The management of bilateral myelolipoma: Case report and review of the literature

Bilateral Adrenal Myelolipoma and Breast Cancer in a Patient With Congenital Adrenal Hyperplasia

Adrenal myelolipoma is a rare, benign tumor of the adrenal gland, typically non-functional, asymptomatic and unilateral. With the increased use of radiological imaging, it has been discovered more frequently as incidental mass. It is common to occur concurrently with hormonal dysfunction conditions like congenital adrenal hyperplasia. However, there are few previous reported cases of malignancy concomitant with adrenal myelolipoma. We present a case of a 33-year-old patient diagnosed with congenital adrenal hyperplasia since birth. She was diagnosed with giant bilateral adrenal myelolipoma incidentally during the investigation done for staging her breast cancer. To the best of our knowledge, this is the second reported case of breast cancer concomitant with adrenal myelolipoma. Although this entity is very rare, physicians should be familiar with such rare adrenal masses and their associations in order to manage them appropriately.

Bilateral adrenal myelolipoma revealing an adrenal insufficiency: A case report

INTRODUCTION

Once mostly discovered on autopsy, adrenal myelolipomas are now increasingly diagnosed due to the frequent use of modern imaging methods. However, bilaterality remains quite rare. We present the case of a 31 years old female patient treated in our department for a bilateral adrenal myelolipoma which revealed an unknown peripheral adrenal insufficiency.

CASE PRESENTATION

We describe the case of a 31-year-old woman in apparent good health with no medical history who was explored for recurrent right lumbar pain by a computed tomography scanner which showed a large right adrenal mass and a smaller lesion in the left adrenal gland. Preoperative biology revealed an unknown peripheral adrenal insufficiency. Right open sub-costal adrenalectomy was performed, Histological examination confirmed the diagnosis of bilateral adrenal myelolipomas and radiological surveillance was planned for the left tumor.

DISCUSSION

Adrenal myelolipoma (AML) is a rare, benign and typically non-functional tumor of the adrenal gland, usually unilateral and asymptomatic, incidentally detected on CT. Commonly diagnosed between the fifth and seventh decades of life. It can affect both sexes our patient is a 31-year-old female and presented with bilateral AML. Unlike previous reported cases, our patient has a previously unknown peripheral adrenal insufficiency, which could be incriminated in the development of his bilateral adrenal myelolipomas. The optimal management depends on both clinical presentation and tumor characteristics.

CONCLUSION

Adrenal myelolipoma is a rare tumor. Endocrinological investigation should be performed to detect and treat endocrine disorders. The therapeutic attitude depends on tumor size complications and clinical complaints.

METHODS

This is a case report from our urology department, and has been reported in line with the SCARE criteria.

Bilateral Adrenal Myelolipomas in a Female Patient With Undiagnosed Non-classic Congenital Adrenal Hyperplasia

Non-classic congenital adrenal hyperplasia (CAH) usually presents later in life with signs of androgen excess but may also be diagnosed after the detection of an incidental adrenal myelolipoma. This is a patient with previously undiagnosed CAH who presented to the emergency department with chest discomfort and palpitations. A computed tomography (CT) scan of the chest done to rule out pulmonary embolism showed bilateral large adrenal myelolipomas. She also had evidence of marked hirsutism on examination, which prompted further workup, and her laboratory data was in keeping with CAH. Further management was unable to be pursued due to the patient's poor compliance, and she was subsequently lost to follow-up. Chronic exposure of the adrenal glands to high adrenocorticotropic hormone (ACTH) levels increases the risk of developing myelolipomas. CAH needs to be considered as a diagnosis in the evaluation of incidental adrenal myelolipomas.

Case report: Adrenal myelolipoma resected by laparoscopic surgery

Introduction

Adrenal myelolipomas are benign tumors composed mainly of lipomatous elements with myeloid cells. With the development of medical imaging technology, the detection rate has gradually increased. We report a case of adrenal myelolipoma successfully excised through the laparoscope and reviewed existing literature in recent ten years to summarize the feasibility of the laparoscopic approach for this tumor.

Case presentation

Herein, we described a case of adrenal myelolipoma resected by laparoscope in a 63-year-old male patient. He did not have any other symptoms except the incidental finding of a left adrenal mass. An abdominal CT examination revealed a mixed-density lesion containing some amount of adipose tissue. In conjunction with the patient's willingness, we performed a laparoscopic operation to remove the lump. The definite diagnosis was confirmed as an adrenal myelolipoma according to the pathology. The patient recovered well postoperatively and without signs of recurrence at a 5-month follow-up.

Conclusion

Adrenal myelolipoma is commonly benign, asymptomatic, and hormonal inactivity. A surgical strategy is suggested for high-complication-risk patients. The laparoscopic approach is safe and effective with an obvious advantage over open procedures.

Adrenal Myelolipoma Masquerading as an Adrenal Malignancy

An adrenal myelolipoma presenting with suspicious features may pose a diagnostic challenge to surgeons and endocrinologists. In this case report of an adult patient with undiagnosed congenital adrenal hyperplasia presenting with bilateral adrenal masses, we review his radiographic and clinical findings which were highly suspicious for adrenal malignancy. Features of adrenal myelolipoma that may resemble malignant lesions are reviewed. This case report highlights important features of adrenal myelolipoma that the surgeon and endocrinologist should be aware of. The importance of avoiding overtreating adrenal myelolipomas presenting as tumors of uncertain malignant potential is crucial.

Laparoscopic adrenalectomy for a giant adrenal myelolipoma: A case report

CASE PRESENTATION

We describe a case of a patient who presented with a mildly symptomatic, giant myelolipoma which was excised by laparoscopic approach without complications.

INTRODUCTION AND IMPORTANCE

Adrenal myelolipoma (AML) is a rare tumour composed by fat and myeloid tissues. Usually it is asymptomatic, so the diagnosis is mostly incidental. It is generally located in the right adrenal gland, but it can also be found bilaterally. If its size exceeds 10 cm it is defined as a "giant myelolipoma"; in this case its treatment of choice would be adrenalectomy with an open surgical approach.

CLINICAL DISCUSSION

Patient's signs and symptoms were mild pain in the right hypochondrium and a positive right Giordano's sign. The mass was detected by a contrast-enhanced CT scan. Once excised it measured 16 cm.

CONCLUSION

Laparoscopic adrenalectomy for giant myelolipoma is a safe approach if performed by an expert surgeon, with low risk of bleeding and a better outcome for the patient.

Management of bilateral adrenal myelolipoma without endocrine disorder: About a rare case report

Adrenal gland myelolipomas are benign, hormonally inactive, and mostly asymptomatic and unilateral tumors. However, it could be symptomatic and bilateral in rare cases. The diagnosis is based on a CT scan and a histological study. We present a rare case of a surgically managed bilateral adrenal gland myelolipoma with a giant mass on the left side in a 40-year-old man who presented in our department for atypical abdominal pain. The patient underwent surgical resection of the left adrenal mass. Due to the resolution of the abdominal pain, a close follow-up for the right mass by CT scan was chosen.

Macroscopic Appearance of Giant Adrenal Myelolipoma During Laparoscopy: An Adjunct in Differential Diagnosis

Giant adrenal myelolipoma is a rare, benign, sizable, mesenchymal tumor. Preoperative differential diagnosis from retroperitoneal liposarcoma may be challenging. A 66-year-old female patient was admitted because of a sizable tumor at the right retroperitoneal space, incidentally discovered during abdominal ultrasonography for screening purpose. Preoperative imaging studies were indicative for the diagnosis of a giant adrenal myelolipoma (11.7 × 12.9 cm in size); however, a retroperitoneal liposarcoma could not be excluded. We decided to proceed with tumor's surgical removal by using laparoscopic transperitoneal approach and three-dimensional high-definition camera. Intraoperatively, the tumor did not infiltrate surrounding tissues and was surrounded by a thin capsule under which there were sparse, orange-colored spots that resembled adrenal cortex. This finding reinforced the initial and most possible diagnosis of adrenal myelolipoma and we easily enucleated the mass. Postoperative course was uneventful, and the patient demonstrated no recurrence on imaging six months postoperatively. Histology confirmed the diagnosis of giant adrenal myelolipoma, measuring 16.5 x 15 x 6.5 cm.

Adrenal myelolipoma: from tumorigenesis to management

Adrenal myelolipoma (MLS) is a rare, benign and non-functional neoplasm, composed of adipose tissue and myeloid. We report a rare case of adrenal myelolipoma of a 20-year-old female revealed with chronic abdominal pain. Computed tomography (CT) scan of the abdomen guided diagnosis and surgical resection was performed given symptomatic and bulky mass. Histological examination confirmed the diagnosis. At 18 months after the surgery, the patient had no evidence of recurrence. The diagnosis of MLS is radiological. Therapeutic abstention is the rule for a small, asymptomatic tumor. The surgical removal is indicated when it is bulky (exceeds 7cm), symptomatic or hormonal activity.

Epithelioid Hemangioendothelioma Arising Within Mediastinal Myelolipoma: A WWTR1-Driven Composite Neoplasm

In this article, we describe a case of conventional epithelioid hemangioendothelioma (EHE) arising within an extra-adrenal myelolipoma. This composite neoplasm arose in the mediastinum of a 51-year-old female. The tumor was composed of a large myelolipoma that contained nodules of EHE consisting of CD31-positive epithelioid endothelial cells that grew in solid cords and were enmeshed in a basophilic hyalinized stroma. Both EHE and myelolipoma are characterized genetically by alterations of WWTR1. We demonstrated the expression of CAMTA-1 chimeric protein by immunohistochemistry both in the neoplastic endothelial cells of EHE and some of the endothelial cells lining the blood vessels in the myelolipoma. To the best of our knowledge, this is the first report of a malignant vascular neoplasm arising in association with myelolipoma.

MANAGEMENT OF ENDOCRINE DISEASE: Differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas

The investigation and management of unilateral adrenal incidentalomas have been extensively considered in the last decades. While bilateral adrenal incidentalomas represent about 15% of adrenal incidentalomas (AIs), they have been less frequently discussed. The differential diagnosis of bilateral incidentalomas includes metastasis, primary bilateral macronodular adrenal hyperplasia and bilateral cortical adenomas. Less frequent etiologies are bilateral pheochromocytomas, congenital adrenal hyperplasia (CAH), Cushing's disease or ectopic ACTH secretion with secondary bilateral adrenal hyperplasia, primary malignancies, myelolipomas, infections or hemorrhage. The investigation of bilateral incidentalomas includes the same hormonal evaluation to exclude excess hormone secretion as recommended in unilateral AI, but diagnosis of CAH and adrenal insufficiency should also be excluded. This review is focused on the differential diagnosis, investigation and treatment of bilateral AIs.

[FIVE CASES OF ADRENAL MYELOLIPOMA WITH SURGICAL TREATMENT; A CLINICAL REVIEW]

(Purpose) We report five cases of adrenal myelolipoma with surgical treatment, and analyze the patients' background and clinical courses. (Patients and methods) From 2004 to 2017, five patients diagnosed adrenal myelolipoma were underwent surgical treatment at our hospital. We investigate the patients' background and clinical courses retrospectively. (Results) Median age was 53 years old. Four of them were male and one was female. The tumor was located on the right side in four cases and the left side in one case. All cases were incidentally found by abdominal ultrasound or computer tomography (CT) during a medical check or image examination for other disease. Whereas all cases were asymptomatic, they have past history either hypertension, diabetes or obesity. The tumor size at the time of diagnosis was from 28 mm to 80 mm (median 58 mm). All tumors were nonfunctioning, and diagnosed by CT scan preoperatively. The median tumor size at the time of operation was 66 mm. (Conclusion) We report five cases of adrenal myelolipoma treated surgically. The opportunity of encountering this disease has been increasing as the recent improvement of diagnostic imaging such as CT, MRI, and etc. However, there is no widely-accepted treatment algorithm. We should manage them carefully, because spontaneous rupture of adrenal myelolipoma has been reported in some cases.

Lipomatous tumours in adrenal gland: WHO updates and clinical implications

Adrenal lipomatous tumour is a group of adrenal tumours with a significant component of adipose tissue. According to the current World Health Organization (WHO) classification of tumours of endocrine organs, adrenal myelolipoma is the only entity amongst the group of tumours being described. In the literature, other more recently documented adrenal lipomatous tumours included 24 lipomas, 32 teratomas and 16 angiomyolipomas. Rare fatty tumours of the adrenal gland comprised liposarcoma, hibernoma, adrenocortical tumours with fat component and rare adrenal tumours with fat component. Myelolipoma comprises approximately 3% of primary adrenal tumour. It is noted more commonly in females and in the right adrenal gland. Approximately 40 bilateral myelolipomas were reported. The tumour is most frequently recorded in patients between fifth and seventh decades of life. Adrenal lipomas are often seen in males and in the right adrenal gland. They were commonly noted in patients in the sixth decade of life. The diagnosis could only be possible on examination of the surgically removed specimen. Adrenal teratomas were more common in females and with a bimodal age distribution. Slightly over 60% of the patients with adrenal teratoma are symptomatic. Adrenal angiomyolipomas were often symptomatic, more common in females and in the fifth decades of life. To conclude, adrenal lipomatous tumour is uncommon. They are often benign and non-functional. It is important to recognize the features of this group of lipomatous tumours in the adrenal gland as they are being detected on increasing incidence as a result of the wide-spread use of modern imaging modalities.

Two case reports of bilateral adrenal myelolipomas

Primary adrenal myelolipoma is a rare, non-functioning adrenal benign tumor that is composed of mature adipose tissue and a variable amount of haemopoietic elements. Clinically, it is difficult to get diagnosed with adrenal myelolipoma because the patient usually doesn’t have obvious symptoms and signs in early stage. In the present study, two cases of primary bilateral adrenal myelolipomas are reported. Clinical presentation, imaging diagnostic features, histopathological changes and surgical treatments of the two patients are discussed. Preoperative diagnostic imaging examinations (B-mode ultrasonography, computed tomography and magnetic resonance imaging sans) assisted getting a prediction diagnosis of bilateral adrenal myelolipomas. A two-stage surgery was used to successfully excise bilateral adrenal myelolipomas in the two patients. Conventional open adrenalectomy was applied to remove the adrenal myelolipomas greater than 6 cm, and laparoscopic adrenalectomy was performed to excise the adrenal tumors smaller than 6 cm. Bilateral adrenal myelolipomas of the two patients were finally confirmed by postoperative histopathological examinations. Understanding clinical, imaging diagnostic and histopathological features of bilateral adrenal myelolipomas will facilitate timely diagnosis and treatment of this condition. Surgical removal of bilateral adrenal myelolipomas is safe, curative and beneficial. The two-stage surgery appears to be the best treatment option for the patients with bilateral adrenal myelolipomas because it achieves optimal treatment effectiveness with minimized sequelae.