7:30

and this was his baseline scan in May.

7:33

And you can see that the adrenal glands look normal here.

7:36

I've got a little bit of the right one,

7:37

faint left, but here we go.

7:39

Little faint little adrenal

7:40

glands here, they look pretty normal.

7:42

The patient comes back for a routine

7:45

follow up about four months later.

7:47

And what are you all seeing in this case Now

7:52

I'll let you guys type if you'd like.

7:59

Okay, yes, somebody's seeing liver mets.

8:01

So indeed we have this lesion here,

8:05

but since this is an adrenal talk,

8:08

there's also a very small adrenal lesion here.

8:10

So we can tell the right one is still normal compared

8:13

to the other side, but this one is now thickened

8:16

with some soft tissue here.

8:18

And then again you're correct,

8:19

there are liver lesions as well.

8:22

So we're thinking metastatic disease.

8:25

So this fits this particular arm.

8:27

So we have prior imaging, so we have a baseline,

8:30

we have something in the adrenal

8:31

that's newer enlarging the patient does

8:34

have a cancer history.

8:36

So we're gonna consider a biopsy

8:37

or a PET scan to prove that it's metastasis.

8:40

Now if the patient has metastatic disease elsewhere,

8:43

that's more easily accessible to a biopsy.

8:46

So it's expected someplace else

8:47

that would be more safe or easier to biopsy.

8:50

We don't necessarily have to biopsy the adrenal gland

8:52

to prove metastasis.

8:54

And in this this case, uh,

8:56

the patient's PSA was markedly elevated.

8:59

So there was more of a pre a presumptive diagnosis

9:02

of metastatic disease,

9:03

especially since the lesions in the liver also appeared.

9:06

So here he is 11 months later and unfortunately

9:10

although the adrenal lesion looks like it has been treated

9:13

to some extent it's not enhancing as much

9:15

and is perhaps slightly smaller.

9:17

The liver lesions are in uh, varying degrees of treatment

9:22

and new disease.

9:23

So he is unfortunately progressing despite therapy.

9:28

So here's another patient with a cancer history.

9:30

Again, the patient with lung cancer,

9:33

and I'm not showing you,

9:34

but this patient previously some years earlier had had a

9:38

normal scan in terms of their adrenals.

9:39

The adrenal glands like normal,

9:41

they were not getting

9:42

contrast material because of an allergy.

9:44

So we have a non-contrast scan here

9:46

and you can see that there is left adrenal

9:48

fullness at this point.

9:52

So here we have again a patient that had had prior imaging

9:56

a new or enlarging mass, again a cancer history.

9:59

So again, we'll consider PET or biopsy.

10:03

And in this case the patient underwent a PET scan which

10:05

showed marked uptake in this lesion

10:08

and it confirms what we suspect in this particular patient

10:10

that we're dealing with metastatic disease.

10:13

So the patient can then be placed on appropriate therapy.

10:19

All right, how about this particular case?

10:22

This is a patient who presented with bloating and nausea

10:26

and had no prior imaging that included the upper abdomen.

10:30

And when I talk about that

10:32

specifically saying there was nothing

10:33

that included the abdomen, you've gotta be very careful.

10:35

You can find that patients have had chest cts

10:38

that might go low enough to see if the adrenal was normal

10:41

previously they may have lumbar

10:43

or um, thoracic spine MRI even that might be uh, something

10:48

that would show an appropriate region

10:49

that you could see the adrenal.

10:51

So don't limit yourself to looking only

10:53

for prior abdominal imaging.

10:56

Look for you know, spine imaging, chest imaging

10:58

that might have the right area.

11:01

So here we have uh, again another left adrenal nodule here

11:04

and I can measure it and it's 17 by 18 millimeters.

11:09

So what do we wanna do with this at this point?

11:14

Well this is what the A CR tells us to do.

11:17

It has indeterminate imaging features

11:19

because we only had one phase of scanning

11:23

so we only had a portal venous phase, which is not enough

11:26

by itself to determine what this lesion is.

11:29

It's between one in four centimeters.

11:32

The patient didn't have any prior imaging that was relevant

11:35

and had no prior cancer history.

11:38

In this particular case it's between one

11:40

and two centimeters.

11:41

So it's probably benign in fact,

11:43

overwhelmingly likely benign in a patient

11:46

without any cancer history.

11:48

So what the A CR tells us to do is

11:50

to consider a 12 month follow up.

11:52

And that follow up should be with a very specific protocol,

11:56

an adrenal mass protocol on ct

11:58

or in some cases you can do an MRI

12:00

and I'll show you those as well.

12:02

But in this particular case that's exactly what happened.

12:05

This is a year later

12:06

and the patient underwent an adrenal protocol which has pre

12:10

contrast images like this one.

12:12

It has portal venous phase images around 65 to 75 seconds

12:17

and then delays at 15 minutes to include the adrenal glands.

12:23

Now you can note for example on this particular case

12:26

that the density of this lesion is seven hounds field units

12:31

prior to any contrast material.

12:34

And if you are in a practice

12:36

that does the non-contrast imaging

12:38

and then has a radiologist check images

12:41

before proceeding with the rest of the adrenal protocol,

12:44

you can stop right here.

12:45

We have characterized this lesion as an adenoma

12:48

because it is less than 10 hounds field units.

12:51

Now the less than 10 hounds field units,

12:53

it comes from the literature from various um, series

12:58

that have looked at what's the best cutoff value

13:00

for an adrenal adenoma.

13:02

And 10 is not arbitrary per se,

13:05

but you can adjust in at least in your practice

13:08

what your threshold is for calling adrenal adenoma.

13:12

For example, if this were a patient that had

13:15

a lung cancer history, you might want this lesion

13:18

to be very definitely an adenoma.

13:21

So you might say I wanna use a cutoff value of zero.

13:23

If it's not under zero,

13:25

I'm not gonna believe it's an adenoma.

13:27

Likewise, if let's say this were a uh, 17-year-old

13:31

who is being worked up for possible appendicitis,

13:35

the likelihood that a 17-year-old would have something other

13:37

than an adenoma is pretty small, exceedingly small.

13:41

And you might say I'm willing to take

13:43

a density measurement up to say even like 15

13:46

or 18 hounds field units

13:47

and be pretty confident it's an adenoma.

13:50

But in any case, in the literature we say 10

13:53

and that's the cutoff that most people use.

13:56

In this case the patient did not get checked with

13:59

that non-contrast and went on to have the other imaging

14:02

and we can see that the density is 72 hounds field units on

14:05

the portal phase and 28 hounds field units at 15 minutes.

14:10

So what's the easiest way to calculate the adrenal washout,

14:13

which is what we're doing here when we have these numbers?

14:17

Well if you google adrenal calculator, this is what came up

14:21

for me the other day and there is one here by Dr. Chang,

14:24

which I find the easiest to use

14:26

'cause it doesn't really have any um, advertising.

14:28

I mean he, I don't think he makes any money from having this

14:31

available and it's been available for a really long time

14:34

and he's at USC.

14:36

I don't have any relationship with him.

14:38

I'm not trying to get you to go to his website,

14:39

but it's a very easy one to use and this is what we do.

14:43

So what we do is we, if we do not have non-contrast images

14:48

but you have portal and delayed images,

14:50

you can input the values in the appropriate boxes.

14:53

So here we put the 72 and we put the 28 and we hit calculate

14:58

and it tells us that this relative washout,

15:01

and you can see here at the bottom what is used

15:04

to calculate those washouts

15:06

and you could do it by hand if you'd like to.

15:08

The relative washout is more than 40%.

15:11

So that's consistent with an adenoma

15:14

and in this case we had the pre contrast images

15:17

so we can put that value in as well.

15:19

And it does also confirm that the absolute washout

15:22

of more than 60% also confirms it's an adenoma.

15:26

So this calculator is a very quick way of getting to

15:29

that answer and it will tell you whether it is

15:32

above the 40% threshold for relative

15:35

or 60% threshold for absolute washout.

15:38

And you can be fairly confident that this is an adenoma.

15:43

So this is the rest of that algorithm

15:45

and you can see that adrenal cts also come into play

15:49

for lesions that are between two and four centimeters.

15:52

And if they are not shown to be an adenoma given

15:56

that adrenal ct, then other things need

15:59

to be considered whether you do imaging follow up, a biopsy,

16:03

a pet ct, or again resection depending upon

16:06

what the clinical picture is.

16:09

So let's move on to some more cases

16:11

and I'm gonna tell you that some

16:12

of the diagnosis we've seen may appear again

16:14

or some of them may not.

16:17

Alright, so here we have a patient

16:20

who had a contrast enhanced scan

16:22

and it's gonna be important for me

16:24

to tell you a little bit about this patient.

16:27

For example, in this case this was an unstable ICU patient.

16:31

So what do you think is going on here?

16:35

Does anybody have any ideas that they wanna

16:38

type into the q and a session?

16:42

Okay, I've got some good answers, right?

16:45

So I will tell you I don't have the images saved

16:48

that have the hounsfield unit numbers,

16:50

but several of you're picking up on the fact

16:52

that these are relatively dense lesions.

16:55

The problem is we've given contrast material

16:57

so we don't know whether they're enhancing and dense

17:00

or they're intrinsically dense.

17:03

In this case the patient had a follow-up without contrast

17:06

and you can see that these lesions are intrinsically dense.

17:09

In fact they were more than 60 hounds field

17:11

units bilaterally.

17:13

The lesions are relatively stable on this short follow-up.

17:16

And so multiple of you have come

17:18

to the conclusion this is a a bilateral

17:20

hemorrhage and you are correct.

17:22

It's also really helpful in these cases if the patient has

17:25

had no cancer history

17:27

or if there was a very recent comparison showing that the

17:31

lesions appeared really quickly

17:34

if there's still confusion over whether

17:36

or not this is hemorrhage.

17:38

Um, MRI is excellent for suggesting hemorrhage, you know,

17:41

given the dark on T two and bright Brighton T one generally,

17:45

but it might be difficult to do that in an ICU patient.

17:47

So really going back

17:49

and getting the non-contrast imaging is helpful.

17:52

The other thing you can do

17:54

if these are noted while the patient is still in the CT

17:56

suite, you can wait that 15 minutes and do wash out on these

18:00

and you'll find that this won't wash out

18:02

because it's not enhancement.

18:03

So that's another thing that can be done if these patients

18:06

are being monitored on the scanner

18:08

as you're getting imaging.

18:11

Okay, here's another patient, this is at baseline

18:15

and here she is four months later.

18:18

So what is important to know about this particular patient

18:22

for you to decide what's going on here?

18:30

Does anybody wanna venture?

18:35

Well I would wanna know does she have a history of cancer?

18:39

Because we here we have within four

18:41

months a very large mass.

18:44

So does she have a history of cancer?

18:45

Would be very important. And it turns out that yes she does.

18:48

She has a history of breast carcinoma.

18:50

So we have a new mass in the right adrenal in a patient

18:52

with breast cancer, it's large

18:55

so we're already worried about it

18:57

and you can tell that there's some areas

18:58

that are not enhancing as well.

18:59

So there is some necrosis in this lesion.

19:03

So this turned out to be a presumptive diagnosis

19:05

of metastatic disease, which is correct.

19:09

And so even without a biopsy we can be pretty sure this is

19:12

metastatic disease and if it's going

19:13

to change the way they're managing the patient

19:16

and they need tissue, this would obviously be a good place

19:19

to go and you would wanna go for those areas

19:21

that have a little more enhancement

19:23

and not the areas that are so necrotic.

19:25

And this did turn out to be metastatic breast cancer.

19:29

So here's another patient

19:37

And we see again that there's macroscopic fat.

19:42

Now the kidney and the adrenal are near this lesion.

19:45

So we have to decide is it arising from the adrenal

19:47

or arising from the kidney.

19:50

And again, I don't see a beak sign here with the kidney

19:53

and if I show you the coronal it looks more like this lesion

19:55

is pushing the kidney down, but's being again splayed,

19:59

those adrenal limbs are being splayed.

20:02

So we can be pretty confident again

20:05

that this is a myelo lipoma

20:09

and this is another myelo lipoma,

20:11

a very large one in fact again

20:13

with macroscopic fat on a non-contrast ct.

20:17

And then we can see areas

20:18

of signal dropout here on anaphase imaging areas

20:21

where there's fat and soft tissue mixed together

20:25

and the lesion does enhance and it's pushing that kidney.

20:29

So again, we're not suspecting that this is an A ML

20:32

but rather an adrenal myelo lipoma

20:35

but one this large, this was resected

20:37

and was indeed a myelo lipoma.

20:39

Now other things you need to think about in the

20:41

retroperitoneum are things like lipo sarcomas which can have

20:46

a fairly similar appearance, maybe not so rounded

20:49

and encapsulated, maybe more infiltrative than this.

20:53

But given its size, one can consider either a biopsy

20:57

to prove myelo lipoma versus lipos sarcoma

21:00

or again in this case because it was so large

21:03

a resection is usually appropriate.

21:07

Alright, whoops, sorry, how about this lesion?

21:10

This is an older woman

21:12

and I will tell you she has no cancer history.

21:21

Ah, somebody has already put in the correct answer.

21:23

Very good. So let me go through the findings here.

21:26

So on the non-contrast images, there is a little bit

21:28

of calcification in this lesion.

21:32

And then once we give contrast material you can see

21:34

that there is peripheral flow here on the earlier phase

21:39

and on a later phase you get a little bit of

21:41

of circumferential fill in here.

21:44

So if I'm talking about this sort of lesion in

21:47

for example the liver or even the spleen,

21:50

it's a little bit easier to say oh this fits a hemangioma

21:55

but they're a little bit more unusual in the adrenal gland.

21:58

But when the characteristics fit we can suggest that.

22:01

So unfortunately not everybody believes that this isn't

22:04

for example central necrosis

22:06

and a metastatic lesion even if the patient doesn't

22:09

have a history of cancer.

22:11

And these are often resected in especially younger patients

22:15

just to prove what they are.

22:18

Here's another one, very similar sort of case,

22:20

a small adrenal lesion here with some peripheral flow

22:24

and it fills in and this patient also got an MRI in an

22:28

attempt to try to characterize this

22:29

and it has some of the features that we see in

22:33

hemangiomas on MRI.

22:36

It had minimally increased in size

22:38

because there is a little bit of hemorrhage.

22:40

Hemangiomas in the adrenal can have hemorrhage.

22:43

They also tend to have very bright peripheral T two signal

22:47

and they have peripheral enhancement that tends

22:50

to fill in a little bit on more delayed imaging.

22:53

So these are some of the characteristics

22:54

of an adrenal hemangioma on MRI.

22:57

Again, you can suggest it, they're unusual,

23:00

they may end up going to biopsy

23:02

or having follow up just to make sure

23:04

that it is indeed a hemangioma.

23:08

Okay, we have another case here.

23:12

Left adrenal looks okay, a little bit

23:14

of right fullness greater than a centimeter.

23:19

So this patient underwent an MRI

23:21

for further characterization.

23:23

So here we have a T two weighted lesion

23:25

T two weighted image, sorry, showing the lesion kind

23:28

of an intermediate signal.

23:30

But does anybody wanna tell me what the sequences are on MRI

23:35

that are most helpful

23:36

to determine whether something is an adenoma?

23:40

Lemme let you think about that for a moment.

23:45

Phase, excellent, exactly or in an opposed phase.

23:49

So here's our endphase image

23:51

and you can see the adrenal lesion here.

23:52

Intermediate signal intensity and here's our opposed phase.

23:57

And you have drop of signal on the outer phase

23:59

or opposed phase imaging.

24:01

And the reason this happens is

24:03

because voxels that contain both fat and fluid

24:07

or soft tissue density, that signal cancels each other out.

24:10

So this is characteristic of an adenoma and is very helpful.

24:15

It can even be helpful in lesions

24:16

that don't have appropriate washout on ct.

24:19

You might be able to characterize a few more lesions

24:21

with washout, sorry, with dropout

24:25

of signal on T two weighted MRI.

24:27

So this is indeed an anoma

24:30

and the patient also for some reason I,

24:34

I sh I didn't show this

24:35

but they did have delayed imaging when they had their CT

24:38

and it was 66 hounds field units initially

24:41

and 36 units on the delayed imaging.

24:44

So we can also rely on our calculator

24:47

and when we calculated this, it was a washout

24:50

relative washout of 46%,

24:52

which again also says it's an adenoma.

24:55

So this patient had a lot of workup

24:56

for something that is benign.

25:01

All right, here is a different patient

25:05

with a very different sort of thing going on.

25:08

So I, I know this lesion is large

25:10

so the first thing you're gonna think of,

25:12

it doesn't really matter what it is, it's gotta come out,

25:14

it's more than four centimeters.

25:16

That's what the guidelines say.

25:17

But what if I told you this patient,

25:20

although they had no prior imaging, had presented

25:22

with weight loss, night sweats, um, so just

25:27

constitutional symptoms just really wasn't feeling well.

25:30

Is there anything else you can think about that might uh,

25:34

lead you to say, you know what,

25:35

I don't wanna just take this right out,

25:36

I wanna think about something else.

25:39

Yeah, I've had a couple suggestions here.

25:41

We have lymphoma, we have TB

25:42

and yeah there is no cancer history in this patient.

25:45

So let's see this lesion, it looks kind

25:47

of more infiltrative almost

25:49

and expansile the adrenal's not even visualized anymore.

25:53

We did do an adrenal protocol on this

25:54

so we could look at the density of it.

25:58

So here it is on the non-contrast

26:00

and you can see that it's 45 hounds field units.

26:03

So it's clearly soft tissue

26:05

and it's well over the 10 hounds field units

26:07

that we would say for an adenoma.

26:10

Here it is at 82 hounds field units on that portal phase

26:14

and 98 hounds field units on the delayed phase.

26:18

So this is not washing out at all in fact it's continuing

26:23

to go up so we don't really even need to use that calculator

26:27

to know it's not gonna have either a, a relative

26:29

or absolute washout 'cause it's not washing out.

26:33

Patient also underwent an MRI

26:35

and you can see here this lesion on the in

26:39

and out phase we don't have signal drop

26:41

so it's not helping us at all either.

26:43

The patient also had a PET scan

26:45

and it's exceedingly hot at PET scans.

26:47

So we are really suspecting malignancy

26:49

and as if some as um, some of you also said lymphoma

26:54

and that's what it turned out to be in this case.

26:56

So although the recommendation says greater than four

27:00

centimeters, it says consider resection.

27:03

Sometimes you need a biopsy.

27:05

If you think the patient might not have adrenal cortical

27:07

carcinoma or a the pheochromocytoma

27:11

or something else that would normally need

27:12

to come out this particular patient

27:14

because the biopsy showed lymphoma,

27:17

the more appropriate therapy is chemotherapy

27:20

and not resection of this lesion.

27:23

So here's another patient who has bilateral kind

27:26

of infiltrative ill-defined adrenal lesions.

27:29

This is also lymphoma and this is the patient

27:32

after chemotherapy where the adrenal lesions have

27:34

disappeared, just kind of melted away.

27:38

Now often these patients will have a uh,

27:40

lymphoma in other areas they may have

27:42

adenopathy but they don't have to.

27:44

It can be isolated to the adrenal glands.

27:48

Alright, here is a patient

27:51

and I will tell you this patient

27:52

does have a history of cancer.

27:53

This patient has lung cancer history and,

27:56

and what do you think about this lesion?

28:02

Well I read an old report

28:04

and it mentioned that the patient had an adrenal nodule

28:06

and it said that the adrenal nodule had been previously

28:09

characterized as an adenoma.

28:11

Okay, well maybe 'cause adrenal adenomas do enhance.

28:14

So perhaps this is just an adrenal adenoma.

28:17

But I thought well you know what,

28:19

I'm not just gonna look at the report, I'm gonna find

28:21

that old image and this is what the adrenal looked like

28:24

and this is the lesion that had been

28:26

characterized as an adenoma.

28:29

So what's going on here?

28:32

At that time the patient also had no uptake in

28:34

that area at PET scan.

28:36

So this is clearly not on malignant lesion.

28:39

Ah yes, somebody says collision.

28:43

So a collision tumor is can be tricky

28:47

'cause you don't wanna give the patient, you know,

28:48

new metastatic or other malignant disease

28:50

and you can have benign lesions that grow.

28:54

But you need to notice that this is very different.

28:56

There is an centric enhancing portion

28:59

of this lesion which is distinctly different than

29:02

what it looked like previously.

29:04

It's almost as though they've the two lesions,

29:07

the adenoma which may be this little low density area here

29:10

and the metastasis is what we're suspecting have collided

29:13

and are now showing up in the same location.

29:16

So the patient did undergo biopsy,

29:18

you can see our biopsy needle here

29:20

and we're gonna be going for

29:21

that more peripheral enhancing portion.

29:25

And then here's the follow-up

29:26

and unfortunately the patient did not respond well

29:29

to chemotherapy and this continued to increase in size

29:31

and this indeed was a collision tumor,

29:34

a lung cancer metastasis in a patient

29:37

that had a prior adenoma.

29:39

And indeed they really did have a prior adenoma.

29:42

It's not that we missed metastatic disease previously.

29:46

So collision tumors can be confusing

29:48

but if you look very carefully,

29:50

don't rely just on old reports

29:52

and suggest biopsy, um, you can get this correct.

29:58

All right, I know that we're supposed to be talking about CT

30:01

and MR mostly, but this was a lesion

30:03

that was found on ultrasound.

30:05

So you can see it's measured here.

30:07

It's uh, up to three centimeters in its longest dimension.

30:10

It's in the right location for an adrenal lesion.

30:15

So it's small, it's well-defined, it's very homogeneous,

30:20

it's hypoechoic, it's very smooth bordered.

30:24

And this is actually a pretty good description

30:26

for an adenoma on an ultrasound.

30:28

But if you wanna be absolutely certain about it, this is

30:32

what the patient underwent.

30:33

So they had an MRI

30:34

and again here we see this lesion intermediate signal on the

30:38

T two and we have drop out of signal

30:42

on our opposed phase they enhance.

30:45

So again this is another adenoma, it just happened

30:48

to be found on an ultrasound which is a little bit unusual.

30:53

Alright, how about this again, I know it's not a CT

30:56

or an MR to start with, this might be a little bit

30:59

of an eye test but you know we're talking

31:03

about adrenal glands.

31:05

You should know where to look

31:07

and how about if I enlarge one of the images?

31:11

Anybody see anything?

31:18

All right, put some arrows on.

31:20

Ah yes, adrenal calcification.

31:22

Now most adrenal calcification if it's not associated

31:25

with a mass, just benign.

31:27

So this patient then underwent a CT scan without contrast

31:30

and you can see that there is

31:33

calcification within both adrenal glands here

31:36

and it's conforming to the shape of the adrenals.

31:38

There is no associated mass so we're not concerned about

31:42

calcifications in say a Myla lipoma or something else.

31:46

So this patient likely had previous hemorrhage

31:48

that then shrunk and calcified

31:50

or perhaps granulomatous disease.

31:53

We do need to, somebody suggested Addison's disease.

31:57

Uh, it's possible that the patient does have adrenal

31:59

dysfunction at this point

32:00

and would need to be worked up to make sure

32:02

that that is not the case.

32:04

But I would hope that they would know prior

32:06

to this incidental finding

32:07

that the patient had adrenal dysfunction.

32:10

But yes, that is something

32:11

that can happen from prior hemorrhage and calcification

32:15

and old burnt out TB as someone else suggested.

32:17

Yes, granulomas disease can also present this way.

32:22

Now here's another mass that has calcifications

32:25

or another case with calcifications,

32:27

but clearly there's a very large mass associated with this.

32:31

And what if I show you the lung bases too?

32:35

So what's the main consideration for this?

32:37

Really large mass centered at the right adrenal gland

32:41

with lung metastases.

32:44

Yes. A CC, exactly. Cortical carcinoma.

32:48

I mean it's gonna be cortical carcinoma in something

32:51

that looks like this pretty much all the time,

32:54

unless I don't think I've ever seen.

32:56

I was gonna say maybe this is also metastatic from somewhere

32:59

else, but I don't think I've ever seen a metastatic lesion

33:01

this large in an adrenal with a primary somewhere else.

33:05

I mean this is pretty, pretty good

33:08

for an adrenal cortical carcinoma.

33:10

And if one wanted to prove the metastases, if

33:12

that was gonna change something, you could biopsy a lung

33:14

nodule instead of biopsying this

33:17

with metastatic disease already.

33:18

It's not likely they're going to,

33:20

they're certainly not gonna be going for adrenal

33:23

resection for primary cure.

33:24

They may want to debulk the disease if it's causing symptoms

33:27

and from mass effect and such.

33:29

But yeah, clearly this is already a problem.

33:33

And here's another lesion

33:34

that also has calcifications quite a bit smaller.

33:38

We do have calcifications on non-con,

33:40

but what else do you see in this

33:42

that will let you make a more definitive diagnosis?

33:46

Does anybody see anything else in this lesion? Yes, fat.

33:51

Exactly. There are areas of macroscopic fat in this lesion.

33:56

So again, I'm showing you a lot of myelo lipomas.

33:59

I'm not sure why I have so many myelo lipomas in my

34:01

collection but they all look a little

34:02

bit different from one another.

34:04

Most of the ones I find are very, very small

34:06

and almost entirely fat density.

34:08

So they're more on the centimeter, couple centimeter range,

34:12

almost miss them because they look like this fat surrounding

34:16

the adrenal and they're not very large.

34:18

But in this case the fact

34:19

that there's macroscopic fat is very helpful.

34:24

Alright, here's another lesion.

34:30

We're on a non-contrast scan here.

34:34

So I'll tell you it's uh 16 hound field units so

34:39

it's a little higher than we like for an adenoma.

34:44

So this patient went on

34:46

and had the routine study to look at for a what this is

34:50

and it's 20 ounce field units on the portal venous phase

34:55

and it's 16 ounce field units on the delayed phase.

34:59

And somebody first suggested a lipid poor adenoma,

35:03

but then a couple of people have the right answer here.

35:06

It's a cyst. And the reason I know that is

35:09

because it hasn't changed hounsfield unit density 16

35:14

to 20 is within that plus minus five to 10 hounsfield units

35:17

that we allow for variation.

35:20

Maybe a little bit of of volume averaging depending upon

35:23

where you put your hounds field unit measurement.

35:25

But that's within a range of not enhancing.

35:28

So adrenal adenomas do enhance and then they wash out.

35:33

So it's very different when you start with 16.

35:35

If we went up to say 40

35:36

and when back down, down to 16, great that's washout.

35:40

This is not, this is staying exactly the same.

35:43

So this is not enhancing to begin with

35:45

and when it's not enhancing to begin with, this is a cyst.

35:48

So it's just a benign adrenal cyst.

35:50

You can tell that it's arising from the adrenal here.

35:52

You get a little bit of normal

35:53

adrenal at the periphery here.

35:55

So we can dismiss this.

35:57

If there was any question in your mind at all,

35:59

it's large enough that it could probably

36:01

be seen by ultrasound.

36:02

So that might be helpful. I don't think an MR

36:05

is necessary in this case.

36:06

I think we can be pretty confident here

36:08

that it's just an adrenal cyst.

36:12

And here's another one. You can have calcifications

36:15

with an adrenal cysts.

36:17

So this is one that has some peripheral calcifications,

36:20

but the majority of this lesion is water attenuation

36:24

and again, another adrenal cyst.

36:30

All right, how about this one? Looks a lot like

36:32

that one I just showed you.

36:36

The density is actually fairly similar to blood pool.

36:39

So fairly similar to the aorta and the IVC next to it.

36:42

So it's not going to measure under 10 hounds field units,

36:46

but this is what it looked like on the arterial phase.

36:50

So clearly not a cyst.

36:52

So what are you guys thinking about this case?

37:00

Yeah, somebody has said pheochromocytoma.

37:03

Well that's a pretty good bet for a number of reasons.

37:05

One, I haven't really shown you one yet

37:07

and I am supposed to be showing you a variety

37:09

of adrenal pathology,

37:11

but they're also known to avidly enhance.

37:13

So yes indeed this was a pheochromocytoma.

37:18

And uh, one thing to mention about them is

37:20

that we would want to make sure

37:22

that the patient had laboratory values

37:24

to see if it's functioning.

37:26

Look at, you know, no epinephrine,

37:28

metanephrines, that sort of thing.

37:29

Urine studies, that's that kind of thing

37:30

to see if it's a functional or non-functional.

37:32

Theo, what about this case?

37:38

So at first glance, this one looks like the patient has

37:43

bilateral adrenal lesions, right?

37:46

Looks like there's 2 1, 2 1

37:50

and then part of the second one.

37:53

Well let me show you a few more images

37:56

and I've kind of tricked you here

37:58

'cause when we go a little bit lower in the body,

38:00

you can say that there's really not two lesions.

38:02

It looks like it's connected here across the midline.

38:05

So what's going on here?

38:15

Okay, someone said maybe we have a horseshoe adrenal.

38:18

Oh, that would be really rare.

38:19

I don't think I've ever seen one in my career.

38:21

Horseshoe kidney. Yeah, sure.

38:23

Never seen a horseshoe adrenal. Any other ideas here?

38:33

Yes, exactly. Someone suggested venous invasion.

38:37

So what we have here,

38:41

there's the normal right adrenal gland.

38:43

So we're not actually having a right adrenal lesion,

38:46

but this is the renal vein here.

38:49

So what happened is we have an adrenal lesion,

38:51

it's gone down the adrenal vein into the renal vein

38:54

and then crossed the left renal vein into the IVC.

38:59

So we are having an adrenal malignancy

39:04

with renal vein invasion

39:06

and it turned out that this was a

39:07

malignant pheochromocytoma.

39:09

Again, we're leaning malignant again for venous invasion,

39:13

but also these areas of necrosis.

39:14

So it's growing rapidly and outgrowing its blood supply.

39:18

So this was a pheo with a renal vein invasion.

39:21

Adrenal cortical carcinoma can also do this.

39:25

Um, adrenal is one of the rare tumors

39:27

with hepatocellular carcinoma,

39:29

renal cell carcinoma being more common to grow into veins.

39:32

I think you'll also notice here there's probably a small

39:35

liver lesion as well.

39:39

All right, now a couple of mimics of adrenal lesions

39:41

before we wrap up here.

39:45

So here we have what looks like a homogeneous

39:49

or relatively homogeneous lesion.

39:52

Here's the adrenal gland.

39:55

So it looks like it's arising from the adrenal gland.

39:58

A couple people have said SALs.

39:59

Okay, maybe, maybe,

40:03

but let me show you a couple more images.

40:07

Got this image. Now what is anybody thinking?

40:16

Yes, gastric, diverticulum or bowel lube.

40:19

So here we've got a little bit of air in that lesion

40:21

and here's actually also some debris in that lesion.

40:24

And this one turned out to be as a couple of you suggested,

40:27

a gastric diverticulum

40:29

because they're most often from the cardiac

40:31

and project backwards.

40:32

They often project in the area of the left adrenal gland.

40:36

And if you're not careful

40:37

or they don't have other content in them,

40:40

it can be very difficult to differentiate them.

40:42

If there's air in the stomach,

40:44

one can consider turning the patient over

40:47

and trying to force some air into the lesion if that's

40:49

what you're suspecting it is,

40:51

especially if you suspect a communication

40:54

with the stomach but don't see it.

40:55

Well. So here's another case.

40:59

Here are a couple of images.

41:00

Again, looks like a very homogeneous lesion in the region

41:03

of the adrenal gland,

41:05

but as I show you, the image is a little bit higher.

41:08

You can see that there's air in that.

41:09

And then again, a little bit of debris.

41:12

So this was also a gastric diverticulum.

41:18

And then this one's a little bit more obvious.

41:20

We have an a, a lesion in the region of the adrenal gland,

41:24

but we can clearly see the communication

41:26

with the stomach here and you can see it also here.

41:29

And we're just pouring some contrast material in there.

41:32

So although it is in the, in the region of the adrenal gland

41:35

because of the contrast material

41:37

and the communication, we can be, you know,

41:40

absolutely confident without having to even think about it.

41:44

All right, how about this one?

41:53

Couple of you, you put this answer for the first case.

41:56

So what, what organ is missing

41:59

that's gonna help us with this case?

42:03

Yeah, I we're up in the left upper quadrant here

42:06

and even on the coronal I don't see anything

42:08

that looks like a spleen.

42:09

And we've got a splenic flexor here pretty high.

42:13

So yes indeed these little nodules here are

42:17

actually spleen needles and you can see the adrenal here.

42:20

So it is very close to it.

42:23

But these remained steady or

42:26

or you know, uh,

42:29

they were the same size on multiple follow-ups.

42:31

This patient had other things going on

42:33

that they were being followed for.

42:35

But if it was just one of these

42:37

and you were really unsure, even in the absence

42:40

of the spleen, you could do studies

42:42

that specifically target splenic tissue like a nuclear

42:45

medicine study that might be helpful.

42:48

That would be something you could consider.

42:51

Or if you did an MRI

42:52

and had multiple sequences, this should follow

42:55

what you'd expect spleen to look like on multiple sequences.

42:58

It would be easier course if the patient had a spleen in

43:01

place to compare it to the actual spleen,

43:04

but in this case it was stenosis.

43:09

Somebody else suggested that perhaps it's a renal lesion.

43:12

And yes, the one other thing I would consider for this,

43:15

there were actually two of them,

43:16

but if there were just this one,

43:18

it could be arising from the renal capsule here

43:22

where you wouldn't get a beak sign.

43:24

And in that case, a, a renal capsule Oma

43:27

would be another good thought for this particular case.

43:31

So that is something else to keep in mind when you don't see

43:33

a beak sign but you think something could be

43:35

arising from the renal capsule.

43:40

Alright, how about this one?

43:46

We have this very vascular lesion right here,

43:55

but the adrenal gland is actually normal.

43:57

It's right here. Yes, somebody's got the answer here.

44:01

If you look carefully, there's a little vascular tail coming

44:04

off this lesion and we can see it here too.

44:06

So that is not a draining vessel.

44:08

That's actually part of the same thing.

44:11

And this one turned out to be a splenic artery aneurysm

44:14

or that was in that area poking up there.

44:18

So yes, an aneurysm is another thing that we could consider.

44:23

So those are the cases that I wanted to show you.

44:25

I've just got a few more messages here.

44:27

Um, many adrenal masses we can actually characterize.

44:31

So we wanna look at the internal content.

44:33

So fat is very important to talk about myelo lipomas

44:37

and again, we're talking about macroscopic fat.

44:40

Uh, a dr uh, renal

44:43

angiomyolipoma can be in a similar location

44:45

and you wanna be careful to determine whether the lesion is

44:48

coming off of the kidney or off of the adrenal.

44:51

But also keep in mind that both of them are benign.

44:55

Uh, angio, my lipomas are usually dealt with

44:59

or either, uh, resected or embolized as they get larger.

45:03

Myelo lipomas also do have a risk of bleeding

45:06

when they get very large lack

45:08

of enhancement at all assist.

45:11

You can also consider a completely necrotic metastasis,

45:15

for example, that's been treated may no longer show any

45:18

enhancement but may not look quite as smooth and and nice.

45:22

There may be still some areas

45:23

around the periphery that might enhance.

45:26

Um, if you do hound hounsfield unit with calculations,

45:29

adenomas can be characterized,

45:31

but there are some caveats to that.

45:33

Hypervascular metastases can also show washout

45:37

and pheochromocytomas may also wash out.

45:40

But these lesions, hypervascular metastases

45:43

and theos tend to enhance

45:45

way more than an adenoma, especially early.

45:50

So that might help you. You might also have that history

45:53

of a hypervascular primary

45:55

or you might have laboratory values that leads you

45:58

to think a, a pheochromocytoma may be there.

46:02

You wanna suspect malignancy when there's areas of necrosis,

46:06

especially with things like vein invasion.

46:09

And then the larger sizes are more likely to be malignant

46:15

Again, if the lesion is less than a centimeter,

46:17

don't mention it, especially if it's completely incidental.

46:21

If they're between one in four centimeters, we can use the

46:26

chart that I showed you from the a CR.

46:28

If they don't have a malignancy,

46:30

it's really likely to be an adenoma.

46:32

So you can check old films

46:34

and again, keep in mind to look for old chest ct,

46:37

old spine CT or MRI.

46:39

And you may not need to characterize the lesion

46:41

or follow up or follow it.

46:44

If it's between one and four

46:46

and they do have a malignancy, there is a higher chance

46:48

that it could be a metastasis.

46:50

So you do wanna think about characterizing it

46:53

and you may need a pet or biopsy ultimately

46:55

for definitive characterization.

46:58

And then again, in most cases they get resected if they're

47:00

more than four centimeters.

47:03

I also wanna mention though,

47:04

there have been a few more recent series that show

47:07

that even in patients that have malignancy,

47:10

an adrenal nodule that for example,

47:12

is found at incidentally at the initial staging.

47:15

So you don't have old images.

47:17

They present, they're being worked up

47:18

and they have a nodule at presentation.

47:21

It's still not likely to be malignant.

47:24

And I'll tell you about a paper.

47:25

There was a paper that was published

47:28

in the last couple of years.

47:30

It looked at 10,250 patients.

47:33

So we're talking about a large series of patients

47:36

that had potentially resectable gastric cancer.

47:39

So we're talking early stage gastric cancer.

47:41

And I know gastric cancer is not one of those

47:44

that routinely goes to the adrenal very early,

47:48

but they found 522 adrenal nodules, which is

47:52

within the range of expected for a population.

47:56

When we look at population based, uh, press, uh, prevalence

48:01

of inst adrenal incidentalomas

48:03

and that was, uh, 460 patients had those.

48:06

So several had more than one nodule in that entire series.

48:09

They only found five nodules

48:14

that were metastasis in two of the patients.

48:17

And both of those patients had other malignancy.

48:19

One had a lung cancer and one had hepatocellular carcinoma.

48:23

So even in a large population, all of whom had malignancy,

48:27

again 10,250 of them with gastric cancer,

48:32

they own, they found no almost no adrenal metastases.

48:35

And the two that did have metastases,

48:37

they were larger lesions,

48:38

they were pretty obvious they were

48:39

mentioned and worked up appropriately.

48:41

So when you think about the fact that,

48:43

that even in this large series of patients with cancer,

48:46

think about all the patients that we image

48:48

that don't have cancer

48:50

and we find these things,

48:51

they're even less likely to have malignancy.

48:54

So we may actually be overworking up a lot of patients

48:57

that don't need workup.

48:59

One last caveat that I'll tell you to keep in mind is

49:03

that a lot of other specialties have different guidelines

49:05

for how to follow adrenal nodules.

49:07

And I'm referring mostly to our endocrinology colleagues.

49:12

They have a very different look at adrenal nodules

49:15

'cause they're looking for nodules

49:17

that are causing the patient adrenal, uh,

49:19

or endocrine symptoms.

49:21

So even if we say explicitly in our reports

49:24

that we don't need to follow up these patients,

49:26

we still encounter these patients

49:28

because other societies think that they need to be followed.

49:31

So we've gotta give a little bit of grace

49:33

to our other colleagues

49:34

and continue to follow some of these lesions

49:36

because their guidelines are not

49:38

necessarily the same as ours.

49:42

So that, uh, again, if,

49:44

and then again, if you're suspecting something

49:45

with function, either uh, an adenoma that's functional

49:48

or a theo, you might have labs.

49:50

Now there is a question here that I'm going to,

49:52

'cause that's the last of the formal talk here.

49:54

What is the, a's logic behind the guideline

49:57

to wait 12 months to confirm a suspected adenoma rather than

50:01

alleviating patient anxiety by doing definitive imaging,

50:04

adrenal protocol, CT or MR at, in and outta phase?

50:07

So you're talking about that, uh,

50:10

it's one to two centimeters.

50:11

We're gonna wait a year to find out what it is.

50:13

The, the logic is that it's overwhelmingly likely benign

50:17

and they say consider doing that.

50:19

They don't even say to do it.

50:22

So you can usually just reassure patients

50:24

and especially in light of all the series that are showing

50:27

almost no likelihood of malignancy without a cancer history

50:31

or even again like I said, in patients with a cancer history

50:34

that gastric cancer, the same group also looked at a series,

50:38

a large series of patients, I think it was colon cancer

50:41

and came to the same conclusion

50:42

that there was such a low rate of malignancy to the adrenal.

50:46

Um, I think patient anxiety is gonna drive the fact

50:49

that often we don't wait

50:51

and we do end up with workups

50:52

of those patients even sooner than that.

50:55

You know, guidelines are guidelines, they're not absolutes.

50:58

You have to take into consideration the type

51:01

of patient you're dealing with

51:02

and what their anxiety level is, what the anxiety level

51:04

of the referring physician is.

51:06

So sometimes we do work those up,

51:08

but there are plenty of people

51:10

who will talk to their doctor.

51:11

The doctor says this has a 0.0000 whatever chance

51:16

of being malignancy extremely low.

51:18

So we're just gonna bring you back in a year.

51:20

If it's stable in a year, we've characterized it,

51:23

we don't even ever need to see you again.

51:25

And there are a lot of patients that are okay with that.

51:30

Is it possible to differentiate between a cyst

51:32

and adenoma on non-contrast ct?

51:35

Also a very good question. No, not necessarily.

51:38

Now the more homogeneous it is, the more likely

51:41

and more maybe a little bit more likely

51:43

to be cyst, but not really.

51:45

Even that theo, I showed you that was 16 hounds field units

51:48

and then enhanced really avidly

51:50

could have been mistaken for cyst as well.

51:52

So I think it is difficult.

51:54

But again, an adenoma versus cyst pretty both are benign.

52:00

Theo are a, uh, are sometimes a little hard.

52:03

That one was a little bit bigger.

52:04

I don't remember exactly how large it was.

52:06

It might have been closer to four centimeters.

52:08

So you're gonna lean a little more toward doing something.

52:13

Apologies if you mentioning this already.

52:15

Did you find washout reliable?

52:17

The European guidance suggests it's not totally.

52:20

And to carry out a non-contrast,

52:22

so you're talking about relative washout as opposed

52:25

to just looking at, um, the hounsfield unit numbers.

52:30

Um, usually in my practice when they, when we go ahead

52:34

and do an adrenal protocol, we actually check all of them.

52:38

So we do the non-contrast

52:39

and if it proves in adenoma we stop.

52:42

So I haven't had to really think about, um,

52:46

comparing relative washout

52:48

to an absolute number on a non-contrast ct.

52:52

Um, and I, I have to apologize.

52:53

I haven't read anything very recently that would lead me

52:58

to feel badly about relative washout,

53:01

but it probably is,

53:03

I think absolute washout is probably a better indicator.

53:06

And I do agree that I like the non-contrast.

53:09

It really is reassuring to me if it is less than 10.

53:14

Anything else? I don't think I've got some. Thank you here.

53:19

You're welcome.

53:21

Yeah, I I think you got 'em all. Dr.

53:23

Baumgarten, thank you so much.

53:25

Okay, you're welcome. It's time we got 1256, so I know

53:29

that you were expecting to be here till exactly one o'clock.

53:31

But go ahead and enjoy four more minutes

53:33

of your life on your own

53:34

and I appreciate you all tuning in. Thank you so much.

53:37

Well, thank you so much again Dr.

53:39

Baumgarten, for sharing your expertise

53:41

and your case review with us today.

53:42

And thanks to all for participating in our noon conference

53:46

and asking great questions.

53:47

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53:50

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53:53

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53:57

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54:00

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54:02

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54:06

CNS Vasculitis.

54:07

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54:14

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