Adrenal Gland Lymphangiomas

The diagnostic dilemma of adrenal vascular tumors: analysis of 21 cases and systematic review of the literature

PURPOSE

Adrenal vascular tumors are mainly represented by adrenal cavernous hemangiomas (ACHs) and adrenal cystic lymphangiomas (ACLs). Their radiological features often overlap with malignant tumors, therefore ruling out malignancy becomes mandatory. We analyzed clinical, radiological, and histopathological data to identify specific characteristics of these tumors.

METHODS

We reviewed 21 patients with ACHs (n = 12), ACLs (n = 8), or adrenal cysts (n = 1) confirmed by histopathology. We selected 82 papers from PubMed to provide a systematic review of the literature.

RESULTS

In our cohort, median age at diagnosis was 58 years, with sex evenly distributed. All tumors were unilateral (median size = 44 mm), with 6 cases of increasing tumor size. All tumors exhibited non-contrast CT density > 10 Hounsfield Unit (HU). Calcifications were found in 5 cases. Hormonal studies revealed 11 non-functioning tumors and 2 cortisol-secreting tumors. Elevated urinary metanephrines were found in 2 cases. Immunostaining showed CD31/CD34/factor VIII expression in ACHs (n = 5, 24%) and podoplanin expression in ACLs (n = 6, 29%). The literature review revealed 71 reported cases of ACHs and 104 reported cases of ACLs. Median age at diagnosis was 46 years, with slightly female prevalence (63%). Median tumor size was 48 mm. 84 cases were symptomatic, with life-threatening hemorrhage reported in only 3 patients. Calcifications were found in 23% of cases. Surgical approaches varied, with open and laparoscopic adrenalectomy performed in 55 and 42 patients respectively.

CONCLUSIONS

ACHs and ACLs represent a diagnostic dilemma in clinical practice due to their rarity and their misleading imaging features.

Adrenal lymphangioma: Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Lymphangiomas (LG) are a rare type of lesion of the lymphatic vessels. They predominantly occur in young patients, mostly female. Adrenal location represents 0.06 % of reported cases in the literature. Characteristically, LGs are often clinically silent and discovered incidentally during abdominal imaging studies performed for other reasons. Definitive diagnosis is done by the histopathologic analysis of the specimen. The rarity of this pathology and the lack of reports makes this entity challenging.

CASE PRESENTATION

We present a 48-year-old man referred to our institution for a left adrenal solid mass incidentally discovered in CT abdominal scan (103 × 62 mm).

CLINICAL DISCUSSION

Patient underwent laparoscopic surgical excision of the tumor. The histopathology examination showed the presence of cystic structures with fibrous walls and parietal calcifications. Immunohistochemical staining was positive for D2-40 and CD31. These findings were compatible with LG of the adrenal gland. We discuss adrenal lymphangioma as a rare differential diagnosis of adrenal cystic lesions.

CONCLUSION

Adrenal LGs are rare tumors and, despite some clues for radiologic diagnosis, preoperative diagnosis is challenging. In symptomatic patients or in cases where malignancy cannot be excluded, surgery is recommended. In general, the prognosis of LGs is excellent.

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.

An Unexpected Case Report of Adrenal Lymphangioma: Mimicking Metastatic Tumor on Imaging in a Patient With Pancreatic Cancer

Adrenal lymphangioma is a very rare benign lesion worldwide and remains challenging for early diagnosis, especially when the patient has some complicated clinical disease. This is an unusual case of a 68-year-old man who was admitted to our hospital with a history of pancreatic tumor. Computed tomography (CT) images and subsequent magnetic resonance imaging (MRI) revealed a mass located in the left adrenal gland, presenting a similar enhancement pattern of the pancreatic tumor, and according to the imaging features, the patient was suspected to have an adrenal metastatic tumor originating from the pancreatic tumor. The patient underwent a surgical resection of the pancreatic tumor and the left adrenal gland. The pathologic diagnosis proved to be lymphangioma deriving from the left adrenal gland. This is the first report presenting an atypical adrenal lymphangioma mimicking a metastatic tumor of pancreatic origin, which might be suggestive in the diagnosis of adrenal lesions and the subsequent clinical treatment, especially when patient has a particular medical history. As we know, imaging examination is helpful for accurate preoperative diagnosis; however, the diagnosis of malignant tumor solely based on imaging procedures should be made cautiously by radiologists.

[Adrenal incidentaloma. Part 1. Computed tomography of adrenal incidentaloma: the possibilities and difficulties of differential diagnosis]

The adrenal incidentaloma is a lesion of a different etiology and found incidentally in patients who underwent a diagnostic study not about the disease of this organ. Lesions can be both hormonally inactive and hormonally active, can arise from different zones of the adrenal gland or have non-specific organ affiliation, can be benign or malignant. Computed tomography characterization of these lesions, especially the differential diagnosis of benign and malignant, is extremely important for the correct diagnosis in order to provide adequate management of the patient. The article presents the key computed tomography criteria that allow radiologist to characterize the lesion most accurately and consider appropriate diagnosis.

A case of adrenal lymphangioma resected laparoscopically with minimal invasiveness

A 33-year-old female presented to us with a left adrenal cystic tumor with a maximum diameter of 70 mm. Because malignant tumor and pheochromocytoma could not be excluded, she underwent left laparoscopic transperitoneal adrenalectomy. The cystic tumor was stored to an endoscopically inactive treatment device and was subsequently punctured within the device; thus, tumor removal could be performed with minimum incision. Pathological findings showed highly suggestive of a cystic lymphangioma. The punctate was found to have an extremely high catecholamine titer. To avoid unnecessarily exposing the tumor contents, the treatment approach described in this report is reasonable and worth reporting.

Adrenal Cystic Lymphangioma: An Unexpected Pathological Finding in a Constellation of Uncontrolled Hypertension and Hypercalcemia

Adrenal cysts are rarely observed lesions. Adrenal cystic lymphangiomas are asymptomatic benign lesions of the lymphatic vessels with the vast majority occurring in women. We herein present a rare case of a middle-aged gentleman with labile blood pressure associated with an incidental finding of an adrenal mass of 4 x 3 x 3 cm. Following surgical resection, pathology revealed the diagnosis of adrenal cystic lymphangioma. 

Incidentally found cystic lymphangioma of the adrenal gland in an elderly male cadaver

Adrenal cystic lymphangiomas are extremely rare entities that are often identified incidentally, with less than 60 cases reported to date. We found a protruding ovoid mass consisting of a multiloculated cystic lesion within right adrenal gland in the cadaver of a 75-year-old Korean man. The epithelial cells lining the adrenal cyst were diffusely positive for cluster of differentiation 31 and podoplanin, and negative for pan-cytokeratin. The histopathological diagnosis confirmed a cystic lymphangioma arising from the adrenal gland. Post-mortem findings of the present case are discussed based on the clinicopathological features of adrenal cystic lymphangiomas.

An adrenal cystic lymphangioma: A case report of a rare tumor

Cystic lymphangioma is a rare benign tumor developing from lymphatic endothelial cells, and is usually described in the neck or axilla. We report a new case of an adrenal cystic lymphangioma fortuitously found in a 37-year-old patient. This case report and review of the literature bring new insights into the diagnostic difficulty and management of cystic lymphangioma of the adrenal gland.

A histopathological study on adrenal cysts in ferrets

Adrenal disorders are common in ferrets, but there are few studies on cystic lesions of the adrenal gland. The present study describes pathological and immunohistochemical features of adrenal cysts in eleven ferrets and discusses their histogenesis. In nine of eleven cases examined, which included seven, one, and one right, left, and bilateral cases, respectively, cysts were in the adrenal cortex and lined with epithelial cells. These epithelial cells contained an Alcian blue-negative/PAS-positive material and were positive for cytokeratin (CK) 7. The staining pattern was similar to that of biliary epithelial cells in the ferret. In five of the cases, there were small ducts adjacent to the cysts that were positive for CK7 and CK20 and negative for CK19. Based on the anatomical proximity between the right adrenal and liver, the immunohistochemical features of the small duct cells were comparable to those of hepatic oval cells. These results indicate the possibility that these adrenocortical cysts in the ferret originated from the biliary system. In the other two cases, the cysts lacked an epithelial cell lining, and there were dilated lymphoid vessels around the cysts. These cysts were assumed to have developed in the adrenal medulla, because the cyst wall was positive for glial fibrillary acidic protein and there were adrenal medullary cells positive for synaptophysin in the cyst wall. Therefore, the medullary cysts may have been associated with dilated vasculatures.

Symptomatic lymphangioma of the adrenal gland: a case report

Lymphangiomas (LAs) are rare benign tumors of the lymphatic vessels. In total, 95% of all reported LAs are located in the head, neck and the mediastinum. LAs of the adrenal gland are very rare and currently, only ~54 cases have been reported in literature. We present a case of a big left-sided adrenal LA. Abdominal imaging revealed a big cystic lesion in the left upper abdomen of unknown origin. For diagnostic and therapeutic reasons we performed explorative midline laparotomy. The left adrenal gland was found to be the origin of the cystic tumor. Hence, the patient underwent adrenalectomy in order to remove the intact cystic lesion. Diagnosis was then confirmed by histological examination. With adrenal LAs being a very rare entity, diagnosis is challenging and only little evidence exists on treatment options. We discuss diagnostic, therapeutic and surgical approaches concerning such cases and provide an overview of the current literature.

Cystic adrenal lesions: focus on pediatric population (a review)

BACKGROUND AND AIM

The cysts may potentially affect any organ; adrenals cysts are rare. This is a review of the literature regarding adrenal cysts, focusing on children and young adults.

GENERAL DATA

Three major types have been described: pure cysts (endothelial, epithelial, and hemorrhagic or pseudocyst), parasitic (as hydatid) cysts and cystic part of a tumour (most frequent are neuroblastoma, ganglioneuroma, pheocromocytoma, and teratoma). The complications are: bleeding, local pressure effects; infection; rupture (including post-traumatic); arterial hypertension due to renal vessels compression. Adrenal hemorrhage represents a particular condition associating precipitating factors such as: coagulation defects as Factor IX or X deficiency, von Willebrand disease, thrombocytopenia; antiphospholipid syndrome; previous therapy with clopidogrel or corticosteroids; the rupture of a prior tumour. At birth, the most suggestive features are abdominal palpable mass, anemia, and persistent jaundice. Adrenal insufficiency may be found especially in premature delivery. The hemorrhage is mostly self-limiting. Antenatal ultrasound diagnosis of a cyst does not always predict the exact pathology result. The most important differential diagnosis of adrenal hemorrhage/hemorrhagic cyst is cystic neuroblastoma which is highly suggestive in the presence of distant metastases and abnormal catecholamine profile. The major clue to differentiate the two conditions is the fact that the tumor is stable or increases over time while the adrenal hemorrhage is expected to remit within one to two weeks.

CONCLUSION

Pediatric adrenal cysts vary from simple cysts with a benign behavior to neoplasia- related lesions displaying severe prognosis as seen in cystic neuroblastoma. A multidisciplinary team is required for their management which is conservative as close follow-up or it makes necessary different surgical procedures in cases with large masses or if a malignancy suspicion is presented. Recently, laparoscopic approach is regarded as a safe procedure by some authors but generally, open surgery is more frequent used compare to adults; in most cases the preservation of normal gland is advisable.