Anatomically the right adrenal gland is adjacent to the inferior part of the right lung posteriorly, liver laterally, spine medially and inferior vena cava anteriorly. This position limits the opportunities available for low risk access for percutaneous biopsy. Previous diagnostic CT examination of this patient also showed the portal vein abutting the anterior surface of the lesion. Following discussion with the performing radiologist, the patient was positioned prone with three pillows elevating the pelvis. This resulted in a "head down" angle at the biopsy site which was designed to afford access to the lesion while avoiding the posterior diaphragm. Expiratory arrested respiration aided in this effort during imaging and needle manipulation.

Three core samples were obtained, each washed from the core needle tip using a jet of saline into the pot of formalin. Minimal bleeding was observed from the site, which was managed with pressure for two minutes and the application of a 3 cm × 6 cm self-adhesive non-stick dressing. The patient was rolled into a supine position on a barouche and made comfortable. Transport to the recovery ward for observation was arranged and the patient was discharged two hours later. Prior to discharge, a chest X-ray was performed to ensure there had been no injury to the adjacent diaphragm resulting in pneumothorax. During the patient’s recovery stay, all observations were well within normal limits and no pain management protocol was required.

In the absence of a cancer history, a non-contrast CT of the adrenal glands is the accepted practice in our organization. Benign adrenal adenoma is the most common finding. Adrenal adenoma is seen as a discrete lesion of relatively uniform density with an average Houndsfield Units (HU) value of 10 or less. Lesions fitting this description are considered low risk and are managed conservatively. Lesions of higher density require more vigorous investigation, especially those which are rapidly growing or greater than 6 cm in diameter. In particular, lesions with irregular contours are suspicious of malignancy and can further be characterized through a multiphasic CT examination. Due to the risk of hypertensive crisis in pheochromocytoma, evaluation of the lesion prior to biopsy is advised.

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