ABSTRACT: Adrenal myelolipoma is a rare benign neoplasm composed of mature adipose tissue and a variable amount of haemopoetic elements. Most lesions are small and asymptomatic discovered incidentally. Herein we are reporting a case of right adrenal myelolipoma incidentally discovered in a 48 year  old women presented with intermittent, dull aching, vague abdominal pain for the past one year. She underwent total thyroidectomy seven years back for multinodulargoiter and was on Tablet thyroxine 100µg once daily (OD). The Physical examination was unremarkable. Ultrasound abdomen revealed right adrenal mass lesion. Routine investigation were normal and MRI suggested right adrenal myelolipoma(8.6 X 7 X 6.2 cm). Laboratory investigations revealed the non-functioning nature of adrenalmass.The patient underwent open right adernalectomy with a smooth post-operative recovery. Histopathology revealed adrenal myelolipoma.

CASE REPORT:

A 48 yrs old female presented with complaints of intermittent, dull aching, vague abdominal pain for the past one year.Nohistory of abdomen distention, burning micturition, fever, vomiting,gastrointestinal bleeding, headache, sweating, palpitation, loss of weight orloss of appetite.No history of comorbid illness such as diabetes mellitus, hypertension ortuberculosis.She underwent total thyroidectomy seven years back for multi-nodular goiter and was on tablet thyroxine 100µg once daily (OD).

On examination,patient was conscious and well-oriented,afebrile, moderately built and moderately nourished, not anemic, not icteric, no cyanosis and pedal edema. There were no palpable lymph nodes. Her height was 150 cm, Weight was 55 kg, and Body Mass Index (BMI) was 24 kg /m². Herpulserate – 82 beats per minute, respiratory rate -22 breaths perminute. Her Blood Pressure (BP) on lying posture was 140/100 mm Hg(right upper limb), on sitting posture – 130/100 mm Hg and on standing posture it was 140/100mm Hg. Physician opinion obtained and was advised to take Tablet Prazosin 2.5 mg HS. Her cardiovascular and respiratory systems were unremarkable. Abdomen was soft, non-tender and no mass was palpable.

USG abdomen revealed right adrenal mass lesion. MRI suggested right adrenal myelolipoma(8.6 X 7 X 6.2 cm).

 

 

Figure 1. MRI image of abdomen showing 8.6cmX7cmX6.2cm right suprarenal mass. Left adrenal gland was normal.

 

Table 1. Laboratory investigations revealed the non-functioning nature of the adrenal mass

serum cortisol 5 µg /dl 5-25µg/dl (normal range)
24 hour urinary metanephrines 53.77g 0 – 350 g/day (normal range)
urinary normetanephrines 53g 0 – 600g/day (normal range)

Hence diagnosis of right adrenal myelolipoma made and planned for open right adernalectomy.

Pre-operative preparation

Patient was started on Tab. Prazosin 2.5 mg hs to control blood pressure. Anesthetic fitness obtained. Three units of o positive packed redcells and four units of fresh frozen plasma were kept ready.

Due to the large size of the tumor, standard transperitonealadrenalectomy was performed without complications. Patient discharged on 10th postoperative day .

 

 

 

Figure 2. Excised specimen of right suprarenal mass.

 

Histopathology revealed myelolipoma measuring 11X7X5cm and weighing 150gm.

Figure 3.Microscopic section shows compressed normal adrenal gland at the periphery and a benign tumour composed of intimate admixture of mature adipose tissue and all the three lineages of haemopoietic elements.

 

Discussion

Myelolipoma is a rare, benign tumor like lesion composed of mature adipose tissue admixed with hematopoietic cells. They form 5% to 7% of adrenal neoplasms. They are mostly unilateral. They commonly occur after the age of 50 years. It can occur in extra adrenal sites in the retroperitoneum[1].They are called “incidentalomas” because their diagnosis isbased on autopsy or imagingmodalities which are performedfor reasons usually unrelated to adrenal diseases.

Many theories have been postulated for the aetiology of myelolipoma but the widely accepted theory is adrenocortical cell metaplasia inresponse to stimulilike the following. The stimuli can be stress, necrosis, infection orinflammation [2].The conditions oftenassociated with adrenal myelolipomas include Cushing’sdisease, obesity, hypertension, and diabetes which can becharacterized as major adrenal stimuli [3]. Stressful lifestyle and unbalanced diet may also be contributory [3]. The tumour occurs more commonly on the right side for reasons not explained [4].

Generally myelolipomas are asymptomatic. The asymptomatic adrenal myelolipomas are usually less than 4cm. The symptoms may arise because of size. A 20 cm tumour weighing 1750 g has presented with a retroperitoneal haematoma in haemorrhagic shock [5]. The mass effect has caused reduced renal perfusion, malignant hypertension and presented as heart failure. Inferior venacavalcompression causing pedal oedema[6].  In our case the patient had hypertension even though the hormone profile was normal. Hypertension could have been caused by adrenal medullary compression[7].CT scaneasily identifies a lipoma by means of its fat content(Hounsfield units between -80 and -120); thus, it can be said it is the imaging modality of choice[8]. Surgery is the treatment for symptomatic cases and those lesions where diagnosis could not be established. Large tumors (≥6 cm) can be excised by laparoscopy also[1].

Conclusion

Adrenal myelolipoma can present as abdominal pain and hypertension. Radiological investigations and a normal adrenal hormone profile helps in establishing the diagnosis. Symptomatic lesions require surgical excision.

Acknowledgements

Dr. Khalilur Rahman M.S., Assistant professor in Department of General Surgery at Saveetha medical college worked up, treated and wrote the manuscript. Dr. Rajesh M.S., Associate professor In Department of General Surgery at Saveetha medical college was involved in the workup and treatment of the patient. Prof. Shruthi Kamal M.S., Professor of operative surgery in Department of General surgery at Saveetha medical college reviewed the manuscript, performed the surgery and was involved in the workup of the patient.

References

1)      Gurushantappa H. Yalagachin  andBharath Kumar Bhat. “Adrenal incidentaloma does it require surgical treatment? Case report and review of literature.”Int J Surg Case Rep. 2013; 4(2): 192–194. PMCID: PMC3540227

2)      A. Meyer and M. Behrend, “Presentation and therapy of myelolipoma,” International Journal of Urology, vol. 12, no. 3, pp. 239–243, 2005.

3)      S. I. Tyritzis, I. Adamakis, V.Migdalis,D. Vlachodimitropoulos, and C. A. Constantinides, “Giant adrenal myelolipoma, a rare urological issue with increasing incidence: a case report,” Cases Journal, vol. 2, no. 9, article 8863, 2009.

4)      P. J. Kenney, B. J. Wagner, P. Rao, and C. S. Heffess, “Myelolipoma: CT and pathologic features,” Radiology, vol. 208, no. 1, pp. 87–95, 1998.

5)      Juping Zhao, MD; Fukang Sun, MD; Xiaolong Jing, MD Wenlong Zhou, MD; Xin Huang, MD,“The diagnosis and treatment of primary adrenal lipomatoustumours in Chinese patients: A 31-year follow-up study,” Can UrolAssoc J 2014;8(3-4).

6)      Parijat S. Joya, Creticus P. Marakb, Nadia S. Nashedc, Achuta K. Guddatid, “Giant Adrenal Myelolipoma masquerading as Heart Failure”, Case Rep Oncol 2014;7:182–187.

7)      Stylianos Kapetanakis, LoannisDrygiannakis, AnastasiosTzortzinis, Nikolaos Papanas and AlikiFiska, “A giant adrenal lipoma presenting in a woman with chronic mild postprandial abdominal pain: a case report,” Journal of Medical Case Reports 2011, 5:136.

8)      Young WF: The incidentally discovered adrenal mass. New Engl J Med 2007, 356:601-610.

 

Author Details

First Authors :

Name               Dr.Khalilur Rahman. A, M.S.,

Designation     Assistant Professor

Department     General Surgery

Address            Department of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Email                dr.khalil09@gmail.com

Phone               +91 9677198691

Fax                    +91 44 66726632

 

Corresponding Author :

Name            Dr.Khalilur Rahman. A, M.S.,

Designation  Assistant Professor

Department  General Surgery

Address          Department of surgery, Saveetha medical college, SaveethaUniversity, Saveetha Nagar, Thandalam, Chennai 602105, India

Email             dr.khalil09@gmail.com

Phone           +91 9677198691

Fax                 +91 44 66726632

 

Coauthors

Name           Prof.Shruthi Kamal. V, M.S.,

Designation Professor

Department General Surgery

Address          Department of surgery, Saveetha medical college, SaveethaUniversity, Saveetha Nagar, Thandalam, Chennai 602105, India

Email             shruthivenkat2002@yahoo.co.in

Phone           +91 9840037030

Fax                 +91 44 66726632

Name          Dr. Rajesh, M.S.,

Designation Associate Professor

Department General Surgery

Address          Department of surgery, Saveetha medical college, SaveethaUniversity, Saveetha Nagar, Thandalam, Chennai 602105, India

Email              drrajesh80@yahoo.com

Phone            +91 9444331763

Fax                 +91 44 66726632

 

MEASUREMENT OF INTRA-ABDOMINAL PRESSURE AS AN INDICATOR OF MORBIDITY AND MORTALITY IN CRITICALLY ILL SURGICAL PATIENTS
Urachal cyst in adult presenting as abdominal pain - Case Report - khalilur Rahman 1, Rajesh 2, Shruthi Kamal3, Dinesh kumar 4,