Adrenal myelolipoma - clinical, radiological and cytological findings: a case report

Spontaneous rupture of adrenal myelolipoma as a cause of acute flank pain: A case report

BACKGROUND

Adrenal myelolipoma is a rare, benign, non-functioning mass that occurs in the adrenal gland. It is composed of an admixture of hematopoietic elements and mature adipose tissue, similar to bone marrow. Even at large sizes, adrenal myelolipomas are usually asymptomatic and often incidentally found by ultrasonography or computed tomography (CT) scan. This paper describes an unusual case of adrenal myelolipoma presenting as flank pain.

CASE SUMMARY

A 50-year-old male with severe right flank pain underwent a CT scan revealing a huge mass extending into the suprarenal space. The mass showed a fat component with retroperitoneal hemorrhage. The tumor was treated laparoscopically, and pathologic examination revealed features of myelolipoma originating from the adrenal gland.

CONCLUSION

Adrenal myelolipomas are generally asymptomatic and can be treated conservatively. However, rupture and hemorrhage of the tumor can cause symptoms requiring surgical removal.

Virtual or real: lifelike cinematic rendering of adrenal tumors

The adrenal gland is small in size and hidden in location. Adrenal tumors are relatively difficult to diagnose due to the wide variety of tumors and partial overlap of image features. Cinematic rendering (CR) is a novel, three-dimensional post-processing technology that simulates how light propagates in the real world, providing high-resolution visualizations that truly present subtle anatomical details. We retrospectively collected a series of pathologically confirmed adrenal tumor cases, raw data was introduced into the post-processing workstation, and different tools and templates of CR software were used for reconstruction and rendering. Compared with traditional black and white two-dimensional images and three-dimensional volume rendering (VR) images, CR images were more colorful, layered, and closer to the truth. CR has potential in diagnosing and preoperative planning of adrenal tumors, allowing vivid and realistic visualization of tumor location, morphology, different components (solid, cystic, fat, calcification, etc.), the pattern of enhancement, and the relationship with surrounding tissues and organs.

Adrenal Myelolipoma Mimics Ectopic Adrenal or Renal Tissue: An Incidental Finding During Cadaveric Dissection

CONTEXT

On naked eye examination adrenal myelolipoma (AML) tissue appears to be an ectopic adrenal or renal tissue, based on the similarity to their external texture. This necessitates a histo-pathological study for confirming the origin of the tissue.

OBJECTIVE

To establish the origin and histological features of the incidental AML tissue found during cadaveric dissection and review the literature for similar findings with clinical picture and treatment description.

SUBJECTS AND METHODS

Unilateral adrenal gland obtained from cadaveric dissection was subjected to histological study by H & E staining of the slides prepared. The literature review was done from articles published in PubMed indexed journals.

CASE REPORT

A case of an incidental finding of AML during cadaveric dissection is presented which on naked eye examination was appearing to be an ectopic adrenal or renal tissue, based on the similarity to their external texture. On histological examination, a thin rim of adrenocortical tissue, surrounding the mature adipose tissue, and attenuated by islets of myeloid, erythroid and megakaryocytic cell lines in varying proportions, resembling the mature bone marrow morphology, was observed. The literature review on PubMed explains similar incidental post-mortem autopsy findings due to the asymptomatic nature of the tumor. The incidence of AML varied between 0.08% and 0.2% in the last decade of the 20th century, which increased up to 10 - 15% of incidental adrenal masses due to the widespread use of non-invasive imaging modalities leading to an increase in the diagnosis of the pathology.

CONCLUSIONS

Before considering the ectopic incidence of tissue during cadaveric dissection, a histo-pathological examination is mandatory for confirmation. Adreno-myelolipoma is an asymptomatic post-mortem finding in 10-15% of cases of adrenal tissue which mimics ectopic adrenal gland or renal tissue due to its external texture.

Indicators of Malignancy of Canine Adrenocortical Tumors: Histopathology and Proliferation Index

Tumors of the adrenal cortex account for 10–20% of the naturally occurring Cushing's syndrome diagnosed in dogs. Differentiating between adrenocortical adenoma and carcinomas is often difficult. The purposes of this study were to determine which histopathologic criteria can be used as markers for malignancy in canine adrenocortical tumors and the relevance of the proliferation marker, Ki-67, for differentiation between cortical adenomas and carcinomas. Twenty-six adrenocortical carcinomas, 23 adenomas, and 11 normal adrenal glands were examined. Morphologic criteria significantly associated with adrenocortical carcinomas included a size larger than 2 cm in diameter, peripheral fibrosis, capsular invasion, trabecular growth pattern, hemorrhage, necrosis, and single-cell necrosis, whereas hematopoiesis, fibrin thombi, and cytoplasmic vacuolation were significantly associated with adrenocortical adenomas. The mean (± SD) proliferation index, measured by immunohistochemistry for the Ki-67 antigen, was 9.3 ± 6.3% in carcinomas, 0.76 ± 0.83% in adenomas, and 0.58 ± 0.57% in normal adrenal glands. The Ki-67 proliferation index was significantly higher in carcinomas compared with adenomas and normal adrenal glands. A threshold value of the proliferation index of 2.4% reliably separated carcinomas from adenomas. Based on these results, it appears that thorough evaluation of morphologic features combined with immunohistochemical assessment of the proliferation index is extremely useful for differentiating between adrenocortical adenomas and carcinomas in dogs.

Intrapulmonary myelolipoma and its computed tomography features: A case report and literature review

Intrapulmonary myelolipoma is a rare, benign tumor composed of mature adipose tissue and normal hematopoietic cells. To the best of our knowledge, 10 cases of intrapulmonary myelolipoma, including the present case, have been reported to date, and the majority have focused on the pathological diagnosis of the disease. The radiological features of intrapulmonary myelolipoma have not been studied. Therefore, the present study reports a case of primary myelolipoma in the lung, and examines its computed tomography features and pathology. Furthermore, other potential diagnoses are discussed in the context of the relevant literature. The present report describes the case of a 57-year-old female who experienced chills, but no coughing or expectoration, with an intermittent fever of 38.6°C that had been apparent for 13 days. Chest CT scan revealed a benign nodule and bronchiectasis in the lower lobe of the right lung. The patient then underwent a lobectomy of the lower right lung by thoracoscopy. The histological analysis of the excised specimen identifid a myelolipoma consisting of mature adipose tissue and hematopoietic cells. There was no recurrence after 513 days of follow-up, as shown by CT.

Giant bilateral symptomatic adrenal myelolipomas associated with congenital adrenal hyperplasia

Adrenal myelolipoma is an uncommon, benign, biochemically non-functioning and endocrinologically inactive tumor composed of variable amounts of mature adipose tissue and scattered islands of haemopoietic elements, including erythroid, myeloid and lymphoid series, as well as megakaryocytes. Diagnosis of myelolipomas is based on imaging, with ultrasonography, CT and MRI being effective in more than 90% of cases. Differential diagnosis includes other containing fat adrenal masses such as teratoma, lipoma and liposarcoma. The optimal treatment depends on the size and symptoms of the myelolipoma. For incidentally discovered, asymptomatic adrenal myelolipomas smaller than 4 cm surveillance seems to be enough while symptomatic, complicated, hormonally active and larger than 7 cm myelolipomas, should be surgically removed. We present a case of giant bilateral symptomatic adrenal myelolipomas associated with congenital adrenal hyperplasia. A 34 year old female, with congenital adrenal hyperplasia because of 21-hydroxylase deficiency, presented with diffuse abdominal pain and vomiting. Physical examination revealed hirsutism, pronounced virilization and palpable masses both on the right and left abdominal area. The abdominal CT demonstrated bilateral large masses in the anatomical position of the adrenal glands with densities indicating adipose tissue. The differential diagnosis was between myelolipoma and liposarcoma. For diagnostic and also therapeutical reasons, as the masses were large and symptomatic and causing pressure to the surrounding structures, the patient was submitted to laparotomy for bilateral excision. Histopathological examination established the diagnosis of adrenal myelolipoma.

Adrenal myelolipoma in a child

A case of adrenal myelolipoma is reported in a 14-year-old girl. Abdominal ultrasound examination revealed a left-sided ovarian cyst 13 cm in diameter and an 8 x 8-cm hyperechoic heterogenous solid mass localized in the right adrenal gland. The ovarian cyst and adrenal mass were removed surgically. Histological examination of the adrenal mass revealed a proliferation of mature adipose tissue with bone marrow-like hematopoietic elements. The ovarian cyst was a simple serous cyst.

Adrenal myelolipoma associated with adenoma

The association of an adrenal myelolipoma with a non-functioning adenoma is very rare. Herein, we report on such a case in an asymptomatic 64-year-old woman. To the best of our knowledge, there is only one other case of non-functioning adrenocortical adenoma associated with myelolipoma in the same gland. Furthermore, only two other adenomas (mineral corticoids and corticosteroid producing tumors) associated with myelolipomas have been reported, and both myelolipomas were less than 1 cm in size. In conclusion, the 8.5 cm myelolipoma in our case is the largest compared with the three previously reported ones.

Laparoscopic adrenalectomy--indications and technique

Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.