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Calissendorff J, Juhlin CC, Sundin A, Bancos I, Falhammar H. Adrenal cysts: an emerging condition. Nat Rev Endocrinol 2023:10.1038/s41574-023-00835-2. [PMID: 37095252 DOI: 10.1038/s41574-023-00835-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 04/26/2023]
Abstract
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.
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Affiliation(s)
- Jan Calissendorff
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sundin
- Department of Surgical Sciences, Radiology & Molecular Imaging, Uppsala University, Uppsala, Sweden
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Khan T, Sabu B, Ranganayaki V, Rafeekha P, Thomas R. Management of giant adrenal pseudocyst in pregnancy - A unique approach and review of literature. Obstet Med 2023; 16:52-55. [PMID: 37139502 PMCID: PMC10150310 DOI: 10.1177/1753495x221089210] [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: 07/09/2021] [Revised: 02/24/2022] [Accepted: 03/03/2022] [Indexed: 11/16/2022] Open
Abstract
Pseudocysts of the adrenal gland are rare and in the majority of cases are non- functioning. They become symptomatic only when they are complicated by hormonal excess, rupture, haemorrhage or infection. Described here is a 26-year-old woman who developed an acute abdomen at 28 weeks of gestation due to a left adrenal haemorrhagic pseudocyst. A conservative approach was adopted, which was followed by elective term caesarean delivery with surgical intervention at the same time. The described case is unique in terms of strategizing timing and mode of management and thus minimizing the risk of prematurity and maternal morbidity associated with interval surgery.
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Affiliation(s)
- Tazeen Khan
- Department of High-Risk pregnancy and
Perinatology, KIMS Health, Trivandrum, Kerala, India
| | - Brinda Sabu
- Department of High-Risk pregnancy and
Perinatology, KIMS Health, Trivandrum, Kerala, India
| | | | - P Rafeekha
- Department of Obstetrics and Gynaecology, KIMS Health, Trivandrum, Kerala, India
| | - Renu Thomas
- Department of Urology, KIMS Health, Trivandrum, Kerala, India
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Mandato VD, Mastrofilippo V, Kuhn E, Silvotti M, Barbieri I, Aguzzoli L, La Sala GB. Adrenal Cyst in Pregnancy: A Surgical Emergency. Urology 2018; 121:22-28. [PMID: 29958968 DOI: 10.1016/j.urology.2018.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/31/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Vincenzo Dario Mandato
- Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy.
| | - Valentina Mastrofilippo
- Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy
| | - Elisabetta Kuhn
- Unit of Pathology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy
| | - Monica Silvotti
- Unit of Radiology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy
| | - Italo Barbieri
- General and Emergency Surgery, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Lorenzo Aguzzoli
- Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy
| | - Giovanni Battista La Sala
- Unit of Obstetrics and Gynecology, Azienda Unità Sanitaria Locale, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Azienda Unità Sanitaria Locale, Reggio Emilia, Italy; y
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Abstract
Benign pseudocyst of adrenal gland (Ag) during pregnancy can turn into complication of pregnancy when it grows large and ruptures. There are very few cases reported as far as the size and the complex echo pattern seen in the case reported here. We assessed the usefulness of routine ultrasonography for the right upper quadrant (RUQ) and back pain symptoms during pregnancy. Cat scan (CT) was also useful in making the surgical treatment diagnosis in this case. Ultrasonography is a readily available imaging modality that is useful in guiding the correct treatment, localizing, and identifying the mass and the echo pattern before turning to CT scan or any other imaging modality. In this case, although the size and the complex echo pattern of the mass did not make it difficult to diagnose, careful scanning made the correct diagnosis.
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Affiliation(s)
- Mahesh Sanghvi
- Sisters of Charity Medical Center, Staten Island, New York; 2 Occident Avenue, Staten Island, NY 10304
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Spontaneous adrenal hemorrhage with associated masses: etiology and management in 6 cases and a review of 133 reported cases. World J Surg 2012; 36:75-82. [PMID: 22057755 DOI: 10.1007/s00268-011-1338-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Spontaneous adrenal hemorrhage associated with a mass is uncommon and treatment strategies are not standardized. Current treatment modalities range from supportive management and blood transfusion to embolization or immediate operative extirpation. Our objectives were to describe six cases from a single institution and to perform a literature review of the etiology of the condition and recommended management of patients with hemorrhagic adrenal masses. METHODS Records from six patients diagnosed with adrenal hemorrhage and an associated mass at a single institution were reviewed. Clinical records and outcomes were analyzed. A comprehensive review of 133 reported cases in the literature was performed. RESULTS Six patients presented with spontaneous adrenal hemorrhage that appeared to be associated with a mass, with tumor sizes ranging from 3.7 to 15 cm. Three patients underwent adrenalectomy for pheochromocytoma or adrenocortical cancer. Three patients did not undergo adrenalectomy: one had a metastasis from lung cancer, one underwent embolization, and one had resolution of the mass on interval imaging. A comprehensive review of the literature identified 133 cases, with pheochromocytoma the most commonly reported lesion (48%). CONCLUSIONS Spontaneous adrenal hemorrhage is rare. When it does occur, a high level of suspicion for malignant disease or pheochromocytoma should be maintained. The possibility of a hematoma masquerading as a neoplasm should also be considered. In cases of ongoing hemorrhage, embolization may be a lifesaving temporizing measure. Acute surgical intervention should be considered in selected patients, and surgery may not be required in all patients. A cautious approach with a comprehensive biochemical and imaging work-up is advised prior to operation.
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Karaman K, Teke Z, Dalgic T, Ulas M, Seven MC, Zulfikaroglu E, Sakaogullari Z, Bostanci EB. Giant hemorrhagic adrenal pseudocyst in a primiparous pregnancy: report of a case. Surg Today 2010; 41:153-8. [PMID: 21191710 DOI: 10.1007/s00595-009-4207-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 09/01/2009] [Indexed: 12/15/2022]
Abstract
Adrenal cysts are rare and are usually discovered incidentally during diagnostic imaging, surgery, or autopsy. Most cystic lesions of the adrenal gland are nonfunctioning and become symptomatic when complicated by rupture, hemorrhage, or infection. A 40-year-old woman presented with a history of gradual-onset pain in her left flank region at 20 weeks' gestation. Ultrasound showed a 20-cm cystic mass in her left abdominal cavity. Pertinent laboratory tests were within normal limits. The patient underwent exploratory laparotomy, which revealed a 20 × 15-cm left adrenal cyst; thus, we performed left adrenalectomy with complete excision of the cyst. Histological examination confirmed a hemorrhagic adrenal pseudocyst. The patient had an uneventful postoperative course, and subsequent routine obstetric ultrasound examinations showed normal fetal activity and development until the pregnancy terminated with a stillbirth caused by pre-eclampsia at 34 weeks' gestation. To the best of our knowledge, this is only the 12th reported case of adrenal pseudocyst discovered during pregnancy. We analyze the clinicopathologic findings and discuss the possible association of pregnancy, with special reference to etiopathogenesis, presentation, diagnosis, and treatment.
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Affiliation(s)
- Kerem Karaman
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey
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El-Hefnawy AS, El Garba M, Osman Y, Eraky I, El Mekresh M, Ibrahim EH. Surgical management of adrenal cysts: single-institution experience. BJU Int 2009; 104:847-50. [PMID: 19389014 DOI: 10.1111/j.1464-410x.2009.08537.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the safety and efficacy of different surgical procedures used for managing benign adrenal cysts. PATIENTS AND METHODS The files of 245 patients presenting with adrenal masses was reviewed retrospectively; all had a thorough history taken and a physical examination. The radiological evaluation included abdominal plain X-rays, grey-scale abdominal ultrasonography and computed tomography with contrast medium. According to their clinical situation, patients had surgical open, laparoscopic intervention or were managed conservatively. The short- and long-term outcome of the open and laparoscopic techniques were evaluated. RESULTS Twenty-six (11%) patients presented with adrenal cysts; the mean (sd, range) age at the time of presentation for adults was 41.4 (15, 17-82) years, while a 1-month female neonate and 1-year-old boy presented with an adrenal cyst. The mean (sd, range) size of the cysts was 10 (3.5, 5-18) cm. Surgical intervention was the treatment of choice in 21 patients; 11 (42%) had open adrenalectomy, while 10 (38%) had laparoscopic intervention. Both groups were comparable in the term of cyst size and operative time, while the laparoscopically managed group had a shorter hospital stay. Five patients were followed with no surgical intervention. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence. CONCLUSIONS Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. Compared with open techniques it has the advantages of a shorter hospital stay, less blood loss and enhanced cosmesis. Unlike aspiration of cyst contents, the recurrence of adrenal cysts after surgical removal is unlikely.
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Arroyo Sebastián A, Carvajal Menéndez R, Costa Navarro D, Serrano Paz P, Candela Polo F, Calpena Rico R. Dolor abdominal y fiebre en mujer de 36 años con tumoración quística en hemiabdomen derecho. Rev Clin Esp 2002. [DOI: 10.1016/s0014-2565(02)71108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Neri LM, Nance FC. Management of Adrenal Cysts. Am Surg 1999. [DOI: 10.1177/000313489906500213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adrenal cysts have been traditionally managed by excision to rule out malignancy. We reviewed the 613 cases of adrenal cysts (including 6 new cases of our own) to evaluate whether this is still appropriate. Descriptive statistics and distribution of each pathologic type have been updated, based on 515 cases, and have changed from statistics compiled on 155 cases by G. A. Absehouse et al. Only seven per cent of all adrenal cysts are malignant or potentially malignant. There is only one reported case of a malignancy found in a nonfunctioning adrenal cyst that was initially thought to be benign. In this case, no CT or aspiration was performed. There have been 19 cases of adrenal cysts managed with aspiration. All were nonfunctioning and benign. One had a bloody aspirate. Reaccumulation occurred in 32 per cent of the cases (six cases); six per cent were symptomatic, four per cent were excised. Follow up was available in 15 cases from 4 months to 3.5 years. Management of the patient with a suspected adrenal cyst should include a careful history and physical and biochemical screening to rule out a functioning lesion. A CT scan, and aspiration of the cyst with a cystogram should be performed to confirm a simple cyst of the adrenal. If the suspicion of malignancy is low, and the lesion is nonfunctional, the adrenal cyst may be managed by aspiration alone. If the cyst recurs and is asymptomatic, it may be observed. If a symptomatic cyst recurs, it may be reaspirated or excised.
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Affiliation(s)
- Linda M. Neri
- Department of Surgery, The Saint Barnabas Medical Center, Livingston, New Jersey
| | - F. C. Nance
- Department of Surgery, The Saint Barnabas Medical Center, Livingston, New Jersey
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