Spontaneous adrenal hemorrhage is rare. When it does occur, a high level of suspicion for malignant disease or pheochromocytoma should be maintained. The possibility of a hematoma masquerading as a neoplasm should also be considered. In cases of ongoing hemorrhage, embolization may be a lifesaving temporizing measure. Acute surgical intervention should be considered in selected patients, and surgery may not be required in all patients. A cautious approach with a comprehensive biochemical and imaging work-up is advised prior to operation.

Abbreviations: DSA = digital subtraction angiography, MDP = methylene diphosphonate, tPA = tissue plasminogen activator

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Patient-specific dosimetry in radiopharmaceutical therapy (RPT) is impeded by the lack of tools that are accurate and practical for the clinic. The aims were to construct and test an integrated voxel-level pipeline that automates key components (organ segmentation, registration, doserate estimation, and curve fitting) of the RPT dosimetry process and then to use it to report patient specific dosimetry in 177Lu-DOTATATE therapy. Methods. An integrated workflow that automates the entire dosimetry process, except tumor segmentation, was constructed. 1) Convolutional neural networks (CNNs) are used to auto-segment organs on CT of SPECT/CT;2) Local contour intensity-based SPECT-SPECT alignment results in volume-of-interest propagation to other timepoints; 3) Dose-rate estimation is performed by explicit Monte Carlo (MC) using the fast, Dose-Planning Method code; 4) The optimal function for dose-rate fitting is automatically selected for each voxel. When reporting mean dose, partial volume correction is applied, and uncertainty is estimated by an empirical approach of perturbing segmentations.Results. The workflow was used with 4-timepoint SPECT/CT imaging data from 20 patients with 77 neuroendocrine tumors, segmented by a radiologist. CNN-defined kidneys resulted in high Dice values (0.91-0.94) and only small differences (2-5%) in mean dose when compared with manual segmentation. Contour intensity-based registration led to visually enhanced alignment and the voxel-level fitting had high R 2 values. Across patients, dosimetry results were highly variable, for example, the average (range) of the mean absorbed dose in Gy/GBq were: