Left Adrenal Gland Mass with Phrenic Vein Invasion in a 9-Year-Old MN Heeler Mix: Case Of the Month March 2019
An adrenal mass……
Wait! Imaging adrenal pathology doesn’t end with just finding the mass. It’s essential to fully interrogate the associated structures for further pathology. Is there phrenic vessel invasion and caudal vena cava invasion? Are the renal veins evident? Full Doppler imaging? Is the specialist able to measure the vessels accurately for potential surgical planning information? Heidi Putnam, SDEP™ technician clinical sonographer for Animal Sounds North West, did all of this and more as demonstrated superbly in the complete imaging in this case.Kudos to the pet owners for being compliant in the recommendation for annual exams. Many thanks to Dr. Meri Brandt and Dr. Jon Duncan of Willakenzie Animal Clinic in the management of this patient and to Amy Roth Jones, DVM, DACVR for her detailed interpretation of this case.
A 9-year-old, MN, Heeler mixed breed canine was presented for his routine annual visit. Upon physical examination a 1.5cm firm subcutaneous mass was discovered on his ventral neck. FNA was performed resulting in blood. CBC/Chem was normal and the patient underwent surgical removal of the mass. An abdominal ultrasound was performed to screen for any signs of metastasis in the abdomen.
The right adrenal gland is normal in size and shape measuring 3.0 cm in length and 0.6 cm in diameter at the caudal pole and 1.3 cm in the cranial pole (increased dimension secondary to positioning). The gland is uniformly homogenous and normal echoic. The left adrenal gland is comprised of a well demarcated and well encapsulated, round soft tissue mass of uniformly heterogenous echogenicity with multiple, small, anechoic cystic structures. It measures 3.6 x 3.8 cm. Color flow Doppler reveals increased vascularity through the entire mass. Several high quality clips of the region document a well-defined, irregularly marginated tubular soft tissue structure of similar, heterogenous echogenicity as the left adrenal mass filling the left phrenic abdominal vein and entering the caudal vena cava. Within the vena cava the structure is free floating and not attached to the wall. Color flow Doppler demonstrates blood flow completely around the structure, which measures approximately 5.0 cm in length within the caudal vena cava and terminates just caudal to entrance into the liver. The dimensions of this intravascular caudal vena caval structure are 5.0 cm in length x 1.2 cm in diameter. However, the dimension of the insertion of the phrenic abdominal vein measures only 5.8 mm. The renal vein is well visualized caudal and peripheral to the mass with no evidence of renal vein invasion.
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Complex left adrenal mass with capsular expansion and undifferentiated heterogenous architecture.
Caudal vena cava invasion by left adrenal tumor and or thrombus.
CVC mass +/- attached thrombus.
Left phrenicoabdominal vascular extension into the CVC.
Normal right adrenal gland.