Giant adrenal hemorrhagic cyst: An unusual abdominal lump.

Dear Editor,

One of the rarest situation regarding adrenal incidentaloma is an adrenal cyst. The incidence of adrenal hemorrhagic pseudocyst is very low. We report a case of giant adrenal hemorrhagic pseudocyst measuring 22 cm in its largest dimension. Cystic lesions of the adrenal gland are uncommon and demonstrate a spectrum of histological changes and may vary from pseudocyst to malignant cystic neoplasm.[1] An “adrenal pseudocyst” is the term given to non-neoplastic, nonparasitic cyst of the adrenal gland in which an epithelial or endothelial lining is not demonstrated.[2] Because of the hemorrhage the diameter of the cyst may enlarge rapidly. But the clinical picture varies from asymptomatic (incidentaloma discovered by a random ultrasound or CT) to an acute complication such as abdominal pain or hypovolemic shock.[3]

A 66-year-old male presented with chief complaint of marked abdominal swelling since last 4 years with vague abdominal pain. There was history of weight loss and anorexia. There was no history of vomiting, hematemesis, melena or jaundice. Bowel and bladder habits were normal. On examination approximately 20 cm × 20 cm nontender firm to hard swelling was found extending from epigastrium to hypogastrium. On investigation blood parameters were absolutely normal. Ultrasonography of whole abdomen revealed a large mass in the left flank suggestive of enlarged hydronephrotic left kidney with infiltrating renal mass. CECT whole abdomen revealed a soft tissue density enhancing mass (19 cm × 15 cm × 20 cm) in the left half of abdomen extending from the left hypochondrium to the left lumbar region with multiple calcifications [Figure 1]. There was a significant displacement of left kidney and stomach bowel loops. FNAC from the mass revealed a benign soft tissue tumor. Exploratory laparotomy was planned after proper resuscitation of the patient. On exploration a huge mass was found arising from retro peritoneum with no adhesion with adjacent structures. The mass was resected as a whole and sent for histopathological examination. The postoperative period was uneventful. The mass was 22 cm in size in its largest dimension. The histopathological report of the tumor was compatible with adrenal hemorrhagic cyst, and there was no evidence of malignancy.

Figure 1

CT scan of abdomen shoeing soft tissue enhancing mass with multiple calcification

Adrenal gland cysts are uncommon entities and four pathological subtypes have been described: (1) cystic degeneration of adrenal neoplasm, (2) true cyst, (3) infectious cyst, (4) pseudocyst.[4] Cystic degeneration of adrenal with hemorrhage has previously been described in various malignant adrenal tumors. The reported incidence of malignancy in the adrenal cystic lesion is approximately 7%.[5] Among adrenal cysts, the most common types are epithelial cyst and pseudocyst. True cysts are lined with endothelial or mesothelial cells; on the contrary, adrenal pseudocyst are devoid of recognizable lining layers. Most of these cystic lesions are clinically silent and are therefore often diagnosed incidentally. Since up to 7% of adrenal cysts are malignant, a careful preoperative hormonal and morphofunctional evaluation is mandatory.[6] Malignancy may be suspected if there are symptoms caused by functioning neoplasm such as Cushing's syndrome, hyperadrenalism, hirsutism in women, acne, balding in men, and hypertension. Our patient did not have any of the symptoms. Radiological workup plays a very helpful role in the localization of the origin, determining the cystic nature and whether the retroperitoneal mass is benign. An asymptomatic tumor larger than 5 cm, symptomatic tumor or a rapidly expanding tumor are indications for surgery.[7]

Cystic lesions of the adrenal are an uncommon finding. We report a case of adrenal hemorrhagic cyst with a largest diameter of 22 cm which is rare. Though majority of the true adrenal cysts are benign, incidence of malignancy is reported. An asymptomatic large tumor (>5 cm), symptomatic tumor and rapidly growing tumor are the indications for surgery. Clinical suspicion, proper radiological investigation, and timely operative intervention are keys to the successful management of adrenal cysts.