OBJECTIVE: The purpose of this study was to determine the spectrum of imaging 
appearances of pheochromocytoma and the associated clinical and biochemical 
features.
MATERIALS AND METHODS: In this retrospective study, a citywide pathology 
database (2000-2011) was searched to identify the records of patients with 
pheochromocytoma. The search yielded the cases of 53 patients (28 men, 25 women; 
mean age, 50 years). The institutional PACS and radiology information system 
records, hospital charts, and the provincial electronic health records of these 
patients were reviewed. Imaging appearances and clinical and biochemical 
features related to pheochromocytomas were recorded.
RESULTS: One chart was not available for review. In the 52 cases analyzed, 40 of 
the patients had symptoms: 31 patients had hypertension; 10 had the triad of 
palpitations, diaphoresis, and headaches; and all had elevated urinary 
metanephrine concentrations. Seven patients had a familial syndrome, and five 
had bilateral pheochromocytomas. One patient had an extraadrenal 
pheochromocytoma, and five had malignant tumors. The mean size of 
pheochromocytomas was 4.0 cm. Most pheochromocytomas were heterogeneous (CT, 
56%; MRI, 65%; ultrasound, 45%) and were MIBG positive (90%). Eleven of 34 (32%) 
pheochromocytomas had T2 signal intensity greater than that of the spleen. Most 
pheochromocytomas were less enhancing than the spleen (CT, 85%; MRI, 71%). 
Contrast-enhanced CT was performed on 33 tumors, of which 20 enhanced less than 
the spleen and 8 showed similar enhancement to the spleen; contrast-enhanced MRI 
was performed on 24 tumors, of which 12 enhanced less than the spleen and 5 
showed similar enhancement to the spleen. Predominant cystic change was found in 
4 of 20 (20%) ultrasound, 9 of 41 (22%) CT, and 11 of 34 (32%) MRI examinations. 
Eight of 34 (24%) pheochromocytomas were hemorrhagic, two (5%) had 
calcifications, and three of six were PET positive. Two cystic pheochromocytomas 
and one lipid-containing pheochromocytoma were misdiagnosed as adrenal adenomas.
CONCLUSION: Most pheochromocytomas were heterogeneous at imaging, were MIBG 
positive, accompanied elevated urinary metanephrine concentrations, and were 
symptomatic. High T2 signal intensity was found in approximately one third of 
solid tumors. Atypical imaging features included homogeneity, cystic change, 
hemorrhage, intense enhancement, calcifications, intracellular lipid, 
bilaterality, and malignancy.