Adrenal Cyst-Management Dilemma: Case Report

Abstract

Adrenal cysts are rare lesions with heterogeneous origin. Endothelial cysts are the most common type, followed by pseudocysts, endothelial, parasitic and epithelial cysts. Adrenal cysts are asymptomatic, and their size determines the clinical presentation. Malignant adrenal tumors and functional adrenal tumors should be included in the differential diagnosis of adrenal cyst as they are reported in the literature. Herein we report A 57-year-old woman presented with episodes of right upper abdominal pain accompanied by headache, elevated blood pressure and vomiting. Abdominal ultrasound revealed right adrenal heterogenous mass 7 cm in size, confirmed by CT scan as adrenal mass with internal septations and density >30 Hounsfield unit. Biochemical evaluation for functional adrenal mass was unremarkable. Notably, 24-hour urine metanephrines and vanilmandelic acid were within normal range on several occasions. Iodine-123 MIBG scintigraphy was not available at the moment of investigations. Clinical suspicion for silent cystic pheochromocytoma was established and the preoperative treatment with α and beta blockers was provided. Laparoscopic adrenalectomy attempt failed due to intraoperative hypertension (300/150 mmHg). An open adrenalectomy was performed three months later with no intraoperative hemodynamic instability. Histopathologic analysis confirmed epithelial cyst with multinuclear giant macrophages, hemosiderin and haemolyzed erythrocytes. Immunohistochemical analysis was positive for AE1/AE3 and negative for podoplanin. Consideration from our report relate to preoperative management in patients with cyst adrenal lesion with alfa and beta blocker. Additionally, co-existence of cystic pheochromocytoma and epithelial cyst is not excluded, as degeneration and size of adrenal cyst could not provide proper histopathological specimen.