Journal of Yeungnam Medical Science

Case report

Ureterosciatic hernia causing obstructive uropathy successfully managed with minimally invasive procedures: Yeong Uk Kim, Jae Ho Cho, Phil Hyun Song; Yeungnam Univ J Med. 2020;37(4):337-340. Published online July 29, 2020; DOI: https://doi.org/10.12701/yujm.2020.00402

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Ureterosciatic hernia is extremely rare. In ureteral herniation, ureter prolapses occur through either the greater or lesser sciatic foramen. Atrophy of the piriformis muscle, hip joint diseases, and defects in the parietal pelvic fascia are predisposing factors for the development of ureterosciatic hernia. Most symptomatic patients have been treated surgically, with conservative treatment reserved only for asymptomatic patients. To the best of our knowledge, long-term follow-up outcomes after ureterosciatic hernia management are sparse. In this paper, we report the case of a 68-year-old woman who presented with colicky left abdominal pain. After computed tomography (CT) scan and anterograde pyelography, she was diagnosed ureterosciatic hernia with obstructive uropathy. We performed ureteral balloon dilatation and double-J ureteral stent placement. After this minimally invasive procedure, CT scan demonstrated that the left ureter had returned to its normal anatomical position without looping into the sciatic foramen. The patient remained asymptomatic with no adverse events 7 years after the minimally invasive procedures. This brief report describes ureterosciatic hernia successfully managed with minimally invasive procedures with long-term follow-up outcomes.

Citations

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Ureterosciatic Hernia in Focus: A Narrative Review of the Literature
Mohamed Mustafa, Afiq Pouzi, Peter Senada, Lokesh Suraparaju, Suresh Gupta
Cureus.2023;[Epub] CrossRef
Urosepsis secondary to ureterosciatic hernia corrected with ureteral stent placement: a case report and literature review
Kohei Kakimoto, Mayu Hikone, Ko Nagai, Jun Yamakawa, Kazuhiro Sugiyama, Yuichi Hamabe
International Journal of Emergency Medicine.2021;[Epub] CrossRef

Case Reports

Adrenocorticotropic hormone (ACTH)-producing pheochromocytoma presented as Cushing syndrome and complicated by invasive aspergillosis.: Jae Ho Cho, Da Eun Jeong, Jae Young Lee, Jong Geol Jang, Jun Sung Moon, Mi Jin Kim, Ji Sung Yoon, Kyu Chang Won, Hyoung Woo Lee; Yeungnam Univ J Med. 2015;32(2):132-137. Published online December 31, 2015; DOI: https://doi.org/10.12701/yujm.2015.32.2.132

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Abstract PDF

Adrenocorticotropic hormone (ACTH)-producing pheochromocytoma has been rarely reported, whereas only a few cases of Cushing syndrome accompanied by opportunistic infections have been reported. We experienced a patient with pheochromocytoma with ectopic Cushing syndrome complicated by invasive aspergillosis. A 35-year-old woman presented with typical Cushingoid features. Her basal plasma cortisol, ACTH, and 24-hour urine free cortisol levels were significantly high, and 24-hour urine metanephrine and catecholamine levels were slightly elevated. The endogeneous cortisol secretion was not suppressed by either low- or high-dose dexamethasone. Abdominal computed tomography (CT) revealed a heterogeneous enhancing mass measuring approximately 2.5 cm in size in the left adrenal gland. No definitive mass lesion was observed on sellar magnetic resonance imaging. On fluorine-18 fluorodeoxyglucose positron emission tomography/CT, a hypermetabolic nodule was observed in the left upper lung. Thus, we performed a percutaneous needle biopsy, which revealed inflammation, not malignancy. Thereafter, we performed a laparoscopic left adrenalectomy, and its pathologic finding was a pheochromocytoma with positive immunohistostaining for ACTH. After surgery, the biochemistry was normalized, but the clinical course was fatal despite intensive care because of the invasive aspergillosis that included the lungs, retina, and central nervous system.

Citations

Citations to this article as recorded by

Ectopic ACTH- and/or CRH-Producing Pheochromocytomas
Patrick F Elliott, Thomas Berhane, Oskar Ragnarsson, Henrik Falhammar
The Journal of Clinical Endocrinology & Metabolism.2021; 106(2): 598. CrossRef
Ectopic adrenocorticotrophic hormone syndrome (EAS) with phaeochromocytoma: a challenging endocrine case with a happy ending
Sharifah Faradila Wan Muhamad Hatta, Leoni Lekkakou, Ananth Viswananth, Harit Buch
BMJ Case Reports.2019; 12(8): e230636. CrossRef
Severe Cushing Syndrome Due to an ACTH-Producing Pheochromocytoma: A Case Presentation and Review of the Literature
Jenan N Gabi, Maali M Milhem, Yara E Tovar, Emhemmid S Karem, Alaa Y Gabi, Rodhan A Khthir
Journal of the Endocrine Society.2018; 2(7): 621. CrossRef

Unusual paradoxical embolic stroke in a patient with persistent left superior vena cava.: Tae Hun Kwon, Kang Un Choi, Byung Jun Kim, Jae Ho Cho, Jae Young Lee, Kyu Hwan Park, Sang Hee Lee, Jang Won Son; Yeungnam Univ J Med. 2015;32(2):118-121. Published online December 31, 2015; DOI: https://doi.org/10.12701/yujm.2015.32.2.118

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Abstract PDF: Cardiogenic embolic stroke accounts for approximately 20% of ischemic strokes and the likelihood of its recurrence is high. Paradoxical embolism may be an important cause of cardioembolic stroke, which can be evaluated through multiple diagnostic modalities including transesophageal echocardiography (TTE) or transcranial Doppler. A persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly, which mainly drains to the right atrium via the coronary sinus. Although rare, PLSVC draining into the left heart predisposes the patient to paradoxical embolism through a right-to-left shunt. We report on a 78-year-old female patient with an ischemic stroke associated with PLSVC draining into the left atrium through the pulmonary vein, which was investigated via TTE with an agitated saline test and computed tomography.

Severe hyponatremia and seizures after bowel preparation with low-volume polyethylene glycol plus ascorbic acid solution.: Jae Young Lee, Byung Ik Jang, Yoon Jeong Nam, Jay Song, Min Cheol Kim, Seung Min Chung, Jong Geol Jang, Jae Ho Cho; Yeungnam Univ J Med. 2015;32(1):55-59. Published online June 30, 2015; DOI: https://doi.org/10.12701/yujm.2015.32.1.55

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Abstract PDF: The widely used polyethylene glycol (PEG)-based solutions have been proven effective for bowel preparation when 4 L of the solution is administered before colonoscopy. However, large volumes of the solutions are generally poorly tolerated. A new PEG-based solution consisting of 2 L of PEG and a high dose of ascorbic acid has recently become available. Electrolyte abnormalities caused by PEG-based solutions have rarely been reported. We report on a case of acute severe hyponatremia with associated generalized tonic-clonic seizures after bowel preparation with a low-volume PEG plus ascorbic acid solution in a 74-year-old woman with no history of seizures. She took a beta blocker, an angiotensin-converting enzyme inhibitor, and glimepiride for hypertension and diabetes mellitus. She showed general weakness, nausea, agitation, muscle cramping, and seizures after ingestion of the PEG plus ascorbic acid solution. Her serum sodium level was 112 mEq/L. Her symptoms improved after intravenous administration of hypertonic saline. Physicians should pay attention to screening for electrolytes and development of neurological symptoms during bowel preparation.

Immune thrombocytopenia associated with sarcoidosis.: Da Eun Jeong, Min Kyoung Kim, Sung Ae Koh, Kyoung Hee Lee, Joon Hyuk Choi, Young Hoon Hong, Jae Ho Cho, Eun Ju Goo, Myung Soo Hyun; Yeungnam Univ J Med. 2015;32(1):26-30. Published online June 30, 2015; DOI: https://doi.org/10.12701/yujm.2015.32.1.26

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Abstract PDF: Sarcoidosis is a systemic disease of unknown cause involving multiple organs and is characterized by noncaseating granuloma. Immune thrombocytopenia (ITP) is an autoimmune disease characterized by increased peripheral platelet destruction due to the presence of an antibody to the platelet and abnormal platelet production. There is no known pathogenesis that occurs concurrently with ITP and sarcoidosis. However, considering together of 2 known pathogenesis, abnormal immune response triggers either ITP or sarcoidosis. The disease that develops first stimulates secondary disease. After development of secondary disease, they stimulate each other. A few cases of ITP associated with sarcoidosis are well documented in English; however, the disease has rarely been reported in Korea. Here, we report on a case of ITP with sarcoidosis in a 29-year-old man. He suffered from easy bruising. The chest X-ray and the contrast-enhanced computed tomography scan showed bihilar lymphadenopathy and reticulonodular infiltrates. Bone marrow study and fluoroscopy-guided percutaneous needle biopsy were performed and the patient was diagnosed with sarcoidosis and ITP. He was put on 400 mg/kg of intravenous immunoglobulin for 5 days and administered oral steroids and further follow-up will be carried out. He has shown a good response without significant bleeding event. However, administration of more oral steroid and additional follow-up is required than for single disease, whether sarcoidosis or ITP.

A Case of Pancytopenia with Hyperthyroidism.: Tae Hoon Kim, Ji Sung Yoon, Byung Sam Park, Dong Won Lee, Jae Ho Cho, Jun Sung Moon, Eui Hyun Kim, Kyu Chang Won, Hyoung Woo Lee; Yeungnam Univ J Med. 2013;30(1):47-50. Published online June 30, 2013; DOI: https://doi.org/10.12701/yujm.2013.30.1.47

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Abstract PDF

There has been an increase in the number of reports of atypical manifestations of Graves' disease (GD), such as jaundice, anemia, thrombocytopenia and leukopenia. Pancytopenia also rarely occurs in GD. In this paper, a case of pancytopenia with GD that was successfully treated with an anti-thyroid drug is reported. In this case, a 69-year-old woman showed pancytopenia with a normal peripheral blood smear, bone marrow aspiration smear and bone marrow biopsy. Her thyroid function test and thyroid scintigraphy confirmed her hyperthyroid status. Her laboratory abnormality and clinical condition improved after she was treated with an anti-thyroid drug. This is a rare case of pancytopenia associated with GD.

Citations

Citations to this article as recorded by

Therapeutic plasma exchange for Graves’ disease in pregnancy
Matthew Lumchee, Mimi Yue, Josephine Laurie, Adam Morton
Obstetric Medicine.2023; 16(2): 126. CrossRef
Non-myeloproliferative Pancytopenia: A Rare Presentation of Thyrotoxicosis
Izzathunnisa Rahmathullah, Maheswaran Umakanth, Suranga Singhapathirane
Cureus.2023;[Epub] CrossRef
Atypical Complications of Graves’ Disease: A Case Report and Literature Review
Khaled Ahmed Baagar, Mashhood Ahmed Siddique, Shaimaa Ahmed Arroub, Ahmed Hamdi Ebrahim, Amin Ahmed Jayyousi
Case Reports in Endocrinology.2017; 2017: 1. CrossRef

Original Articles

Differentiation of Chromophobe Renal Cell Carcinoma and Clear Cell Renal Cell Carcinoma by Using Helical CT.: Hong Chul Kim, Jae Ho Cho; Yeungnam Univ J Med. 2012;29(1):14-18. Published online June 30, 2012; DOI: https://doi.org/10.12701/yujm.2012.29.1.14

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Abstract PDF

BACKGROUND
The purpose of this study was to differentiate chromophobe renal cell carcinoma and clear cell renal cell carcinoma on helical CT. METHODS: The CT images of 9 patients histopathologically proven to have chromophobe renal cell carcinoma and 20 patients with clear cell renal cell carcinoma were reviewed. The tumor sizes, margins, enhancement degrees and patterns, presence or absence of calcification, and tumor spread patterns (including perinephric changes, venous invasion, lymphadenopathy, and distant metastasis) were compared. RESULTS: All the chromophobe renal cell carcinomas showed well-demarcated margins. Thechromophobe renal cell carcinomas showed milder enhancements than the clear cell renal cell carcinomas. The sensitivity and specificity for differentiating the chromophobe renal cell carcinoma from the clear cell renal cell carcinoma were 100 and 88%, respectively, when 101 Hounsfield units was used as the cut-off value in the corticomedullary phase, and 95 and 100% when a less-than-three-time enhancement change was used as a cut-off value in the corticomedullary phase (p<0.05). The chromophobe renal cell carcinomas (67%) tended to show a homogeneous enhancement whereas the clear cell renal cell carcinomas (85%) usually showed a heterogeneous enhancement (p<0.05). Statistical analysis revealed that the frequencies of the tumor spread pattern and calcification in the two subtypes didnot differ significantly (p>0.05). CONCLUSION: The CT findings of the chromophobe renal cell carcinomascompared to those of the clear cell renal cell carcinomas showed that there were mild enhancements in the corticomedullary phase, homogeneous enhancements, and well-demarcated margins.

Citations

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Density of Orbital Fat and Extraocular Muscle in Thyroid-Associated Myopathy and Idiopathic Orbital Myositis
Hye Mi Cheong, Woo Jin Jeong, Hee Bae Ahn
Journal of the Korean Ophthalmological Society.2013; 54(11): 1641. CrossRef

Ultrasonographic and Magnetic Resonance Imaging Findings of Testicular Lymphoma.: Jae Ho Cho; Yeungnam Univ J Med. 2010;27(2):105-112. Published online December 31, 2010; DOI: https://doi.org/10.12701/yujm.2010.27.2.105

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Abstract PDF: PURPOSE: To evaluate the specific radiologic findings of testicular lymphoma which will be able to differentiated from other testicular tumors. MATERIAL AND METHODS: Pathologically confirmed eight cases were included in this study. All eight cases were performed ultrasonography and four cases were performed magnetic resonance image. On ultrasonography, the size, location, shape, margin, internal echogenicity, homogeneity and vascularity were evaluated. On magnetic resonance image, the shape, margin, homogeneity, signal intensity on T1- and T2-weighted images, degree and homogeneity of the contrast enhancement and contrast enhancement change on dynamic enhancement study. RESULTS: The margin of the mass was smooth on 6 of 8 patients. Internal echogenicity of the mass lesion was hypoechoic than normal testicular parenchyme on 7 of 8 patients. Four cases were homogeneous, 3 cases were relatively homogeneous and 1 case was heterogeneous. All 8 cases showed increased vascularity. The mass lesion was iso-signal intensity on T1-weighted image and low-signal intensity on T2-weighted image. All four cases were enhanced homogeneously and mildly than enhancing normal testicular parenchyme. On dynamic enhancement study, the mass lesion is progressively enhanced with time. CONCLUSION: The possibility of testicular lymphoma should be considered when testicular mass was homogeneously hypoechoic and low signal intensity on T2-weighted image in old age patients.

Radiologic Findings of Renal Oncocytomas.: Jae Ho Cho; Yeungnam Univ J Med. 2009;26(1):30-37. Published online June 30, 2009; DOI: https://doi.org/10.12701/yujm.2009.26.1.30

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Abstract PDF: PURPOSE: To radiologically differentiate renal oncocytoma from other renal solid tumors, we analyzed and characterized, retrogradely, radiologic findings of renal oncocytomas. MATERIALS AND METHODS: Radiologic findings of pathologically proven renal oncocytoma were analyzed in 9 patients. CT was performed in all patients, ultrasonography in 4 patients and MRI in 3 patients. (51) RESULTS: On ultrasonography, the echogenicity of the mass was slightly more hyperechoic than normal renal parenchyma in all 4 cases. Two cases were homogeneous and the remaining two cases were relatively homogeneous. On CT, all 8 cases showed iso-density to slightly low density compared to normal renal parenchyma and 5 cases were homogeneous but the central portion of the mass was of a slightly lower density than the peripheral portion in 3 cases. All six cases had an arterial phase scan and were heterogeneously enhanced. An irregular, lower-enhancing portion was found in the central portion of the mass. Segmental inversion of contrast enhancement was found in 5 of 6 cases that had a dynamic enhancement study. On MR T1-weighted imaging, the mass was of iso-signal intensity to normal renal parenchyma and the central portion of the mass had a slightly hypo-signal intensity than the peripheral portion. On T2-weighted imaging, 2 cases were heterogeneous; the peripheral portion was of low signal intensity and the central portion was of higher signal intensity than normal renal parenchyma. One case was relatively homogeneous and showed a slightly lower signal intensity than that of normal renal parenchyma, except for a central small portion showing high signal intensity. For 2 cases that had a dynamic study, a segmental inversion of contrast enhancement was noted. CONCLUSION: Renal oncocytoma is seen as a well-marginated solid mass lesion. On enhanced scans it is heterogeneously enhanced and segmental inversion of contrast enhancement may be seen. The possibility of oncocytoma can be suggested in cases showing these radiologic findings.

Power Doppler Sonography for the Upper Urinary Tract Infection in Children.: Jung Youn Choi, Jae Ho Cho, Yong Hoon Park; Yeungnam Univ J Med. 2007;24(2):179-185. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2.179

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Abstract PDF

BACKGROUND
Urinary tract infection (UTI) is common in children. The available gold standard methods for diagnosis, Tc-99m dimercaptosuccinic acid (DMSA) scan and computed tomography (CT) are invasive and expensive. This study was performed to assess the role of power Doppler ultrasound (PDU) for diagnosis of acute pyelonephritis (APN). MATERIALS AND METHODS: A prospective study was conducted in 25 children with aged 2 weeks to 5 years who were hospitalized with the first episode of febrile UTI suggesting acute pyelonephritis. All children were examined in the first 3-5 days of admission by PDU and Tc-99m DMSA scan. The comparison between PDU and DMSA scan was performed on the basis of patients. RESULTS: The sensitivity and specificity of PDU for the detection of affected kidneys were 38.1% and 50.0%, and the positive predictive value and negative predictive value were 61.9% and 50.0%, respectively. Vesicoureteral refluxes (VUR) were identified in 11 patients (44.4%) and 18 kidneys (36%). The PDU and DMSA scan showed a matching perfusion defect in 23.8% and 50.0% respectively. CONCLUSION: These data indicate the PDU has a relatively low sensitivity and specificity for differentiating APN from lower UTI but may be a complement tool to DMSA scan for the prediction of VUR in infants and children.

Citations

Citations to this article as recorded by

Comparison of 99mTc-DMSA Renal Scan and Power Doppler Ultrasonography for the Detection of Acute Pyelonephritis and Vesicoureteral Reflux
Hee Jung Bae, Yong-Hoon Park, Jae Ho Cho, Kyung Mi Jang
Childhood Kidney Diseases.2018; 22(2): 47. CrossRef
Urinary tract infections in pediatric oncology patients with febrile neutropenia
Kyoo Hyun Suh, Sun Young Park, Sae Yoon Kim, Jae Min Lee
Yeungnam University Journal of Medicine.2016; 33(2): 105. CrossRef

Case Reports

Supratentorial Leptomeningeal Hemangioblstoma －Case Report－: Han Won Jang, Woo Mok Byun, Jae Kyo Lee, Jae Ho Cho, Kil Ho Cho, Mi Soo Hwang, Bok Hwan Park, Joon Hyuk Choi; Yeungnam Univ J Med. 2007;24(2 Suppl):S770-774. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S770

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Hemangioblastoma is a benign tumor that most commonly occurs in the cerebellum and associated with von Hippel-Lindau (VHL) disease. Supratentorial hemanigoblastomas are exceptionally rare. We describe the magnetic resonance imaging (MRI) and histopathologic findings of a supratentorial leptomeningeal hemangioblastoma.

Citations

Citations to this article as recorded by

Sporadic supratentorial hemangioblastoma with meningeal affection: A case report and literature review
Juan Francisco Sánchez-Ortega, Marta Claramonte, Mónica Martín, Juan Calatayud-Pérez
Surgical Neurology International.2021; 12: 394. CrossRef
Supratentorial hemangioblastomas in von Hippel–Lindau wild-type patients – case series and literature review
Luís Rocha, Carolina Noronha, Ricardo Taipa, Joaquim Reis, Mário Gomes, Ernesto Carvalho
International Journal of Neuroscience.2018; 128(3): 295. CrossRef
Meningeal Supratentorial Hemangioblastoma in a Patient with Von Hippel-Lindau Disease Mimicking Angioblastic Menigioma
Hoon Kim, Ik-Seong Park, Kwang Wook Jo
Journal of Korean Neurosurgical Society.2013; 54(5): 415. CrossRef
Supratentorial hemangioblastoma: clinical features, prognosis, and predictive value of location for von Hippel-Lindau disease
S. A. Mills, M. C. Oh, M. J. Rutkowski, M. E. Sughrue, I. J. Barani, A. T. Parsa
Neuro-Oncology.2012; 14(8): 1097. CrossRef

Cystic Dystrophy in Heterotopic Pancreas of Duodenal Wall －A Case Report－: Mi Jin Gu, Won Kyu Park, Yeung Kyong Bae, Jae Ho Cho, Jay Chun Chang, Jae Woon Kim, Kil Ho Cho, Mi Soo Hwang, Bok Hwan Park, Joon Hyuk Choi; Yeungnam Univ J Med. 2007;24(2 Suppl):S647-651. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S647

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Abstract PDF: Cystic dystrophy is an uncommon, benign poorly understood disease. It is characterized by the development of cysts in heterotopic pancreatic tissue. A 57-year-old-man was hospitalized for abdominal pain for a week. He is a heavy alcohol drinker. There was a cyst at second portion of duodenum on CT. Under the impression of peptic ulcer perforation, Whipple’s operation was performed. Grossly, a cystic space, measuring 3.0 cm in diameter, was noted within the thickened duodenal wall. Microscopically, the cyst was lined by columnar epithelium and granulation tissue and embedded in ectopic pancreatic tissue. The adjacent pancreatic tissue showed focal chronic pancreatitis.

A Case of Reversed Intestinal Rotation: Won Kyu Park, Jae Ho Cho, Jay Chun Chang, Jae Woon Kim, Mi Soo Hwang; Yeungnam Univ J Med. 2007;24(2 Suppl):S632-635. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S632

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Abstract PDF: Diagnosis and treatment of a patient with a congenital anomaly of the midgut with persistent symptom in adult can be difficult because it is particularly in adults. Reversed rotation of the midgut is the rarest of all malrotation anomalies. We report a case of reversed intestinal rotation and review the embryology, clinical presentation, and radiographic findings of this disorder. Although this anomaly is rare, it may be diagnosed by the knowledge of embryology and anatomy.

Review Articles

Ultrasonography of the Scrotum: Bok Hwan Park, Jae Ho Cho; Yeungnam Univ J Med. 2007;24(2 Suppl):S24-35. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S24

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Abstract PDF: Ultrasonography is an important imaging tool in the evaluation of the scrotal structures and various scrotal disorders because of excellent anatomic resolution, easy and speedy applicability, and safety with no inonizing radiation. Furthermore, a blood flow information can be obtained by the use of color Doppler ultrasonography and spectral waveform analysis. It plays a primary role in the detection, characterization, and localization of scrotal masses and fluid collections. Knowledge of characteristic imaging findings enables appropriate, expeditious evaluation of various scrotal disorders. The objective of this article is to familiarize the reader with the ultrasonographic features of various scrotal disorders.

Radiological Diagnosis of Adrenal Diseases: Jae Ho Cho; Yeungnam Univ J Med. 2007;24(2 Suppl):S170-185. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S170

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Abstract PDF: Adrenal glands are relatively small than other upper abdominal solid organs but they are affected by complex physiologic and neoplastic processes. In the past, normal adrenal gland and small adrenal masses are difficult to examine because adrenal gland is small and located deeply in the abdominal cavity. However, by the recent remarkable advance of the MR and CT machines and imaging techniques detection of normal adrenal gland and detection and differential diagnosis of various adrenal lesions are possible. And so radiology is playing a critical role in not only the detection of adrenal abnormalities but in characterizing them as benign or malignant. In the diagnosis of adrenal lesions, various imaging modalities are used including, ultrasonography, CT, MR imaging and nuclear medicine imaging. Ultrasonography plays a role as a screening imaging modality. CT is the imaging modality of choice for both detection and characterization of adrenal masses. MR imaging is a problem solving modality in cases of inconclusive or insufficient on CT. The purpose of this article is to give an overview of adrenal diseases and their imaging appearances and describe the current concepts of differentiating a benign from a malignant adrenal mass.

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