E-Poster Presentation ESA-SRB-ANZBMS 2021

Bilateral adrenal myelolipomas: When is the right time for surgical intervention? (#390)

Su Win Htike 1 , Miriam Blackburn 1
  1. Endocrine and Diabetes Department, The Canberra Hospital , Canberra, ACT, Australia

Adrenal myelolipoma (AML) is a rare, non-functioning, benign tumour1. 70% of AMLs are small. Very few are bilateral. Myelolipomas (≥6 cm) can cause mass effects, haemorrhagic changes and resection should be considered2.

A 56-year-old man was incidentally diagnosed with bilateral AMLs in 2017. The right-sided tumour measured 52 x 32 x 47 mm and left one was 42 x 30 x 35 mm with marked hypo-intensity -40 Hounsfield units3. He underwent active surveillance to avoid bilateral adrenalectomy. He was asymptomatic until the results of the most recent scan which showed a significant increase in size of right adrenal lesion. He subsequently noted bilateral flank pain over a few weeks. On examination, he was normotensive and clinical features did not suggest Cushing's syndrome. The adrenal lesions were not palpable.

Plasma metanephrines, renin to aldosterone ratio and DHEAS were normal, suggesting non-secreting tumours. There is a theory that elevated ACTH may drive the growth4, but ACTH was not raised. Addison's disease and congenital adrenal hyperplasia (CAH)5 were excluded. 1 mg dexamethasone suppression test excluded Cushing’s syndrome. Repeat CT in 2018 revealed an increase in size of right lesion with a stable left one. In 2021, the right-sided lesion further grew bigger 73 x 65 x 82mm, despite stable left mass (Figure 1).

There are no specific guidelines for management of AML and management is individualised. Given significant growth rate (maximum diameter up to 8.2 cm), it was decided at the endocrine radiology meeting that, it would be reasonable to remove right adrenal lesion with ongoing monitoring of left side radiologically. Risk of left adrenal haemorrhage is low. Currently, he is awaiting surgical review.

 

 

6111012e35ced-Picture+1.png

Figure 1: CT (Right to left) right adrenals: 52 x 32 x 47 mm (2017), 54 x 31 x 59 mm (2018), 73 x 65 x 82mm (2021).

 

  1. Ibrahim Boukhannous, Mehdi Chennoufi, Mohamed Mokhtari, Anouar El Moudane, Ali Barki, Management of bilateral adrenal myelolipoma without endocrine disorder: About a rare case report, Urology Case Reports, Volume 39, 2021, 101755, ISSN 2214-4420.
  2. Hamidi O, Raman R, Lazik N, Iniguez-Ariza N, McKenzie TJ, Lyden ML, Thompson GB, Dy BM, Young WF Jr, Bancos I. Clinical course of adrenal myelolipoma: A long-term longitudinal follow-up study. Clin Endocrinol (Oxf). 2020 Jul;93(1):11-18. doi: 10.1111/cen.14188. Epub 2020 Apr 23. PMID: 32275787; PMCID: PMC7292791.
  3. Samimagham H, Kazemi Jahromi M. Bilateral Adrenal Myelolipoma, A Case Presentation and Brief Literature Review. Iran J Kidney Dis. 2020 Jan;14(1):62-64. PMID: 32156843.
  4. Craig WD, Fanburg-Smith JC, Henry LR, Guerrero R, Barton JH. Fat-containing lesions of the retroperitoneum: radiologic-pathologic correlation. Radiographics. 2009 Jan-Feb;29(1):261-90. doi: 10.1148/rg.291085203. PMID: 19168848.
  5. Lam AK. Lipomatous tumours in adrenal gland: WHO updates and clinical implications. Endocr Relat Cancer. 2017 Mar;24(3): R65-R79. doi: 10.1530/ERC-16-0564. Epub 2017 Jan 31. PMID: 28143811.
  6. Shenoy VG, Thota A, Shankar R, Desai MGJIjouIjotUSoI. Adrenal myelolipoma: controversies in its management. 2015;31(2):94.