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Paul A, Toale C, Egan M, Whelan M, Feeney J, Crowther S, Gibney J, Conlon K. Management of patients with adrenal myelolipoma: experience from a tertiary referral centre. Ir J Med Sci 2024:10.1007/s11845-024-03779-2. [PMID: 39230649 DOI: 10.1007/s11845-024-03779-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/02/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Adrenal myelolipomas are rare, benign, tumours of the adrenal cortex. AIMS This study reports the experience of a tertiary adrenal surgery referral centre's approach to the management of patients with adrenal myelolipoma. METHODS A retrospective observational cohort study was conducted on all adult patients (> 18 years age) diagnosed with adrenal myelolipoma from January 1, 2014, to December 30, 2022. Demographics, imaging characteristics, histological diagnosis (where applicable) and follow-up data were compared between patients undergoing surgery and those referred to surveillance. Indications for operative intervention were recorded at the time of multidisciplinary team discussion, consisting of surgeons, endocrinology physicians, radiologists, pathologists and specialist nursing representatives. RESULTS Of the 522 patients with an adrenal lesion discussed in adrenal tumour meeting between 2014 and 2022, n = 15 (2.8%) were diagnosed with adrenal myelolipoma. Of the 15 patients, 4 underwent adrenalectomy at first presentation (27%), while 1 patient underwent adrenalectomy after interval follow-up. Indications for operative intervention were as follows: 'indeterminate lesion' (n = 3), 'abdominal pain and size (> 4 cm)' (n = 1) and 'mass effect on adjacent organs' (n = 1). The mean rate of lesion growth in patients referred for surveillance (n = 10) was 0.13 cm/year. Histology confirmed adrenal myelolipoma as the diagnosis in all resected tumours. CONCLUSIONS For patients with adrenal myelolipoma, the presence of symptoms and/or indeterminate features on imaging may be more clinically useful indications for operative intervention over size alone. The surveillance of adrenal myelolipomas, even in patients with adrenal lesions > 4 cm, is a safe clinical strategy, provided the imaging characteristics are benign and patients remain asymptomatic.
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Affiliation(s)
- Anant Paul
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Conor Toale
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.
- Trinity Centre for Health Sciences at Tallaght University Hospital, Dublin 24, Dublin, Ireland.
| | - Marie Egan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - John Feeney
- Department of Radiology, Tallaght University Hospital, Dublin, Ireland
| | - Stephen Crowther
- Department of Histopathology, Tallaght University Hospital, Dublin, Ireland
| | - James Gibney
- Department of Endocrinology, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Kevin Conlon
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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Shen X, Yao Q, Qi X, Ma L. Malicious Tumor? Pathological Fracture of the Femur in Children Caused by Myelolipoma: A Case Report and Review of Literatures. Case Rep Oncol Med 2024; 2024:5838618. [PMID: 38778879 PMCID: PMC11111296 DOI: 10.1155/2024/5838618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/03/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
Myelolipoma is a kind of benign lipoma containing myeloid cells. It is a rare type of tumor that typically presents as an occasional adrenal tumor, generally manifesting as a nonfunctional adrenal mass. Although it can occur in extra-adrenal tissues, its occurrence in bone tissue is extremely rare. Most cases are discovered accidentally during physical examinations of adults, and there are currently no reports of cases with pathological fractures as the main symptoms. We present a case of a 15-year-old teenager who developed a pathological fracture caused by femoral myelolipoma. The diagnosis of the specific type of bone tumor of the patient was determined through pathology and imaging. To treat the condition, we utilized a technique known as the "soft drill" to fully access the tumor space, remove the bone septum, and scrape away the diseased tissue. The fracture was then stabilized using a hybrid external fixation. After a 2-year follow-up period, there was no recurrence of the bone tumor. This case is the first case of intraosseous myelolipoma that occurred in a minor with the initial symptom of pathological fracture, filling the gap in our existing body of knowledge and providing a reference for the treatment of this type of intraosseous myelolipoma.
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Affiliation(s)
- Xiaoyu Shen
- Department of Orthopaedic Surgery, Hebei Medical University Third Hospital, Shijiazhuang 050035, China
| | - Qiang Yao
- Internal Medicine, The First Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Xiangbei Qi
- Department of Orthopaedic Surgery, Hebei Medical University Third Hospital, Shijiazhuang 050035, China
| | - Lijie Ma
- Department of Orthopaedic Surgery, Hebei Medical University Third Hospital, Shijiazhuang 050035, China
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Rezaee H, Tavallaii A, Keykhosravi E, Abouei Mehrizi MA, Safdari Z, Pishjoo M, Aminzadeh B, Alenabi A. Spinal myelolipoma - an extremely rare pathology within the lumbar spine: a case report and literature review. Br J Neurosurg 2023; 37:1805-1808. [PMID: 34027765 DOI: 10.1080/02688697.2021.1926923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Myelolipoma is a benign tumor containing mature adipose cells and a combination of myeloid and erythroid elements. This tumor is typically found in the adrenal glands; however, it has been detected outside the adrenal glands in rare cases. We report an extremely rare case of myelolipoma in the lumbar spine causing significant neural compression due to the involvement of the posterior spinal elements. Given the significant neurological deficit, the patient was surgically managed as soon as possible. Extra-adrenal myelolipomas are rare lesions, and only one case has been reported in the spine so far. However, this diagnosis should be considered in cases with its characteristic imaging features.
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Affiliation(s)
- Hamid Rezaee
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Tavallaii
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Zohre Safdari
- Department of Radiology, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Masoud Pishjoo
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad Aminzadeh
- Department of Radiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Anita Alenabi
- Department of Pathology, Mashhad University of Medical Sciences, Mashhad, Iran
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Andriandi, Cleven A, Hanff D, Hartgrink H, Dijkstra P. Presacral myelolipoma, case report and literature review. Ann Med Surg (Lond) 2020; 57:274-280. [PMID: 32904073 PMCID: PMC7452051 DOI: 10.1016/j.amsu.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Myelolipomas are very rare benign tumours consisting of hematopoietic cells and mature adipose tissues. They are most commonly found in the adrenal glands. However, there have been several reported cases of extra-adrenal myelolipomas, most commonly in the presacral region. Nearly all presacral lesions are small and asymptomatic; thus, most are discovered incidentally on imaging studies. PRESENTATION OF CASE We report two cases of presacral myelolipomas. The first is a 48-year-old female presenting with atypical back pain, found to have a mass in her presacral region with a size of 3,3 cm. The second case is a 59-year-old female, who presented for evaluation of a hip fracture, found to have a 4,7 cm presacral lesion. Both presacral myelolipomas were discovered incidentally and were confirmed by percutaneous guided fine-needle aspiration biopsy. Both were treated conservatively. DISCUSSION Accepted indications for the surgical excision of myelolipomas are symptomatic tumour, size >4 cm, metabolically active tumour, and a suspicion of malignancy on an imaging study. However, previous reports have documented that nearly half of the conservatively managed myelolipomas with a mean initial size of 5,1 cm, has increased in size or became symptomatic over a 3-years period. CONCLUSION We conclude that symptomatic presacral myelolipomas or lesions larger than 4 cm should be en-bloc resected, and we present an intuitive decision-making algorithm.
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Affiliation(s)
- Andriandi
- Department of Orthopaedic and Traumatology, Adam Malik General Hospital / Faculty of Medicine Universitas Sumatera Utara, Medan, Indonesia
| | - A.H.G. Cleven
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | - D.F. Hanff
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - H. Hartgrink
- Department of Surgery Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - P.D.S. Dijkstra
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
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Kabeel K, Marjara J, Bhat R, Gaballah AH, Abdelaziz A, Bhat AP. Spontaneous hemorrhage of an adrenal myelolipoma treated with transarterial embolization: A case report. Radiol Case Rep 2020; 15:961-965. [PMID: 32419895 PMCID: PMC7214766 DOI: 10.1016/j.radcr.2020.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/14/2023] Open
Abstract
Adrenal myelolipoma is a benign tumor of the adrenal cortex composed predominantly of fat and hematopoietic tissue. These lesions are usually asymptomatic, and most often incidentally detected on imaging. Uncommonly, they present with retroperitoneal hemorrhage, and these have been traditionally treated with emergent surgery. Although, transarterial embolization has been effectively and safely used in patients presenting with active hemorrhage from acute traumatic and nontraumatic causes, literature specifically pertaining to adrenal artery embolization is scant, perhaps due to smaller size and variability of adrenal arteries. With recent advances in endovascular techniques and imaging, there are emerging case reports and series of adrenal artery embolization in acute and nonacute settings. We report a case of spontaneous hemorrhage within an adrenal myelolipoma in a 43-year-old male patient, successfully treated with transarterial embolization, thereby avoiding major surgery. Our report adds to the growing body of literature pertaining to adrenal artery embolization.
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Affiliation(s)
- Khalid Kabeel
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Jasraj Marjara
- University of Missouri-Columbia School of Medicine, Columbia, MO 65212, USA
| | - Roopa Bhat
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Ayman H Gaballah
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Amr Abdelaziz
- Department of Radiology, Body Imaging Section, University of Missouri, Columbia, MO 65212, USA
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
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Practical guide on the initial evaluation, follow-up, and treatment of adrenal incidentalomas Adrenal Diseases Group of the Spanish Society of Endocrinology and Nutrition. ACTA ACUST UNITED AC 2020; 67:408-419. [PMID: 32349941 DOI: 10.1016/j.endinu.2020.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 12/16/2022]
Abstract
Initial evaluation of adrenal incidentalomas should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion. Our recommendation is that, except when cortisol levels <1.8μg/dL in the dexamethasone suppression test rule out diagnosis and levels ≥5μg/dL establish the presence of autonomous cortisol secretion, diagnosis should be based on a combined definition of dexamethasone suppression test ≥3μg/dL and at least one of the following: elevated urinary free cortisol, ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, dexamethasone suppression test should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism. The initial radiographic test of choice for characterization of adrenal incidentalomas is a computed tomography scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6-12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed. We think that patients with autonomous cortisol secretion with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy. The indication for unilateral adrenalectomy is clear in patients with overt hormonal syndromes or suspected malignancy. In conclusion, adrenal incidentalomas require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.
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Yugandhar S, Sureka SK, Yadav P, Lal H. A rare case of extra-adrenal bilateral perirenal and periureteric myelolipoma. BMJ Case Rep 2017; 2017:bcr-2017-221846. [PMID: 28993361 DOI: 10.1136/bcr-2017-221846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old immunocompetent female presented with right flank pain since 3 years. MRI revealed a large well-defined T1 and T2 hypointense mildly enhancing lesion in the right anterior pararenal space displacing the right kidney and encasing the right ureter with T2 hyperintense wall thickening of the left renal pelvis and ureter. A provisional diagnosis of solitary fibrous tumour was kept. Bilateral double J stenting was done for hydronephrosis. Surgical debulking of the lesion was done with biopsy from the left periureteral wall thickening and was found to be myelolipoma on histopathological examination. This case is a novel variety of myelolipoma which is lipid poor, extra-adrenal and in bilateral perirenal and periureteric location.
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Affiliation(s)
- Samireddypalle Yugandhar
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjoy Kumar Sureka
- Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyank Yadav
- Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Gaujoux S, Aimé A, Assié G, Ciuni R, Bonnet S, Tenenbaum F, Bertherat J, Dousset B. Adrenalectomy for incidentaloma: lessons learned from a single-centre series of 274 patients. ANZ J Surg 2017; 88:468-473. [DOI: 10.1111/ans.14095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 04/29/2017] [Accepted: 05/03/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Sébastien Gaujoux
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
- Paris Descartes Medical School, University Paris Descartes; Sorbonne Paris Cité; Paris France
- INSERM Unit 1016, CNRS UMR 8104; Institute Cochin; Paris France
| | - Adeline Aimé
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
| | - Guillaume Assié
- Paris Descartes Medical School, University Paris Descartes; Sorbonne Paris Cité; Paris France
- INSERM Unit 1016, CNRS UMR 8104; Institute Cochin; Paris France
- Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
| | - Roberto Ciuni
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
| | - Stéphane Bonnet
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
- Paris Descartes Medical School, University Paris Descartes; Sorbonne Paris Cité; Paris France
- INSERM Unit 1016, CNRS UMR 8104; Institute Cochin; Paris France
| | | | - Jérome Bertherat
- Paris Descartes Medical School, University Paris Descartes; Sorbonne Paris Cité; Paris France
- INSERM Unit 1016, CNRS UMR 8104; Institute Cochin; Paris France
- Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
| | - Bertrand Dousset
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital; APHP; Paris France
- Paris Descartes Medical School, University Paris Descartes; Sorbonne Paris Cité; Paris France
- INSERM Unit 1016, CNRS UMR 8104; Institute Cochin; Paris France
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Abstract
Adrenal myelolipomas (AMLs) are rare, benign neoplasms of the adrenal gland with varied clinical presentations. The rarity of these tumors precludes any case-controlled or randomized study into their management. The available literature is limited to case reports and short series from referral centers. This review is an effort to put the available literature into perspective such that clinical decision making can be done with some clarity. The PubMed and Cochrane databases were searched with key words Adrenal Myelolipoma, Adrenal Incidentaloma (AI) and Adrenal Collision Tumor (ACT). From over 1300 search results, 547 relevant publications dating from 1954 to 2014 were reviewed. Details of about 1231 AMLs in the indexed literature were analyzed. Increasing usage of imaging studies has significantly increased the discovery of AMLs. Although AMLs are benign tumors, those measuring larger than 6 cm are prone to rupture and hemorrhage. Thorough endocrine work-up may benefit a selected group of patients, especially those who are hypertensive, diabetic/pre-diabetic, young patients (<50 years) and those with bilateral AML. Regular observation is needed for AML patients who are being treated non-operatively, as many of them may require surgery during follow-up. Although the AACE/AAES guidelines for AI (2009) exclude AML from mandatory metabolic work-up for a newly discovered AI, we feel that a significant number of patients with AML would benefit from metabolic work-up. In the literature, endocrine dysfunction in AML is 7% as compared with 11% in AI. Endocrine dysfunction in AML is probably underdiagnosed.
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Affiliation(s)
- Vasanth G Shenoy
- Department of Urology, Dr. B.R. Ambedkar Medical College, Bangalore, Karnataka, India
| | - Anuroop Thota
- Department of Urology, Dr. B.R. Ambedkar Medical College, Bangalore, Karnataka, India
| | - Ravi Shankar
- Department of Urology, Dr. B.R. Ambedkar Medical College, Bangalore, Karnataka, India
| | - Mallikarjun G Desai
- Department of Urology, Dr. B.R. Ambedkar Medical College, Bangalore, Karnataka, India
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