Cystic adrenal neoplasms

Adrenal cyst presenting with clinical features of a pheochromocytoma

Benign adrenal cysts are relatively uncommon variants of all adrenal incidentalomas. When identified, most benign adrenal cysts are asymptomatic, which differentiates them from other functional adrenal lesions. There are various types of adrenal cysts, although the most common being an endothelial cyst. Ultimately, evaluation and management approaches are aimed at ruling out a functional adrenal mass and management of symptoms if present. We present a unique presentation of an otherwise healthy male with a large incidental adrenal cyst, later identified as a benign endothelial cyst, who presented with classic symptoms of catecholamine excess. The patient had a negative hormonal evaluation, and his episodic symptoms were resolved with surgical removal of the adrenal mass. This case report and brief review provides valuable insight into the evaluation and management of a unique clinical scenario, where a benign cystic mass led to compression-related symptoms of catecholamine excess that were resolved after removal of the nonfunctional, cystic, mass.

Percutaneous Aspiration and Sclerotherapy as Primary Management for a Symptomatic Benign Adrenal Cyst

Adrenal cysts are a rare benign adrenal pathology. Although the majority of adrenal cysts are asymptomatic, large cysts may present with debilitating symptoms of mass effect. Surgical adrenalectomy or cyst fenestration has been the primary mode of management for such symptomatic cysts, but these interventions can be associated with excessive morbidity, particularly when considered in the context of benign disease. Here, we present a case of a 34-year-old female with a longstanding, growing, benign left adrenal cyst associated with nonspecific abdominal symptoms. After multidisciplinary discussion, the patient was managed with primary ultrasound/fluoroscopic guided percutaneous sclerotherapy of her adrenal cyst. This technique achieved complete cyst resolution that was durable on 7-month follow-up and was associated with significant improvement of the patient's symptoms. This case illustrates the potential for primary percutaneous sclerotherapy for primary management of benign adrenal cysts.

Endothelial cyst of the adrenal gland: A rare case report

Adrenal gland cysts are rare and uncommon manifestations. Mostly asymptomatic, discovered incidentally during radiological studies or at autopsy, or without characteristic symptoms. The spectrum of these entities may include benign cysts or malignant cystic neoplasms. They are classified into four types: pseudocysts, endothelial cysts, epithelial cysts, and parasitic cysts. Though pseudocysts are reported to be the most frequently clinically recognized adrenal cysts in surgical series, endothelial cysts are more frequent in autopsy series. Even with advanced imaging modalities, it is still difficult to differentiate a benign adrenal neoplasm from a malignant one. As a result, getting a definitive diagnosis and starting treatment is challenging. In both symptomatic and asymptomatic cases with a large diameter or increasing sizes during follow-up, or with any abnormality of adrenal hormones, surgery is the treatment of choice in symptomatic. Herein, we present a 47-year-old female with a nonfunctional left adrenal endothelial cyst, who was incidentally found during a computerized tomography scan. The patient presented with left-sided nephritic colic due to renal lithiasis. The objective of this paper is to recall the clinical characteristics and to specify the diagnostic contribution of imaging as well as the therapeutic modalities of this entity.

True mesothelial cyst of the adrenal gland: its clinical profile and management

The incidence of adrenal cysts is 0.06% and only 9% of these are true mesothelial cysts. Here, we present a case of a true mesothelial cyst together with a review of the literature. A female in her 30s presented to the surgical outpatient department complaining of right flank pain. Her contrast-enhanced CT scan revealed a 7.5×6.5×4.5 cm right adrenal gland cyst. The patient underwent a laparoscopic right adrenalectomy. Immunohistopathology revealed the cyst to be mesothelial in nature. The majority of true mesothelial adrenal cysts are benign, unilateral and more common in women. Any adrenal cyst diagnosed as a functional lesion or one that may be malignant or with a diameter of 5 cm or greater requires surgical care whereas smaller lesions can be managed conservatively. Laparoscopic adrenalectomy for an adrenal cyst of diameter greater than 6 cm is a safe and feasible procedure in expert hands if there is no invasion of surrounding tissue.

Adrenal Cysts: To Operate or Not to Operate?

Adrenal cysts are uncommon and usually asymptomatic, and therefore are usually incidentally discovered adrenal lesions. They have a broad pathohistological spectrum that includes pseudocysts and endothelial (vascular), parasitic, and epithelial (mesothelial) cysts. Although most adrenal cysts are benign and hormonally non-functional lesions, some can have ambiguous imaging appearances and mimic malignant adrenal neoplasms. On the other hand, the actual malignant neoplasms could undergo cystic transformation. Additionally, immune cell infiltrations, thrombosis, or haemorrhage seen in sepsis can frequently cause adrenal cyst development, raising a question about the possible connection between severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and adrenal cystic lesions. Due to the disease's rarity, the likelihood of malignancy, and the lack of specific guidelines, the management of adrenal cysts is always challenging especially in a young person. This review discusses the important diagnostic and the current treatment possibilities for adrenal cystic lesions. Aiming to emphasize clinical dilemmas and help clinicians navigate the challenges when encountering a patient with an adrenal cyst in everyday practice, we based our review on a practical question-answer framework centred around the case of a young woman with an incidentally discovered large adrenal cyst.

A Rare Case of Obstructed Recurrent Incisional Hernia With Incidentalomas

Incisional hernias (IHs) are the most common postoperative complication of incisions during laparotomy and contribute to a significant burden. The aetiology of IHs varies depending on the surgical technique, patient's condition, and surgeon's experience. Many patients present with abdominal swelling and some degree of discomfort, and in an emergency, the presentation is usually as bowel obstruction or strangulation, necessitating immediate exploration. Hernias can be repaired by closing the defect with a nonabsorbable suture or using mesh. Amidst the use of invasive techniques and mesh, the rate of recurrence remains high for IHs, with pain and infection being the most common symptoms. The consequence of IH repair is affected by comorbid conditions such as chronic cough, constipation, urethral stricture, benign prostate hyperplasia, ascites, and obesity. We present a case of a 63-year-old male with an IH, adrenal adenoma, and adrenal cyst, which was an incidental finding.

Cystic lesions of the adrenal gland

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively.

Adrenal cysts: an emerging condition

Adrenal cysts are rare lesions representing approximately 1-2% of adrenal incidentalomas. The majority of these rare lesions are benign. Rarely, phaeochromocytomas and adrenal malignant masses can present as cystic lesions and can occasionally be difficult to distinguish from benign cysts. Histologically, adrenal cysts are subdivided into pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. The radiological appearance of an adrenal cyst is generally similar to that of cysts in the kidney. They are thus well demarcated, usually rounded, with a thin wall and homogenous internal structure, low attenuating (<20 Hounsfield Units) on CT, low signalling on T1-weighted MRI sequences and high signalling on T2-weighted MRI sequences, and anechoic or hypoechoic on ultrasonography. Benign adrenal cysts have a slight female predominance and are usually diagnosed between the ages of 40 and 60. Most adrenal cysts are asymptomatic and are detected incidentally, although very large adrenal cysts can lead to mass effect symptoms, with surgery required to alleviate the symptoms. Thus, conservative management is usually recommended for asymptomatic cysts. However, when uncertainty exists regarding the benign nature of the cyst, additional work-up or follow-up is needed. The management of an adrenal cyst should preferably be discussed at an adrenal multidisciplinary team meeting.

Clinical, imaging and biochemical presentation of cystic pheochromocytomas

OBJECTIVE

Cystic adrenal mass is a rare imaging presentation of pheochromocytoma. We aimed to describe the clinical, biochemical and imaging characteristics of patients with cystic pheochromocytoma.

DESIGN

Single-centre, retrospective study, 2000-2020.

PATIENTS

Consecutive patients with cystic pheochromocytoma were identified from our institutional pathology and adrenal tumour database.

RESULTS

Of the 638 patients with pheochromocytomas, 21 (3.2%) had cystic pheochromocytomas (median age: 57 years, 57% women). Most pheochromocytomas were discovered incidentally (57%) or due to symptoms of catecholamine excess (24%). The median tumour size was 6.4 cm. On imaging, cystic pheochromocytomas were round or oval (90%), heterogeneous lesions (86%) with a thick solid rim (median rim thickness 13.9 mm, unenhanced computed tomography (CT) attenuation 40 Hounsfield units (HU), venous-phase CT attenuation 83 HU), and a median cystic component of 40% (unenhanced CT attenuation 17.6 HU, venous-phase CT attenuation 20.4 HU), and rarely with calcifications (15%). All 20 patients with biochemical testing had functioning tumours (adrenergic in 80%, noradrenergic in 20%). Total urinary metanephrine excretion correlated with the volume of the solid component (R2  = .75, p < .0001) but not the cystic component (R2  = .04, p = .4386). All patients underwent adrenalectomy (48% laparoscopic, 52% open), and the median duration of hospital stay was 4 days.

CONCLUSIONS

Cystic pheochromocytomas are rare, large tumours with a phenotypic appearance that can masquerade as other adrenal cystic lesions. The degree of biochemical abnormality in cystic pheochromocytomas is associated with the volume of the solid component. All patients with adrenal cysts that have a solid component or an unenhanced attenuation >10 HU should undergo biochemical testing for pheochromocytoma.

Laparoscopic excision of a large adrenal pseudocyst: diagnostic dilemma and technical challenges

A woman in her 40s attended the hospital with worsening left upper abdominal dull aching pain for the past 6 months. Clinical examination and radiological investigations with ultrasonography and contrast-enhanced CT of the abdomen confirmed it to be a cystic lesion of the left adrenal of size 13 cm × 12 cm × 11 cm. With the possibility of an incidental malignancy due to large size, laparoscopic cyst excision meticulously without spillage of cyst content was possible due to preoperative planning. It was a difficult task to mobilise the cyst intact due to the thin wall to prevent accidental rupture and gross spillage of the cyst contents. The cyst wall sent for histopathological examination confirmed it to be an adrenal pseudocyst without any malignant focus. Adrenal pseudocysts are rare and mostly benign. However, the index of suspecting a malignancy should be high in large cysts, and meticulous dissection is warranted.

Multimodality imaging of adrenal gland pathologies: A comprehensive pictorial review

The assessment of acute abdominal and pelvic emergencies typically involves a multimodal approach consisting of plain radiographs, ultrasound, computed tomography (CT), and rarely magnetic resonance imaging (MRI). Although MRI is not traditionally employed in acute care settings, there are several instances in which MRI provides superior functional and prognostic information. In this manuscript, we highlight multimodal findings of adrenal gland emergencies: Hemorrhage, infarction, and infection. The purpose of our study is to highlight significant findings in various modalities, including CT, MRI, ultrasound, and PET/CT. Due to the scarcity of published data and limited clinical use, primary ultrasound findings are limited in our multimodal review. In conclusion, we find that synergistic use of CT, MRI, and functional imaging provides an effective tool for evaluation and management of adrenal pathology.

Clinical course and imaging characteristics of benign adrenal cysts: a single-center study of 92 patients

OBJECTIVE

Benign adrenal cysts are rare lesions of the adrenal glands. Limited data are available to guide management. We aimed to describe the presentation and outcomes of patients with benign adrenal cysts.

DESIGN

Retrospective longitudinal cohort study.

METHODS

Consecutive patients with histologically or radiologically confirmed adrenal cysts between 1995 and 2021 were identified. Pheochromocytomas and malignancy were excluded.

RESULTS

Benign adrenal cysts were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and others in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year). On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Patients treated with adrenalectomy (46, 50%) were younger (36.9 years vs 50.8 years, P = 0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 mm/year vs 0.4 mm/year, P = 0.0002).

CONCLUSION

Benign adrenal cysts are usually incidentally discovered, non-functional, homogenous lesions without vascular enhancement that demonstrate minimal growth. Adrenalectomy should be reserved for patients with heterogeneous lesions, abnormal hormonal evaluation, or those with mass effect symptoms.

Case report: Significant liver atrophy due to giant cystic pheochromocytoma

Introduction

Pheochromocytoma is a neuroendocrine tumor originating from chromaffin cells in the adrenal medulla. Giant pheochromocytomas with a maximum diameter of over 20 cm are particularly rare.

Case presentation

We present a case of giant cystic pheochromocytoma in a 64-year-old woman who was found to have a right abdominal mass during an ultrasound examination, which is the largest pheochromocytoma ever documented in China. Meanwhile, obvious atrophy of the right lobe of the liver was found in preoperative CT and during the operation. Our literature review identified 20 cases with a diameter of over 20 cm. The average age at diagnosis was 51.7 (range 17–85), and 35% of cases did not exhibit classic symptoms.

Conclusion

Giant pheochromocytoma is an uncommon neoplasm. It can be discovered late due to a lack of clinical manifestations. Diagnosis is dependent on imaging recognition together with catecholamine secretion. Surgical resection is the only curative treatment for such tumors.

Case Report: Adrenal Epithelial Cyst in an 11-Year-Old Leptailurus Serval

Case Description

A serval (Leptailurus serval) presented for progressive enlargement of the right adrenal gland, which had been found incidentally on abdominal ultrasound 2 years previously and upon subsequent ultrasound examinations enlarged progressively from 1.26 to 1.43 cm.

Clinical Findings

Clinical signs had not been recorded by the zookeeper, however, progressive weight gain and lethargy were reported. Computed tomography (CT) confirmed the presence of a right caudal pole adrenal mass measuring 1.8 cm.

Treatment and Outcome

The right adrenal with associated mass was surgically resected via a ventral midline laparotomy that included the resection of the right phrenicoabdominal vein in association with the mass. Histopathological examination identified the mass as an epithelial cyst. Chromogranin A staining for a possible pheochromocytoma was performed but was negative. The serval recovered at the zoo without complication and has been on display for 18 months.

Clinical Relevance

Epithelial adrenal cysts have not been previously reported in felids. An adrenal cyst should be included on the differential list for any animal with an enlarged, slowly growing adrenal gland mass with non-specific clinical signs.

Robotic-assisted left adrenal cystic mass excision in a pregnant patient

A symptomatic adrenal mass diagnosed during pregnancy is a rare clinical scenario. Two primary considerations are the timing of intervention and determining the appropriate surgical approach. Here, we present the case of a young female patient with flank pain, whom on diagnostic imaging, was found to have a large cystic adrenal mass. She was taken for a robotic-assisted resection of her left-sided adrenal mass during the second trimester of pregnancy. Preoperative and postoperative assessment demonstrated a viable intrauterine pregnancy. She tolerated the procedure well and was discharged 5 days later with resolution of her symptoms on follow-up. As one of only three reported cases of robotic adrenal surgery during pregnancy, we demonstrate that a robotic-assisted surgical approach is a viable and durable surgical option under the given clinical circumstances.

A Cyst-ematic Analysis of the Adrenal Gland: A Compilation of Primary Cystic Lesions From Our Institution and Review of the Literature

OBJECTIVES

Although primary adrenal lesions and metastases are most commonly encountered, de novo cysts of the adrenal gland can occasionally occur.

METHODS

We analyzed the pathology archives at the Hospital of the University of Pennsylvania for diagnoses of cystic lesions of the adrenal gland between 1998 and 2020. Patient demographics and clinical information were extracted, and pathology slides and stains, as appropriate, were analyzed. The literature between 1998 and 2020 was also searched for large case series involving cystic adrenal lesions.

RESULTS

We found 18 cystic lesions of the adrenal gland in our archives, categorized as pseudocysts (7), endothelial cysts (5), mesothelial cysts (2), mature teratoma (1), cystic adrenal cortical adenoma (1), cystic pheochromocytoma (1), and cystic metastasis (1). The mean age at time of diagnosis was 52.3 years, and the mean size of the cysts was 6.0 cm. There was a slight female predilection, and cysts were more likely to be found on the left side. All lesions were incidental findings. The cystic metastasis was clear cell renal cell carcinoma. Our findings were also compared with those found in the literature published within the same timeframe.

CONCLUSIONS

Adrenal cysts are rare entities. Our findings are concordant with other large studies and provide additional cases to the existing literature. In addition, our literature search expands the possible differential diagnoses for cystic lesions arising in the adrenal gland.

Giant Adrenal Pseudocysts: An Enigma for Surgeons

Adrenal pseudocysts are cystic lesions arising within the adrenal gland enclosed by a fibrous connective tissue wall that lacks lining cells. They can attain a huge size and pose a diagnostic challenge with a broad range of differentials including benign and malignant neoplasms. There are only a few small case series and case reports describing these lesions. We report a series of five patients who presented with “indeterminate” abdominal cystic lesions and were later on found to have adrenal pseudocyst. Four out of five patients presented with non-specific abdominal symptoms, and one patient presented with symptoms suggestive of a functional adrenal tumor. The size of these tumors ranged from 6 to 30 cm. They had variable radiological features and in two cases even a percutaneous biopsy could not establish the diagnosis. In four of these “indeterminate” abdominal masses, an adrenal origin was not suspected preoperatively. Surgical excision provided a resolution of symptoms, ruled out malignancy, and clinched the diagnosis.

Overview of the 2022 WHO Classification of Adrenal Cortical Tumors

The new WHO classification of adrenal cortical proliferations reflects translational advances in the fields of endocrine pathology, oncology and molecular biology. By adopting a question-answer framework, this review highlights advances in knowledge of histological features, ancillary studies, and associated genetic findings that increase the understanding of the adrenal cortex pathologies that are now reflected in the 2022 WHO classification. The pathological correlates of adrenal cortical proliferations include diffuse adrenal cortical hyperplasia, adrenal cortical nodular disease, adrenal cortical adenomas and adrenal cortical carcinomas. Understanding germline susceptibility and the clonal-neoplastic nature of individual adrenal cortical nodules in primary bilateral macronodular adrenal cortical disease, and recognition of the clonal-neoplastic nature of incidentally discovered non-functional subcentimeter benign adrenal cortical nodules has led to redefining the spectrum of adrenal cortical nodular disease. As a consequence, the most significant nomenclature change in the field of adrenal cortical pathology involves the refined classification of adrenal cortical nodular disease which now includes (a) sporadic nodular adrenocortical disease, (b) bilateral micronodular adrenal cortical disease, and (c) bilateral macronodular adrenal cortical disease (formerly known primary bilateral macronodular adrenal cortical hyperplasia). This group of clinicopathological entities are reflected in functional adrenal cortical pathologies. Aldosterone producing cortical lesions can be unifocal or multifocal, and may be bilateral with no imaging-detected nodule(s). Furthermore, not all grossly or radiologically identified adrenal cortical lesions may be the source of aldosterone excess. For this reason, the new WHO classification endorses the nomenclature of the HISTALDO classification which uses CYP11B2 immunohistochemistry to identify functional sites of aldosterone production to help predict the risk of bilateral disease in primary aldosteronism. Adrenal cortical carcinomas are subtyped based on their morphological features to include conventional, oncocytic, myxoid, and sarcomatoid subtypes. Although the classic histopathologic criteria for diagnosing adrenal cortical carcinomas have not changed, the 2022 WHO classification underscores the diagnostic and prognostic impact of angioinvasion (vascular invasion) in these tumors. Microscopic angioinvasion is defined as tumor cells invading through a vessel wall and forming a thrombus/fibrin-tumor complex or intravascular tumor cells admixed with platelet thrombus/fibrin. In addition to well-established Weiss and modified Weiss scoring systems, the new WHO classification also expands on the use of other multiparameter diagnostic algorithms (reticulin algorithm, Lin-Weiss-Bisceglia system, and Helsinki scoring system) to assist the workup of adrenal cortical neoplasms in adults. Accordingly, conventional carcinomas can be assessed using all multiparameter diagnostic schemes, whereas oncocytic neoplasms can be assessed using the Lin-Weiss-Bisceglia system, reticulin algorithm and Helsinki scoring system. Pediatric adrenal cortical neoplasms are assessed using the Wieneke system. Most adult adrenal cortical carcinomas show > 5 mitoses per 10 mm² and > 5% Ki67. The 2022 WHO classification places an emphasis on an accurate assessment of tumor proliferation rate using both the mitotic count (mitoses per 10 mm²) and Ki67 labeling index which play an essential role in the dynamic risk stratification of affected patients. Low grade carcinomas have mitotic rate of ≤ 20 mitoses per 10 mm², whereas high-grade carcinomas show > 20 mitoses per 10 mm². Ki67-based tumor grading has not been endorsed in the new WHO classification, since the proliferation indices are continuous variables rather than being static thresholds in tumor biology. This new WHO classification emphasizes the role of diagnostic and predictive biomarkers in the workup of adrenal cortical neoplasms. Confirmation of the adrenal cortical origin of a tumor remains a critical requirement when dealing with non-functional lesions in the adrenal gland which may be mistaken for a primary adrenal cortical neoplasm. While SF1 is the most reliable biomarker in the confirmation of adrenal cortical origin, paranuclear IGF2 expression is a useful biomarker in the distinction of malignancy in adrenal cortical neoplasms. In addition to adrenal myelolipoma, the new classification of adrenal cortical tumors has introduced new sections including adrenal ectopia, based on the potential role of such ectopic tissue as a possible source of neoplastic proliferations as well as a potential mimicker of metastatic disease. Adrenal cysts are also discussed in the new classification as they may simulate primary cystic adrenal neoplasms or even adrenal cortical carcinomas in the setting of an adrenal pseudocyst.

Imaging features of atypical adrenocortical adenomas: a radiological-pathological correlation

OBJECTIVE

Adrenal adenomas are frequently picked up incidentally on cross-sectional imaging and are known to have a classic imaging appearance on CT and MRI. However, not all adrenal adenomas have this typical radiologic appearance. Our aim is to present the radiological features of atypical adrenocortical adenomas with pathological correlation.

METHODS

All the imaging from the pathologically proven adrenal adenoma cases in our hospital (Tallaght University Hospital, Dublin, Ireland) database (from 2004 to 2019) was reviewed. 8 out of 48 cases (16%) had an atypical radiological appearance and were selected for presentation.

RESULTS

Eight cases demonstrated atypical radiological features including heterogeneous density, incomplete washout on post-contrast imaging, the presence of macroscopic fat and calcification. Lipomatous metaplasia was present in two of the cases pathologically.

CONCLUSION

Adrenocortical adenomas are the most common adrenal mass encountered on CT, however, may not always have classic imaging features. Radiologists should be familiar with both the typical and atypical imaging manifestations of these benign adrenal lesions.

ADVANCES IN KNOWLEDGE

This paper comprehensively describes the atypical features of adrenocortical adenomas with case examples and radiologic-pathologic correlation. Guidelines and an approach to the work-up of adrenal lesions with atypical appearances are also provided.

Use of the SAND balloon catheter for safe and easy laparoscopic removal of adrenal cysts

INTRODUCTION

Surgical resection should be considered for giant adrenal cysts if they are functional, if malignancy cannot be ruled out, or if there is a risk of bleeding. However, preventing cyst damage, including fluid leak, and ensuring a good field of view could be challenging in laparoscopic surgery. We report on our successful use of the SAND balloon catheter in laparoscopic adrenalectomy.

CASE PRESENTATION

The patient was a 40-year-old man with a right adrenal cyst that exhibited growth tendency. We performed laparoscopic adrenalectomy using a SAND balloon catheter through a preexisting port. Use of the catheter allowed for not only aspiration of the cyst fluid without leakage into the operative field but also gentle grasping of the cyst wall, which enabled us to easily remove the adrenal gland, including the cyst.

CONCLUSION

Use of the SAND balloon catheter facilitates safe and easy laparoscopic resection of giant adrenal cysts.

Lymphangiomatous endothelial cyst of the adrenal gland: A case report

Cystic adrenal tumors are rare with an incidence of approximately 0.06% in the general population. Four main histological types are distinguished: Endothelial cysts of lymphangiomatous or angiomatous origin, pseudocysts, epithelial cysts and cysts of parasitic origin. Surgery is recommended for signs of complications, suspicion of malignancy and large size. In other cases, simple surveillance can be proposed.

We report here a case of a lymphangiomatous endothelial cyst of the adrenal gland. The objective is to recall the clinical characteristics and to specify the diagnostic contribution of imaging as well as the therapeutic modalities of this entity.

An Uncommon Presentation of Adrenal Cyst with Subclinical Cushing's Syndrome: A Diagnosis Dilemma

Adrenal cysts are a rare entity that is usually nonfunctional and asymptomatic. Their association with adrenal neoplasms was rarely described in the literature. We report a unique case of a 40 -year-old woman who was referred for evaluation of a left adrenal incidentaloma with subclinical Cushing's syndrome. The tumor was suspicious for malignancy regarding computed tomography scan (CT scan) features. Therefore, a laparoscopic left partial adrenalectomy was performed. Pathology examination showed multilocular spaces lined by endothelial cells which are compatible with endothelial adrenal cyst, associated to an adrenocortical adenoma. We further discuss the management of adrenal cyst with review of the literature.

Cross-sectional imaging features of unusual adrenal lesions: a radiopathological correlation

The detection rates of adrenal masses are increasing with the common and widespread use of cross-sectional imaging. Adrenal adenomas, myelolipomas, metastases, pheochromocytomas, and adrenocortical tumors are well-known and relatively common adrenal tumors. However, there are many less-known neoplastic and nonneoplastic adrenal diseases that might affect the adrenal glands in addition to these common lesions. These rare entities include, but are not limited to, hydatid cysts, congenital adrenal hyperplasia, Wolman disease, adrenal tuberculosis, primary adrenal lymphoma. This article aims to present imaging findings of these unusual lesions in accordance with their pathologic characteristics. We think that the simultaneous presentation of the pathological findings with the imaging features may facilitate the learning process and may potentially enhance the recognition of these entities.

Cystic adrenal lesions: A report of five cases

Background

Cystic adrenal lesions are rare and uncommon manifestation with few cases reported so far. Different types of adrenal cysts have been described with heterogeneous etiology and overlapping clinical findings, ranging from benign to malignant cystic neoplasm. They are usually asymptomatic or may rarely present with abdominal pain or fullness. Optimum management of adrenal cysts still remain controversial, owing to its low incidence. In this study, we report our institutional experience on diagnosis and management of different histological types of cystic adrenal lesions.

Cases

During 4 years period, 55 patients underwent adrenalectomy with five cases presenting as adrenal cysts. All the five patients were biochemically nonfunctional and underwent adrenalectomy (laparoscopic anterior n = 2, retroperitoneoscopic approach n = 1, and open anterior transperitoneal approach n = 2). The primary indications for surgery were larger size and/or suspicion of malignancy. Histological evaluation revealed two epithelial cysts, one endothelial cyst, one pseudocyst, and a very rare case of adrenocortical carcinoma arising in a pseudocyst.

Conclusion

Cystic adrenal lesions are rare with varied etiologic and clinical presentation that may sometimes lead to diagnostic and management dilemma. These cases must undergo biochemical and radiological evaluation to rule out underlying malignancy followed by referral for surgical intervention.

A Rare Case of Adrenal Cysts Associated With Bilateral Incidentalomas and Diffuse Hyperplasia of the Zona Glomerulosa

Characterization of adrenocortical disorders is challenging because of varying origins, laterality, the presence or absence of hormone production, and unclarity about the benign or malignant nature of the lesion. Histopathological examination in conjunction with immunohistochemistry is generally considered mandatory in this characterization. We report a rare case of bilateral adrenocortical adenomas associated with unilateral adrenal endothelial cysts in a 65-year-old woman whose condition was not diagnosed before surgery. Detailed histological examination of the resected adrenal glands revealed hyperplasia in the zona glomerulosa. Despite hyperplasia, the patient had normal serum aldosterone levels and renin activity without clinical evidence of hypertension. The patient was treated with a sodium-glucose cotransporter protein 2 (SGLT2) inhibitor. This may have stimulated the renin-angiotensin-aldosterone system. To the best of our knowledge, this is the first case in which both relatively large bilateral adrenocortical adenomas and unilateral adrenal endothelial cysts were detected. This case also highlights the complexity and difficulty of preoperative diagnosis. Furthermore, this case reports the first detailed histopathological examination of adrenal lesions with SGLT2 treatment and the possibility of SGLT2 inhibitor treatment resulting in histological hyperplasia in the zona glomerulosa; however, it is difficult to prove a causative relationship between SGLT2 inhibitors and hyperplasia of the zona glomerulosa based on the data of this case. It can be confirmed only under limited conditions; therefore, further studies on adrenal gland histology employing SGLT2 inhibition are warranted.

A giant adrenal hemorrhagic pseudocyst mimicking a parapelvic renal cyst: A case report and review of the literature

Adrenal pseudocysts are rare, nonfunctional, asymptomatic cystic masses that originate from the adrenal gland and are usually located in the suprarenal area. They are usually incidentally discovered during imaging, but diagnosis can be challenging because they are similar to benign and malignant cystic lesions of the adrenal gland and adjacent organs. We describe a giant, adrenal hemorrhagic pseudocyst that was atypically located, extending from the middle to the lower poles of the kidney, admixed with a renal cortical cyst.

The Pathological Features of Surgically Managed Adrenal Cysts: A 15-year Retrospective Review

Adrenal cysts are rare. Most are benign but some may contain malignancy. There are no established guidelines for their surgical management. The purpose of this study was to determine the pathological findings and likelihood of malignancy in hormonally inactive adrenal cysts after adrenalectomy. Using the pathology registries at two centers, we identified patients who underwent excision of an adrenal cyst between 1994 and 2009. Hormonally active cysts including pheochromocytomas were excluded. Charts were reviewed for patient demographics, presentation, surgical management, and postoperative course. Of 551 adrenalectomy specimens, 15 (2.7%) contained an inactive adrenal cyst or cystic component. Cysts were more likely to be in women (67%) and right-sided (73%). Three patients (20%) were symptomatic from their lesion. Laparoscopic adrenalectomy was performed in nine patients (60%). Pathology revealed eight hemorrhagic cysts, four lymphangiomas, one hemangioma, one epithelial cyst, and one metastatic pulmonary adenocarcinoma. Laboratory and radiographic workup are essential in determining whether adrenal cysts have hormonal function or a solid tissue component before adrenalectomy. Although nonfunctional adrenal cysts may contain malignancy, most are benign. It is reasonable to observe asymptomatic, nonfunctioning, benign-appearing adrenal cysts in patients in whom follow-up can be ensured.

Adrenal cortical adenoma: current update, imaging features, atypical findings, and mimics

Adrenal adenoma is the most common adrenal lesion. Due to its wide prevalence, adrenal adenomas may demonstrate various imaging features. Thus, it is important to identify typical and atypical imaging features of adrenal adenomas and to be able to differentiate atypical adrenal adenomas from potentially malignant lesions. In this article, we will discuss the diagnostic approach, typical and atypical imaging features of adrenal adenomas, as well as other lesions that mimic adrenal adenomas.

Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis

Background

Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma.

Methods

We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU).

Results

In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I²=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU.

Conclusions

Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.

Giant adrenal pseudocyst in trauma patient

Adrenal pseudocysts are a subclass of adrenal cysts frequently found as incidentalomas. Here, we present the case of a 67-year-old man with an adrenal pseudocyst suspicious for hemorrhage after a fall who was urgently transferred to a tertiary care trauma center for care.

Mimics, pitfalls, and misdiagnoses of adrenal masses on CT and MRI

Due to the widespread use of imaging, incidental adrenal masses are commonly encountered. A number of pitfalls can result in misdiagnosis of these lesions, including inappropriate choice of imaging technique, presence of pseudolesions, and overlap of imaging features of different adrenal lesions. This article explores the potential pitfalls in imaging of the adrenal glands, on computed tomography and magnetic resonance imaging, that can lead to misinterpretation. Clues to correct diagnoses are provided to evade potential misinterpretation.

Cystic lymphangiomatous lesions of the adrenal gland: A clinicopathological study of 37 cases including previously unreported cysts with papillary endothelial proliferation

Published data regarding lymphangiomatous cysts of the adrenal glands (also known as adrenal cystic lymphangiomas) are limited to case reports and a few small case series. We analyzed the clinicopathologic features and histomorphologic spectrum of 37 cases of adrenal cystic lymphangiomatous lesions. There were 26 females and 11 males ranging from 12 to 67 years old (median, 34 years). Twenty two lesions (59.5%) were diagnosed incidentally on imaging studies for unrelated causes, while 15 cases (40.5%) were symptomatic: 8 patients presented with abdominal or flank pain and 7 patients presented with arterial hypertension. Clinically, 4 lesions (10.8%) were reported to have concurrent hormonal hypersecretion. Follow-up data were available for 23 patients (62.2%), ranging from 6 to 156 months (median, 52 mo). One of the 22 patients showed local recurrence at 12 months after partial adrenalectomy. The median size of the adrenal lymphangiomatous cysts was 4.5 cm (range, 1.5 to 10 cm). Based on the histopathologic findings these lesions were grouped into three, morphologically distinct types: typical multicystic lymphatic malformation (n = 16), typical unilocular lymphangiomatous cyst (n = 14) and lymphangiomatous cyst with papillary endothelial proliferation (n = 7). The median patient age of the first group was significantly higher than that of the other groups and calcifications in these cysts were more common than in the other two groups. The unilocular lymphangiomatous cysts were more frequently associated with a history of previous intra-abdominal surgical procedures and/or inflammatory processes than the other two groups. Cysts with papillary endothelial proliferation were significantly larger than other cysts and shared some microscopic features with a vascular neoplasm known as papillary intralymphatic angioendothelioma (PILA). In conclusion, adrenal lymphangiomatous cysts are usually asymptomatic, incidentally diagnosed lesions with a female predominance. They may imitate other adrenal tumors, both radiologically and clinically. Despite being non-functioning lesions, they should be considered as a possible cause of pseudopheochromocytoma. Although most adrenal lymphangiomatous cysts seem to be non-neoplastic, vascular abnormalities (malformations or lymphangiectasias), those with papillary endothelial proliferations may represent true neoplastic lesions.

Challenges in surgical pathology of adrenocortical tumours

Adrenocortical carcinomas are rare tumours that can be diagnostically challenging. Numerous multiparametric scoring systems and diagnostic algorithms have been proposed to differentiate adrenocortical adenoma from adrenocortical carcinoma. Adrenocortical neoplasms must also be differentiated from other primary adrenal tumours, such as phaeochromocytoma and unusual primary adrenal tumours, as well as metastases to the adrenal gland. Myxoid, oncocytic and sarcomatoid variants of adrenocortical tumours must be recognized so that they are not confused with other tumours. The diagnostic criteria for oncocytic adrenocortical carcinoma are different from those for conventional adrenocortical carcinomas. Adrenocortical neoplasms in children are particularly challenging to diagnose, as histological features of malignancy in adrenocortical neoplasms in adults may not be associated with aggressive disease in the tumours of children. Recent histological and immunohistochemical studies and more comprehensive and integrated genomic characterizations continue to advance our understanding of the tumorigenesis of these aggressive neoplasms, and may provide additional diagnostic and prognostic utility and guide the development of therapeutic targets.

Benign vascular tumors, cysts, and pseudocysts of the adrenal gland: a contemporary multi-institutional clinicopathological analysis of 55 cases

Benign adrenal vascular tumors, cysts, and pseudocysts are a heterogeneous group of relatively uncommon entities that may pose diagnostic challenges radiologically and pathologically. However, there are only a few small cases series systematically characterizing the clinicopathological features of these lesions. We identified 55 cases of benign adrenal vascular tumors, cysts, and pseudocysts (23 pseudocysts, 17 hemangiomas, 8 lymphangiomas, 6 angiomatous endothelial cysts, and 1 arteriovenous malformation) from a multi-institutional urologic pathology database between 2000 and 2017 and retrospectively analyzed their clinicopathological features. We found that these lesions have a female predominance and most are right sided. These lesions may occur simultaneously with other adrenal tumors associated with hormonal hypersecretion. A substantial portion of pseudocysts were semisolid or solid with no fluid collection, mimicking a solid adrenal tumor and resulting in adrenalectomy. In addition, a small proportion of benign vascular lesions may have coexisting epithelial tumors, requiring extensive specimen sampling and thorough microscopic examination.

Giant adrenal pseudocyst: A rare diagnosis

We present a rare case of giant adrenal pseudocyst as a cause of right upper quadrant (RUQ) pain and highlight the typical multimodality imaging features. The case demonstrates the imaging features associated with giant adrenal pseudocysts to aid accurate and timely diagnosis. Despite the rarity of these lesions they are important to consider as benign lesions can closely mimic malignant ones. Unenhanced and contrast-enhanced CT is the imaging of choice for adrenal cysts. However, MRI can provide more exquisite assessment of cystic, solid and enhancing components. Pseudocysts can be purely cystic, mixed or solid. Classically, adrenal pseudocysts are described as cystic lesions (of homogenous water density) with a fibrous wall and thin internal septations. Mural/septal calcification is commonly demonstrated due to haemorrhage, this is discernible from central/amorphous calcification seen in malignant disease. As in this case, pseudocysts can contain solid components or layering secondary to haemorrhage. The key to differentiating organised haematoma from tumour is the lack of enhancement. If serial imaging is undertaken in these patients rapid changes in the solid components may be seen reflecting resolving haematoma. Adrenal pseudocysts are rare and have a wide differential. Cystic adrenal lesions warrant multimodality assessment as their imaging features aid diagnosis and differentiation from malignant disease. We suggest that MRI plays a complimentary role to CT. CT is superior at demonstrating mural/septal calcification but MRI aids in determining cystic components and differentiating haemorrhage from tumour.

Non-neoplastic adrenal pseudocysts: A clinicopathologic study of 44 cases with potential insights into pathogenesis

BACKGROUND

Literature on non-neoplastic adrenal pseudocysts (NNAPC) remains limited and to date no large series have been reported. The pathogenesis of these lesions remains poorly defined, however a vascular origin is most often suggested in the literature. We aimed to evaluate the clinicopathological features and the spectrum of vascular changes within NNAPC, in order to better understand the mechanisms and circumstances of their pathogenesis.

METHODS AND RESULTS

We reviewed 44 cases of surgically resected NNAPC. There were 30 females and 14 males ranging from 23 to 82 years (median, 53 years). On the basis of histopathologic and immunohistochemical analysis of the vascular changes the following types were defined: pseudocysts with lymphatic-related changes (type 1, n = 16), pseudocysts with large vein-related changes (type 2, n = 15) and pseudocysts with blood vessel microvasculature-related changes (type 3, n = 13). The median patient age of the latter group was higher than that of type 1 and 2 (64 years versus 51 and 50 years, respectively; p = 0.0002). Type 3 pseudocysts were more frequently associated with a history of systemic vascular and vascular-related disorders than type 1 and type 2 pseudocysts (92% versus 33% and 64%, respectively; p = 0.008). Type 1 pseudocysts were more frequently connected with a history of previous intra-abdominal surgical procedures than type 2 and 3 pseudocysts (60% versus 7% and 25%, respectively; p = 0.0079).

CONCLUSIONS

NNAPC are clinically heterogenous and can arise on a background of various vascular changes. They may represent end-stage processes related to lymphangiomatous lesions, changes in adrenal venous structures or microvasculature.

Heterotopic pancreatic cyst in the adrenal gland: A case report and review of literature

RATIONALE

The incidence of heterotopic pancreas (HP) is relatively rare and mainly found in the upper gastrointestinal tract, and no case of HP cyst in the adrenal gland has been reported. Informed consent has been obtained from the patient for the publication of the case details.

PATIENT CONCERNS

A 21-year-old woman who presented with chronic lower back pain for a week without urinary disturbance or gastrointestinal discomfortable.

DIAGNOSES

Ultrasound (US) revealed a left renal cyst, and computed tomography (CT) showed a cyst in the area of the adrenal gland.

INTERVENTIONS

Cystectomy was successfully performed laparoscopically. Histopathologic examination of the removed cyst wall showed heterotopic pancreatic cyst accompanied by cystic degeneration.

OUTCOMES

No unusual drainage or abdominal signs were observed during the 6-month follow-up.

LESSONS

Despite of its rarity, HP accompanied by cyst formation in the adrenal gland area can present with waist pain. Therefore, the possibility of such disease needs to be considered. For thorough evaluation, in addition to abdominal US, CT, and/or magnetic resonance imaging, histopathological examination should sometimes be performed to make a definite diagnosis. Total excision and regular follow-up is necessary for such cases due to the potential risk of complications or recurrent cyst formation.

A Case of Hemorrhagic Adrenal Pseudocyst Mimicking Solid Tumor

Patient: Female, 78

Final Diagnosis: Adrenal pseudocyst

Symptoms: None

Medication: —

Clinical Procedure: Operation

Specialty: Urology

Clinicopathological and immunohistochemical analysis of epithelial-lined (true) cysts of the adrenal gland with proposal of a new histogenetic categorization

Epithelial- lined (true) cysts are rare lesions and until now the only information we had about their histogenesis was based on the analysis of a few cases. We retrospectively reviewed 8 cases of cysts with a true epithelial lining (confirmed immunohistochemically). The pathological findings and immunohistochemical analysis of the epithelial linings allowed for categorization of the cysts into 3 groups. Five cysts had pure mesothelial lining, which was flattened to cuboidal, and demonstrated a positive reaction for mesothelial markers (eg. calretinin, WT1), and a negative reaction for EpCAM, EMA, PAX8 and ER. Two cysts had cuboidal to flattened lining, the cells of which were diffusely or focally positive for mesothelial markers, for some epithelial markers (eg. EpCAM and EMA) and despite a lack of müllerian-type epithelium demonstrated a positive reaction for PAX8 and focally for ER. A cyst derived from adreno-hepatic fusion (AHF)-related intra-adrenal bile ductules was diagnosed in a right adrenal gland which was directly adherent to the liver, microscopically features of AHF were visible with intermingling of adrenal and liver parenchymal cells. The immunoreactivity pattern was similar among the preserved cells of the cyst-lining, the intra-adrenal bile ductules and the normal bile ductules in the adjoining liver parenchyma. On the basis of this case series from a single institution (8 presented now and 1 reported before) we propose a new histogenetic categorization of adrenal epithelial cysts into: 1. pure mesothelial cysts (the most common type), 2. mesothelial cysts with incomplete or complete müllerian metaplasia 3. AHF-related cysts.

Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy

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Giant cystic pheochromocytoma is a rare entity.

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Preoperative diagnosis is very difficult to obtain.

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Open surgery is the gold standard to treat these giant masses, but comparison studies are lacking.

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Posterior retroperitoneoscopic approach has advantages over transperitoneal laparoscopic method.

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This is the first report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy.

Introduction

Giant cystic pheochromocytoma (>10 cm) is rare with only a few cases described in the literature. Preoperative diagnosis is very difficult because clinical, biochemical and radiologic finds are usually not consistent with a pheochromocytoma. Open surgery is traditionally the gold standard.

Case presentation

A 51 year-old male patient resorted to surgery department with an adrenal cystic incidentaloma. He was asymptomatic, mild hypertension easily controlled, with increased plasma fractionated metanephrines. MRI and MIBG scans confirmed the presence of a right adrenal giant cystic pheochromocytoma (14 cm). A right posterior retroperitoneoscopic adrenalectomy was performed, complicated with an unintended disruption. At follow-up he was asymptomatic and with plasma fractionated metanephrines normalized.

Discussion

Although laparoscopic surgery is effective and safe, traditional open surgery is the gold standard in the presence of adrenal tumours with suspicion of malignancy, like masses larger than 8 cm (including giant cystic pheochromocytomas). Minimal invasive techniques have the advantages of less postoperative pain and ileus, less morbidity, improved cosmetics, and faster recovery, but with the negative impact in R0 resection and probably a higher risk of cystic rupture. However comparisons between open and minimally invasive surgery are lacking. Additionally posterior retroperitoneoscopic approach has several advantages over laparoscopic transperitoneal method.

Conclusion

This is the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy, but the occurrence of the unintended rupture may be a factor against this approach. More studies are needed to compare open and minimally invasive techniques in terms of resectability and cystic rupture rate.

A unique presentation of a complex haemorrhagic adrenal pseudocyst

A man aged 33 years presented with a 3-day history of left-sided testicular discomfort. Clinical examination revealed a large left-sided varicocele. He was referred for a testicular ultrasound, which demonstrated a moderate left-sided varicocele and an associated large suprarenal mass. An urgent (CT) scan was arranged which confirmed this, with associated compression of adjacent structures, including the left kidney and left renal vessels. The patient was admitted 1 week following the CT scan with features of sepsis. An inpatient adrenal MRI scan suggested the presence of a large left-sided haemorrhagic adrenal cyst. This was removed surgically through a left subcostal incision. Histology confirmed there was no malignancy. The patient was discharged and a follow-up CT scan at 6 months showed complete resolution of the cyst with no further testicular discomfort. This is the first known case of an adrenal cyst presenting with a varicocele.

A giant lymphatic cyst of the adrenal gland: report of a rare case and review of the literature

Lymphatic type of adrenal cysts is most common; however, this type of endothelial cyst is quite rare in excessively large adrenal cysts. A 37-year-old Japanese woman was admitted to our institution with distension of her left flank and the upper quadrant of her abdomen. Abdominal ultrasonography revealed a cystic lesion with a homogenous anechoic texture, and measuring 21 cm in diameter. Computed tomography and magnetic resonance imaging displayed a giant cystic lesion adjacent to the liver, pancreas, kidney, and spleen. The origin of the cyst was not identified. We were not able to make a preoperative diagnosis; therefore, the patient underwent resection of the mass by open laparotomy for therapeutic diagnosis. Intraoperatively, the mass was identified to be cystic and adhered to the left adrenal gland. It was filled with more than 2000 mL of serous brown-red fluid. The content of the cyst contained no atypical cells on cytological examination. The wall of the cyst was composed of a lining of a single layer of lymphatic vessel-derived cells, and the cyst was pathologically classified as a true cyst. No abdominal symptoms were observed and a postoperative radiological work-up showed no evidence of recurrence during a 6-year follow-up period. We describe a case of a patient with a giant lymphatic cyst of the adrenal gland. The preset data suggest that surgeons should decide treatment strategy for large adrenal cysts in consideration of hormonal function, degree of size, and possibility of malignancy.

Adrenal Tumors in Adults

Although most adrenal tumors are not diagnostic dilemmas, there are cases that are challenging. This may be due to the tissue provided, for example fragmented tissue received in the setting of morcellation, or it may be due to inherently challenging histology, such as in cases with equivocal features of malignancy. Additionally, much has been learned about the molecular alterations of adrenal tumors, especially pheochromocytomas. Many of these alterations represent germline mutations with significant clinical implications for patients and their families. The aim of this review is to provide an overview of the most common adrenal tumors in adults so that pathologists can tackle these interesting tumors.