Endocrine Abstracts

Case history: A 26-year-old female presented with acute left-sided loin pain. There was a preceding dull ache for two months. She had no dysuria or haematuria. Her past medical history was unremarkable except for rhinosinusitis.

Investigations: Abdominal CT revealed oval shaped lesion adjacent to the upper pole of the left kidney. The left adrenal gland could not be separately visualized. The lesion had mass effect on the fundus of the stomach. Adrenal MRI confirmed presence of a 6 X 5.5 X 4.5 cm fluid-containing lesion centred in the left adrenal gland, in keeping with an adrenal cyst. The patient had normal aldosterone-renin ratio, overnight dexamethasone suppression test and 24-hour urine metanephrines.

Results and treatment: Due to the size of the mass and the associated symptoms, laparoscopic left adrenalectomy was performed. The cyst ruptured intraoperatively, and mucinous content was noted. Histopathology showed cystic lesion separate to the adrenal gland. It had ciliated lining and an island of cartilage within the wall of the cyst. These findings were consisting with bronchogenic cyst (BC).

Conclusions and points for discussion: Adrenal cysts are uncommon, they represent 1% of adrenal lesions identified incidentally on CT scans. They are usually unilateral and asymptomatic. Abdominal or flank pain, abdominal mass, spontaneous haemorrhage and rupture have been reported. Adrenal cysts are categorized into four subtypes: endothelial, epithelial, pseudocyst, and parasitic. One of the conditions that can mimic an adrenal cyst is a sub-diaphragmatic bronchogenic cyst. BCs are developmental anomalies, usually located in the mediastinum or lung parenchyma. In some cases, they may detach and migrate to the abdomen and can be found anywhere in the abdominal cavity. BCs in the retroperitoneum are extremely rare and tend to occur on the left side (82% of cases), in the pancreas or the left adrenal gland. Frequently, BCs can be identified only post-operatively as definitive diagnosis required histopathological examination. Cystic endocrine active adrenal lesions have been described, and consequently functional status should be evaluated for all cysts. Risk of malignancy was reported to be 7% in one series. There is no general agreement on management of adrenal cysts. Many authors recommend surgical management for: • Symptomatic or functional cysts. • Cysts with features suggestive of malignancy • Cysts larger than 5 cm in diameter.Sometimes due to cyst size or location, adrenalectomy is required. Asymptomatic, small lesions can be conservatively followed with imaging, although no surveillance protocol has been described.