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Saini V, Garg R, Kataria K, Nelson T. True mesothelial cyst of the adrenal gland: its clinical profile and management. BMJ Case Rep 2024; 17:e258485. [PMID: 38395468 PMCID: PMC10895221 DOI: 10.1136/bcr-2023-258485] [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] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Vikram Saini
- Department of Surgical Discipline, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Richa Garg
- Department of Surgical Discipline, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kamal Kataria
- Department of Surgical Discipline, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Surani V, Chatterjee S, Jaggi S, Banka N, Desai S, Rodge G. Curious Case of a Giant Retroperitoneal Cyst. Cureus 2024; 16:e51758. [PMID: 38318574 PMCID: PMC10843365 DOI: 10.7759/cureus.51758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/07/2024] Open
Abstract
Adrenal cysts are uncommon fluid-filled masses that develop in the adrenal gland. Typically, they are non-functional, asymptomatic, and smaller than 10 cm in diameter when incidentally detected. However, the presence of giant adrenal cysts, exceeding 10 cm in diameter, creates a diagnostic challenge due to the difficulty in determining their origin. Surgical intervention is advised when the cyst surpasses 10 cm in diameter, produces symptoms, causes endocrine abnormalities, exhibits intracystic bleeding, or raises suspicion of malignancy. The preferred treatment approach involves adrenalectomy, performed either through open surgery or laparoscopy. In cases where the diagnosis is unequivocal, ultrasound-guided percutaneous drainage serves as an alternative. Here, we present an exceptional case of a massive retroperitoneal mass caused by a rare giant adrenal cyst.
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Affiliation(s)
- Viral Surani
- Gastroenterology and Hepatology, Bombay Hospital and Medical Research Center, Mumbai, IND
| | | | - Sunila Jaggi
- Radiology, Bombay Hospital and Medical Research Center, Mumbai, IND
| | - Niranjan Banka
- Gastroenterology and Hepatology, Bombay Hospital and Medical Research Center, Mumbai, IND
| | - Shivani Desai
- General Surgery, Bombay Hospital Institute of Medical Sciences, Mumbai, IND
| | - Gajanan Rodge
- Gastroenterology and Hepatology, Bombay Hospital and Medical Research Center, Mumbai, IND
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3
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Yu N, Du J, Zheng G, Zheng Y. Giant Adrenal Cyst: A Case Report. Cureus 2023; 15:e37086. [PMID: 37153235 PMCID: PMC10159221 DOI: 10.7759/cureus.37086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/07/2023] Open
Abstract
Giant adrenal cysts are rare lesions, most often discovered incidentally. In this case report, a patient presenting with nonspecific abdominal distension is described. Imaging studies revealed a vast cystic mass closely attached to the left adrenal gland. Neither routine laboratory tests nor endocrine function tests revealed abnormalities. By performing open surgery, the cystic mass was completely removed. According to the pathological results, the wall of the cystic mass has an endothelial structure and some vascular components. Comprehensive analysis indicated that this case was an angiomatous adrenal endothelial cyst which was an extremely uncommon form of an adrenal cyst. Over a one-year follow-up, no evidence of recurrence was observed in the patient postoperatively. Through this case, we wish to raise awareness of this disease.
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Devereux SL, Baltzer WI, Piripi SA, Owen MC. Case Report: Adrenal Epithelial Cyst in an 11-Year-Old Leptailurus Serval. Front Vet Sci 2022; 9:897469. [PMID: 35733637 PMCID: PMC9207559 DOI: 10.3389/fvets.2022.897469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Case DescriptionA 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 FindingsClinical 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 OutcomeThe 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 RelevanceEpithelial 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.
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Affiliation(s)
- Sacha L. Devereux
- Small Animal Surgery Department, School of Veterinary Science, Massey University Veterinary Teaching Hospital, Massey University, Palmerston North, New Zealand
- *Correspondence: Sacha L. Devereux
| | - Wendy I. Baltzer
- Small Animal Surgery Department, University Veterinary Teaching Hospital, Sydney, NSW, Australia
| | - Susan A. Piripi
- IDEXX Laboratories, Clinical Pathology, School of Veterinary Science Complex, Massey University, Palmerston North, New Zealand
| | - Mark C. Owen
- Radiology Department, School of Veterinary Science, Massey University Veterinary Teaching Hospital, Massey University, Palmerston North, New Zealand
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Sargar KM, Khanna G, Hulett Bowling R. Imaging of Nonmalignant Adrenal Lesions in Children. Radiographics 2018; 37:1648-1664. [PMID: 29019745 DOI: 10.1148/rg.2017170043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The adrenal glands in children can be affected by a variety of benign lesions. The diagnosis of adrenal lesions can be challenging, but assessment of morphologic changes in correlation with the clinical presentation can lead to an accurate diagnosis. These lesions can be classified by their cause: congenital (eg, discoid adrenal gland, horseshoe adrenal gland, and epithelial cysts), vascular and/or traumatic (eg, adrenal hemorrhage), infectious (eg, granulomatous diseases), enzyme deficiency disorders (eg, congenital adrenal hyperplasia [CAH] and Wolman disease), benign neoplasms (eg, pheochromocytomas, ganglioneuromas, adrenal adenomas, and myelolipomas), and adrenal mass mimics (eg, extralobar sequestration and extramedullary hematopoiesis). Multimodality cross-sectional imaging helps to define the origin, extent, and relationship of these lesions to adjacent structures, as well as to guide treatment management. The anatomic and functional imaging modalities used to evaluate pediatric adrenal lesions include ultrasonography, computed tomography (CT), magnetic resonance imaging, and iodine 123 metaiodobenzylguanidine scintigraphy. Identifying the imaging features of nonmalignant adrenal lesions is helpful to distinguish these lesions from malignant adrenal neoplasms. Identifying characteristic imaging findings (eg, enlarged adrenal glands, with cerebriform surface, and stippled echogenicity in CAH; a T2-hyperintense mass with avid contrast enhancement in pheochromocytoma; low CT attenuation [<10 HU] and signal intensity drop on opposed-phase chemical shift images in adenoma; and enhancing suprarenal mass supplied by a systemic feeding artery in extralobar sequestration) can aid in making the correct diagnosis. In addition, clinical features (eg, ambiguous genitalia in CAH and hypertension in pheochromocytoma) can also guide the radiologist toward the correct diagnosis. ©RSNA, 2017.
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Affiliation(s)
- Kiran M Sargar
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131-MIR, St Louis, MO 63110
| | - Geetika Khanna
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131-MIR, St Louis, MO 63110
| | - Rebecca Hulett Bowling
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131-MIR, St Louis, MO 63110
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Koperski Ł, Pihowicz P, Szczepankiewicz B, Fus Ł, Cyran A, Bogdańska M, Górnicka B. Clinicopathological and immunohistochemical analysis of epithelial-lined (true) cysts of the adrenal gland with proposal of a new histogenetic categorization. Pathol Res Pract 2017; 213:1089-1096. [PMID: 28781196 DOI: 10.1016/j.prp.2017.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/27/2017] [Accepted: 07/19/2017] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Łukasz Koperski
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland.
| | - Paweł Pihowicz
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland
| | | | - Łukasz Fus
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland
| | - Agata Cyran
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland
| | - Magdalena Bogdańska
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland
| | - Barbara Górnicka
- Department of Pathology, Medical University of Warsaw, Pawińskiego 7, 02-106 Warsaw, Poland
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Lin TP, Chen M, Chen CK, Hsu JM, Lin WR. Adrenal cystic lymphangioma: A case report and review of the literature. UROLOGICAL SCIENCE 2014. [DOI: 10.1016/j.urols.2013.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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8
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Sebastiano C, Zhao X, Deng FM, Das K. Cystic lesions of the adrenal gland: our experience over the last 20 years. Hum Pathol 2013; 44:1797-803. [PMID: 23618356 DOI: 10.1016/j.humpath.2013.02.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/06/2013] [Accepted: 02/08/2013] [Indexed: 11/28/2022]
Abstract
Cystic lesions of the adrenal gland are uncommon, often presenting with nonspecific clinical and radiologic findings, and are thus underrecognized. They are occasionally associated with malignant neoplasms, which can greatly mimic benign lesions and carry detrimental clinical consequences if misdiagnosed. Here we present our 20-year experience (1992-2012) with these lesions at an academic medical center. Among more than 4500 adrenal gland specimens, 31 cases of adrenal lesions with a predominant cystic component were identified in 30 patients with an age range of 34 to 86 years (median, 55.5 years) and a male/female ratio of 13:17. Macroscopic descriptions, available histologic and immunostain slides, and available radiologic records were reviewed for all included cases. Radiologic studies and gross examination correlated well, and hemorrhage (26 cases; 84%) and encapsulation (25 cases; 81%) appeared to be nonspecific radiologic/gross features shared across histologic subtypes. Microscopic review identified 12 cases (39%) of pseudocysts, 2 cases (6%) of endothelium-derived cysts, and 17 cases (55%) of epithelium-derived cysts. Among these 31 cystic adrenal lesions, 2 cases (6%) were malignant neoplasms (1 epithelioid angiosarcoma, 1 adrenocortical carcinoma). Radiologic impression and histopathologic diagnosis were concordant in 11 (73%) of the 15 cases for which radiologic records were available. This study represents the second largest case series to date on cystic adrenal lesions and presents a comprehensive review on their demographic, clinical, radiologic, and gross and microscopic pathologic features, as well as their differential diagnoses.
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Affiliation(s)
- Christopher Sebastiano
- Department of Pathology, New York University Langone Medical Center, New York, NY 10016, USA
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Matsukuma S, Kono T, Takeo H, Sato K. Intra-adrenal bile ductules associated with adreno-hepatic fusion: a possible origin for adrenal epithelial cysts. Histopathology 2013; 62:799-804. [DOI: 10.1111/his.12088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 12/14/2012] [Indexed: 12/11/2022]
Affiliation(s)
- Susumu Matsukuma
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan.
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10
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Chien HP, Chang YS, Hsu PS, Lin JD, Wu YC, Chang HL, Chuang CK, Tsuei KH, Hsueh C. Adrenal cystic lesions: a clinicopathological analysis of 25 cases with proposed histogenesis and review of the literature. Endocr Pathol 2008; 19:274-81. [PMID: 18972224 DOI: 10.1007/s12022-008-9046-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Adrenal cystic lesions are uncommon and we analyzed clinical and pathologic features of 25 such cases from a single institute over 23 years. There were 16 pseudocysts, eight endothelial cysts, and one epithelial cyst. Seven of eight endothelial cysts were confirmed to be lymphangiomatous by D2-40 immunostaining. We suggest that pseudocysts and endothelial cysts may have different histogenesis. The proposed mesothelial origin of adrenal epithelial cyst cannot be confirmed in our example. Seven adrenal pseudocysts were associated with tumor, including two pheochromocytomas, one neuroblastoma, one adrenal cortical carcinoma, one adrenal cortical adenoma, one myelolipoma, and one schwannoma. The distinction of true cystic lesion from cystic neoplasm is important and requires thorough sampling of the specimens.
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Affiliation(s)
- Hui-Ping Chien
- Department of Pathology, Chang Gung Memorial Hospital, No. 5 Fu-Shin Street, Kuei-Shan, Taoyuan, Taiwan, Republic of China
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11
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Abstract
We report a rare case of fetal adrenal cyst, diagnosed prenatally during routine ultrasound screening at 36 weeks' gestation. Serial ultrasonographic evaluations demonstrated a slight increase in the size of the cyst during pregnancy. A healthy female baby, weighing 2,810 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, was delivered vaginally at term. She underwent successful surgery at the age of 10 days. The postoperative course was smooth and the baby is currently doing well. Histology revealed an adrenal cyst.
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Affiliation(s)
- Hung-Chune Maa
- Division of Urologic Surgery, Department of Pathology, Kaohsiung Municipal Women's and Children's General Hospital, Kaohsiung City, Taiwan.
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12
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Abstract
OBJECTIVE To characterize adrenal lymphangiomas and discuss management strategies based on findings. METHODS We present a case report and review the pertinent literature. RESULTS In a 35-year-old man with painless hematuria for several days, a computed tomographic (CT) scan of the abdomen disclosed an 8-cm right adrenal mass. It had the appearance of a loculated cyst with several septations. The histologic diagnosis of the excised lesion was lymphangioma with cystic degeneration. The most frequently occurring cystic adrenal masses are endothelial lesions. Lymphangiomas of the adrenal gland have a characteristic mutiloculated appearance on ultrasonography and CT. Small asymptomatic smooth adrenal cysts with clear fluid can simply be observed, whereas large symptomatic adrenal lymphangiomas should be excised. CONCLUSION The preferred studies for detection of adrenal lymphangiomas are CT and ultrasonography. The size of the lesion, type of cystic fluid, symptomatic status, and cytologic findings dictate management options.
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Affiliation(s)
- D T Ness
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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13
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Affiliation(s)
- D L Bartlett
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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14
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Yang HY, Lee JH, Lee HR, Choi CO, Park JP, Jin TS, Lee SY. A case of adrenal lymphangiectatic cyst associated with severe hypertension. Korean J Intern Med 1990; 5:108-11. [PMID: 2098094 PMCID: PMC4535004 DOI: 10.3904/kjim.1990.5.2.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Adrenal lymphangiectatic cyst is a very rare pathological and clinical disease entity, and its clinical silence and lack of characteristic symptoms and signs makes it difficult to diagnose preoperatively. We experienced a case of adrenal lymphangiectatic cyst, accompanied by severe refractory hypertension, which was corrected by surgical removal of the cyst. We report it with a review of the literature.
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Affiliation(s)
- H Y Yang
- Department of Internal Medicine, Dea Rim Saint Mary's Hospital, Seoul, Korea
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Abstract
We report a rare case of massive retroperitoneal hemorrhage owing to rupture of an adrenal cyst after blunt abdominal trauma. A large retroperitoneal hematoma was evacuated and subtotal adrenalectomy was performed. Convalescence was uneventful. Histology revealed an endothelial-lined adrenal cyst suggesting a vascular or lymphatic etiology.
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Affiliation(s)
- R M Pasciak
- Department of Urology, Northwestern University Medical School, Chicago, Illinois
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Abstract
A case of cystic lesion of the adrenal gland is presented. Ultrasonography and computerized tomography greatly facilitate the diagnosis of these lesions. The cause, differential diagnosis, and treatment of adrenal cysts are discussed.
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Khuri FJ, Alton DJ, Hardy BE, Cook GT, Churchill BM. Adrenal hemorrhage in neonates: report of 5 cases and review of the literature. J Urol 1980; 124:684-7. [PMID: 7005460 PMCID: PMC7131664 DOI: 10.1016/s0022-5347(17)55609-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The differential diagosis of masses in the suprarenal area in neonates is discussed in relation to clinical, laboratory and radiologic findings. Neonatal adrenal hemorrhage can be accurately diagnosed clinically. In the neonate neuroblastoma in situ is self-limiting and exploration to exclude it is unnecessary. Operative intervention should be reserved for controlling massive adrenal hemorrhage or if an abscess forms.
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Siemens: Urologia in clinica ed in ambulatorio. Urologia 1979. [DOI: 10.1177/039156037904600404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kearney GP, Mahoney EM, Maher E, Harrison JH. Functioning and nonfunctioning cysts of the adrenal cortex and medulla. Am J Surg 1977; 134:363-8. [PMID: 331976 DOI: 10.1016/0002-9610(77)90407-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenal cysts are rare clinical and pathologic entities. The vast majority are minute in size, unilateral, and found in females at autopsy. They come to the physician's attention when they produce symptoms or are identified on x-ray studies. When symptomatic, they generally produce lumbar discomfort and gastrointestinal symptoms, and occasionally are palpable by abdominal examination. There is no significant agreement as to cause and pathogenesis of the disease. The most common histologic types are lymphangiomatous endothelial cysts, secondary to lymphangiectasis, and the fibrous wall or hemorrhagic pseudocysts. In many patients preoperative diagnosis is now possible with high quality nephrotomography, ultrasonography, and adrenal arteriography. The presence of a suprarenal mass with peripheral or laminar calcification strongly suggests the presence of an adrenal pseudocyst. Selective biochemical studies are mandatory to rule out the presence of an occult cystic pheochromocytoma, and adrenal cortical tumor. Adrenal cysts must be differentiated from all space-occupying lesions of the upper abdomen. Surgical exploration is recommended in almost all patients for accurate diagnosis and to rule out malignant disease or occult pheochromocytoma. The choice of the surgical approach should be planned to provide for safe and adequate exposure, depending on the size and location of the lesion. Careful dissection with preservation of the adjacent kidney, liver, and pancreas should be performed.
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