Adrenal Cyst: An Uncommon Cause of Adrenal Incidentaloma
Presentation Number: SAT 368
Date of Presentation: April 1st, 2017
Prince Sultan Military Medical City, Riyadh, Saudi Arabia
Adrenal cysts are rare, around 600 cases have been reported in the Medical literature. They are usually non-functional, asymptomatic and less than 10 cm in diameter when discovered incidentally. They may occur at any age, but most of them are seen in the 3rd to 4th decades of life with a higher preponderance in females. Traditionally, adrenal cysts are divided into neoplastic and nonneoplastic groups. Non-neoplastic adrenal cysts may be further categorized as any of the 4 major types: pseudocyst(39%), epithelial (9%), parasitic (7% generally echinococcal), or endothelial cysts (45%). Symptoms occur when adrenal cysts become large enough to cause pain or as a consequence of intracystic bleeding or infection. Less frequent presentations include hypertension or spontaneous rupture of the cyst. Radiologic evaluation is helpful in identification benign versus malignant lesions (7 % of adrenal cyst are potentially malignant). Any functional lesions, potentially malignant lesions, or benign lesions more than 5 cm in diameter deserves surgical treatment. For small, benign lesions, conservative management is a viable option, although no surveillance protocols have been described.
A 41 years old male referred to endocrinology in the context of left adrenal mass found in CT abdomen performed to evaluate right loin pain, patient is normotensive and no history of adrenal hyper functioning. physical examination showed normal blood pressure with no signs of adrenal hyper functioning.
CT scan showed mass originating from the lateral limb of the left adrenal gland measuring 6 X 5 cm and showing CT characteristic of clear fluid with attenuation value 13 HU consistent with adrenal cyst. No evidence of solid component or septations. No evidence of calcifications. There is no infiltration or invasion of surrounding structure.The right adrenal gland is normal.
MRI adrenals showed thin walled well defined rounded 6 x 5 cm lesion involves the lateral limb of the left adrenal gland. It depicts high T2 and low T1 signal intensity and no change of signal in the out of phase sequence. No septa or hemorrhagic component.
Laboratory investigations showed negative hydatid antibody, normal DST and normal urinary metanephrines.
Patient offered left adrenalectomy but he elects to wait with follow up images.
CT abdomen a year later showed increase in the size of the cyst to 6.7X6.8 cm, 2 years later the size increase to 8.2x7.4 cm, and 3 years later the size increase to 10x9 cm no change in the radiological characteristic. Patient remain asymptomatic. Repeated hormonal screen was again normal. Patient finally agree for adrenalectomy which will be done in 2 months.
With the increasing use of imaging modalities in patient evaluation, an increase in incidentally detected adrenal cysts is expected. Surgical excision of these cysts is an acceptable method of treatment where the indications are met.
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