Macroscopic Appearance of Giant Adrenal Myelolipoma During Laparoscopy: An Adjunct in Differential Diagnosis

Abstract

Giant adrenal myelolipoma is a rare, benign, sizable, mesenchymal tumor. Preoperative differential diagnosis from retroperitoneal liposarcoma may be challenging. A 66-year-old female patient was admitted because of a sizable tumor at the right retroperitoneal space, incidentally discovered during abdominal ultrasonography for screening purpose. Preoperative imaging studies were indicative for the diagnosis of a giant adrenal myelolipoma (11.7 × 12.9 cm in size); however, a retroperitoneal liposarcoma could not be excluded. We decided to proceed with tumor's surgical removal by using laparoscopic transperitoneal approach and threedimensional high-definition camera. Intraoperatively, the tumor did not infiltrate surrounding tissues and was surrounded by a thin capsule under which there were sparse, orange-colored spots that resembled adrenal cortex. This finding reinforced the initial and most possible diagnosis of adrenal myelolipoma and we easily enucleated the mass. Postoperative course was uneventful, and the patient demonstrated no recurrence on imaging six months postoperatively. Histology confirmed the diagnosis of giant adrenal myelolipoma, measuring 16.5 x 15 x 6.5 cm.

Case report: Adrenal myelolipoma resected by laparoscopic surgery

“…The laparoscopic operation was once considered contraindicated for adrenal tumors exceeding 5-6 cm (26). However, the laparoscopic approach is being increasingly used and extended for larger-size adrenal tumors, and we found 18 articles published reported 23 cases in recent 10 years (3,4,17,25,(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). Table 1 provides further details of these reports.…”

“…Several known risk factors contribute to its pathogenesis, including inflammation, degeneration, trauma, stress, obesity, hypertension, diabetes, and Cushing’s syndrome ( 9 , 10 ). Reticuloendothelial cell metaplasia of adrenal capillaries, emboli from bone marrow, and adrenal embryonic remnants of hematopoietic elements have been suggested as postulated mechanisms ( 3 ).…”

“…Table 1 provides further details of these reports. Our literature review observes that AML with diameters up to 16 cm can be safely removed through transperitoneal laparoscopy ( 3 , 4 ). Only one patient converted to open exploratory laparotomy due to multiple adhesions of the previous abdominal surgery which was conducted 6 years ago for a motor vehicle accident ( 27 ).…”

“…Although prevailingly asymptomatic, enormous AML can present unregulated pain in the abdominal or flank due to compressing the surrounding tissue, further associated with hemorrhage or rupture ( 2 ). Imaging studies contribute to the diagnosis and detectable rate of AML; pathological examination reaches a definitive diagnosis ( 3 ). Generally, conservative treatment strategies are preferred.…”

Updates in Pathology for Retroperitoneal Soft Tissue Sarcoma

“…However, they can occasionally occur within the retroperitoneum, particularly in in the presacral region. In such cases careful histologic assessment and MDM2 testing may be required to distinguish a myelolipoma from a WDLPS [ 71 , 72 ].…”