N Sezhian, D Rimal, G Suresh
James Paget Healthcare Trust, Lowestoft Road, Great Yarmouth, Norfolk
Correspondence to: Debesh Rimal, Flat 15, James Paget NHS Trust, Great Yarmouth, Norfolk, NR31 6LA Tel: +44-1493 452485
E-mail: kathmanducity@aol.com
SMJ 2005 50(2): 81
CASE REPORT
A 38-year-old lady was admitted with an acute onset of left loin pain. On examination she was afebrile with left loin tenderness. The blood and urine tests were within normal limits. An initial IVU revealed flattening and distortion of the left upper pole calyces. The findings were suspicious of an adrenal mass. A subsequent CT scan revealed an adrenal mass measuring 10cm by 9cm with a density measurement suggestive of phaeochromocytoma. There was also a hypodense lesion in the liver which was consistent with a metastasis. (Fig 1)
Ultrasound revealed the lesion to be mostly cystic, favouring a complex renal cyst rather than an adrenal mass. A complete endocrine workup including the estimation of urinary metanephrines, VMA and free cortisol failed to detect any hormonal hypersecretion. With a working diagnosis of an adrenal mass, she was readmitted for an elective laparotomy. A large cystic lesion with the left adrenal stretched over its surface was removed. There was also a 1cm soft lesion felt in the right lobe of the liver which was consistent with a haemangioma. The patient had an uneventful post- operative recovery. The histopathology revealed the lesion to be an adrenal pseudocyst with no epithelial lining. The adrenal gland was histologically normal. A follow up CT scan 12 months later showed no changes in the liver lesion. She was completely symptom free at five year follow up visit.
Discussion
Adrenal pseudocysts have fibrous walls and lack a true epithelial lining. The exact aetiology is unknown. The presence of cystic spaces lined by endothelial cells filled with erythrocytes, points out to a vascular origin.1 There is at least one case reported in the literature, where an adrenal pseudocyst co-existing with focal nodular hyperplasia of the liver, extending the concept of vascular malformations as a likely aetiology.2 The small liver lesion in our patient could well be one of such co-existing vascular anomaly. The haemorrhages in these lesions often give atypical imaging features on CT and Ultrasonography, which could be confused with an adrenal tumour.3 Complete endocrine workup is mandatory in these patients to detect any hormonal hypersecretion. Fine needle aspiration of these lesions are often haemic and inconclusive. Histopathology of the excised specimen gives confirmatory diagnosis. In conclusion, pseudocysts of the adrenals are rare but a recognised entity and could be confused with adrenal tumours both clinically and radiographically.4 Surgery is required for symptomatic lesions and also to solve the diagnostic dilemma.
REFERENCES
1 Laforga JB, Bordallo a, Ara Fi. Vascular adrenal pseudocyst: cytologic and immunohistochemical study. Diagn Cytopathol 2000 Feb; 22(2):110-2
2 Chetty R, Dada MA. Focal nodular hyperplasia of the liver co-existing with an adrenal pseudocyst. S Afr J Surg 1998 Aug;36(3):82-3
3 Sakamoto I, Nakahara N, Fukuda T, Nagayoshi K, Matsunaga N, Hayashi K Atypical appearance of adrenal pseudocysts. J Urol 1994 Jul; 152(1): 150-2
4 de Bree E, Schoretsanitis G, Melissas J, Christodoulakis M, Toittsis D. Cysts of adrenal gland : diagnosis and management. Int Urol Nephrol 1998:30(4):369- 76