|Year : 2014 | Volume
| Issue : 2 | Page : 123-124
Adrenal gland cyst: A diagnostic conundrum: Report of a case with review of literature
Jyoti Ramnath Kini1, Keyoor Gautam1, Alfred Augustine2
1 Department of Pathology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||18-Sep-2014|
Dr. Jyoti Ramnath Kini
Department of Pathology, Kasturba Medical College, Manipal University, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
Cystic lesions of the adrenal gland are uncommon and mostly asymptomatic. They demonstrate a spectrum of histological changes and may vary from pseudocysts to malignant cystic neoplasms. Adrenal pseudocysts are rare cystic lesions surrounded by a layer of fibrous tissue that lack a recognizable lining layer. They are most often discovered incidentally during radiological studies or at autopsy. The radiographic appearance of adrenal pseudocysts though characteristic, can be difficult to distinguish an adrenal pseudocyst from an adrenal neoplasm with prominent cystic change, presenting as diagnostic conundrums. Extensive sampling of resected tissues is important to rule out malignancy in patients, with cystic adrenal lesions. Herein, we present a 47- year-old male with a non functional and asymptomatic left adrenal pseudocyst. The literature is reviewed and the different diagnostic and management options are discussed.
Keywords: Adrenal cyst, Cystic adrenal neoplasm, Pseudocyst
|How to cite this article:|
Kini JR, Gautam K, Augustine A. Adrenal gland cyst: A diagnostic conundrum: Report of a case with review of literature. J Med Soc 2014;28:123-4
|How to cite this URL:|
Kini JR, Gautam K, Augustine A. Adrenal gland cyst: A diagnostic conundrum: Report of a case with review of literature. J Med Soc [serial online] 2014 [cited 2022 Jun 30];28:123-4. Available from: https://www.jmedsoc.org/text.asp?2014/28/2/123/141107
| Introduction|| |
Cystic lesions of the adrenal gland are rare. ,,,,, The incidence in autopsy studies ranges from 0.064% to 0.18%.  The radiographic appearance of adrenal pseudocysts though characteristic, can be difficult to distinguish an adrenal pseudocyst from an adrenal neoplasm with prominent cystic change, presenting as diagnostic conundrums. Herein, we report a case of a 47-year-old man with an incidentally detected adrenal cyst.
| Case Report|| |
A 47-year-old male had come to the hospital for a routine check-up. On computed tomography (CT) scan, a large well-defined, rounded, rim enhancing fluid density lesion measuring 8.8 × 7.5 × 7.5 cm, with surrounding rim of calcification and few calcified septae were visualized in the left suprarenal region [Figure 1]a, displacing the left kidney inferiorly. Left adrenal gland was not seen separately and a radiological impression of a large left adrenal cyst was given. His physical and laboratory findings, urine sediment, catecholamines and metanephrines were all within normal limits.
|Figure 1: (a) An enhanced computed tomography scan, showing a large well-defined left adrenal cyst (b) Outer surface of the resected adrenal cyst (c) Cut surface of the resected adrenal cyst was multiloculated, cyst wall was shaggy and showed foci of calcification (d) Microscopic appearance of the cyst wall with clusters of normal adrenal cells incorporated within the fi brocollagenous wall. (H&E ×100) (e) High power view of above. (H&E ×400)|
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On explorative laparotomy, the cyst was seen to be adherent densely to the omentum, splenic ligaments and the left kidney. Adhesiolysis and identification of the cyst was followed by needle aspiration. This yielded hemorrhagic fluid, which was sent for cytology. The resected adrenal cyst was sent for histopathological examination.
Cytological examination revealed a few lymphocytes and cyst macrophages against a hemorrhagic background. Grossly, the cyst was multilocular, containing serous, hemorrhagic and gelatinous material. The cyst wall was shaggy and showed foci of calcification [Figure 1]b and c. Microscopically, the fibrocollagenous cyst wall was devoid of any lining and had areas of dystrophic calcification with focal chronic inflammatory infiltrate and hemosiderin laden macrophages. Multiple and thorough sectioning of the cyst showed only islands of normal adrenocortical tissue without any evidence of a neoplastic change [Figure 1]d and e. Though cystic change in an adrenal cortical adenoma or hyperplasia could not be definitely excluded, malignancy was ruled out after extensive sampling. A final diagnosis of an adrenal pseudocyst was rendered.
| Discussion|| |
Adrenal cysts are rare lesions, little more than 300 cases have been published in the literature with adrenal pseudocysts comprising only about 125 cases.  Adrenal cysts occur in all age groups but most frequently in the third and sixth decade.  They can range from microscopic to 12 cm in diameter and can contain several liters of fluid.  They are usually unilateral with a mild female predominance. Although they can be clinically silent, they may present with vague abdominal pain, gastrointestinal symptoms or a palpable abdominal mass. , An acute abdomen and a tender mass have been reported occasionally, likely to be due to intracystic hemorrhage, rupture or infection. ,,
Complete blood counts may show low hemoglobin and hematocrit levels, if there is heavy intracystic bleeding. Electrolytes and hormonal profiles are usually within normal limits except rarely where hypoadrenocorticism is present or pseudocysts in functional tumors are the cause. 
Ultrasound and CT scan are useful diagnostic tools and the rate at which adrenal cysts are discovered is increasing, yet the etiology remains unclear; a vascular neoplasm or malformation, cystic degeneration of primary adrenal neoplasm and hemorrhage/infection in adrenal tissue are proposed origins. ,
Traditionally, adrenal cysts have been classified as endothelial cysts, pseudocysts, epithelial cysts and parasitic cysts. Pseudocysts are reported to be the most common clinically recognized adrenal cysts ranging up to 39% in surgical series. , Adrenal pseudocysts are cystic lesions arising within either the cortex or medulla surrounded by a fibrous wall devoid of a recognizable lining layer. Unusual variants of adrenal pseudocysts have been reported including those with intracystic fat and myelolipomatous metaplasia, with features of a dermoid cyst and those with ectopic thyroid tissue. 
Cystic adrenal neoplasms must be differentiated from adrenal cysts. About 19% of pseudocysts have been observed in association with an adrenal neoplasm.  Extensive degeneration or hemorrhage within an adrenal cortical neoplasm or pheochromocytoma may result in a pseudocyst. Hemorrhage and degeneration must be distinguished from tumoral necrosis, an ominous finding in an adrenal neoplasm. The malignant potential rate of adrenal cysts is approximately 7%.  The distinction between malignant and benign adrenal cysts can be difficult. Thus, extensive sampling of resected tissues is needed to evaluate the histological features and to search for foci of tumor in the cyst wall. Presence of normal cortical islands, absence of autonomous hormonal production or atrophy of the adjacent cortex provides clues to distinguish from a cortical neoplasm.
To alleviate symptoms and exclude malignancy an adrenalectomy is generally preformed. Some have recommended aspiration of adrenal cysts larger than 3.5 cm. A clear aspirate generally excludes malignancy. Non-functional adrenal cyst smaller than 6 cm, with a round well-defined border and wall thickness less than 3 mm, can be treated conservatively with aspiration only and follow-up with interval CT scans, if the aspirate is clear. A bloody aspirate or malignant cytology or cyst greater than 6 cm, with a thick wall or large central/peripheral calcification or non-homogenous nature on CT require excision. 
In conclusion, cystic adrenal lesions are uncommon, span a broad spectrum ranging from pseudocysts to cystic primary adrenal tumors and can be associated with benign and malignant adrenal neoplasm. The evaluation of cystic adrenal lesions is important both in recognizing true adrenal cysts and in differentiating these lesions from cystic malignant neoplasms of the adrenal gland.
| References|| |
|1.||Sroujieh AS, Farah GR, Haddad MJ, Abu-Khalaf MM. Adrenal cysts: Diagnosis and management. Br J Urol 1990;65:570-5. |
|2.||Gaffey MJ, Mills SE, Fechner RE, Bertholf MF, Allen MS Jr. Vascular adrenal cysts: A clinicopathologic and immunohistochemical study of endothelial and hemorrhagic (pseudocystic) variants. Am J Surg Pathol 1989;13:740-7. |
|3.||Erickson LA, Lloyd RV, Hartman R, Thompson G. Cystic adrenal neoplasms. Cancer 2004;101:1537-44. |
|4.||Favorito LA, Lott FM, Cavalcante AG. Traumatic rupture of adrenal psuedocyst leading to massive hemorrhage in retroperitoneum. Int Braz J Urol 2004;30:35-6. |
|5.||Sioka E, Symeonidis D, Chatzinikolaou I, Koukoulis G, Pavlakis D, Zacharoulis D. A giant adrenal cyst difficult to diagnose except by surgery. Int J Surg Case Rep 2011;2:232-4. |
|6.||Khilnani GC, Kumar A, Bammigatti C, Sharma R, Gupta SD. Hemorrhagic pseudocyst of the adrenal gland causing acute abdominal pain. J Assoc Physicians India 2008;56:379-80. |
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