CASE 10112 Published on 18.01.2017

Adrenal pseudocyst

Section

Paediatric radiology

Case Type

Clinical Cases

Authors

Dr. Abeer Ahmed Alhelali1 , Dr.Hesham Soliman2, Dr.Lois Richard3.

(1) MBBS, Arab board of radiology and medical imaging.
(2) MD, Consultant pediatric surgeon, Prof. of pediatric surgery, Division head at SKMC.
(3) Consultant pathology/hematopathology

Sheikh Khalifa Medical City
AbuDhabi, UAE

Acknowledgements:
I would like to thank Dr. Daniela Pugh (Consultant paediatric radiology) who suggested publishing this case.

Abu Dhabi 00971 Abu Dhabi, United Arab Emirates; Email:aalhelali@seha.ae
Patient

2 days, male

Categories
Area of Interest Adrenals, Paediatric, Foetal imaging ; Imaging Technique Percutaneous, MR, Ultrasound, Ultrasound-Colour Doppler
Clinical History
A term baby presented at 2 days of age with a large abdominal mass detected during antenatal ultrasound. Abdominal examination revealed a large firm abdominal mass occupying the left side of the abdomen and crossing the midline, which was not freely mobile. Ultrasound and MRI were performed.
Imaging Findings
Ultrasound showed a well-defined multiloculated cystic mass in the left retroperitoneal area, displacing the left kidney into the pelvis. There was a solid tissue component. No peripheral curvilinear calcification nor speckled calcification was appreciated. Doppler imaging confirmed the avascular nature of the mass.

MRI of abdomen and pelvis without contrast showed a large cystic mass in the retroperitoneal area displacing the left kidney inferiorly, the spleen superiorly and bowel loops to the right side. The mass couldn't be separated from the left adrenal gland and this was considered to be the probable site of origin. It had smooth margins and contained septa and a fluid-fluid level suggesting blood products. The soft-tissue component noted posteriorly raised the possibility of hemorrhage or hyalinized thrombus.

Exploratory laparotomy & surgical removal of the mass done resulted in full relief of the patient’s signs with no post-operative complications. Adrenal pseudocyst was diagnosed on histopathology.
Discussion
Adrenal pseudocyst is a rare lesion, particularly if large in size. It is usually asymptomatic and non-functional [1].

The incidence of adrenal pseudocysts on computed tomography (CT) ranged between 0.35% to 4.4% and between 1.4% to 5.7% on autopsy. Female to male ratio is 2:1 [2]. Incidental detection of suprarenal masses has increased with the improvement of radiological technology [3]. Although an adrenal pseudocyst is rare it is one of the common non-neoplastic adrenal gland lesions [2]. The aetiology is not clear but there are a few suggested mechanisms for the occurrence of adrenal pseudocyst, such as cystic degeneration of a vascular neoplasm or primary adrenal neoplasm, and malformed adrenal veins with haemorrhage into the adrenal gland [3].

Patients may present with dull pain in the upper abdomen, gastrointestinal symptoms or a palpable mass (as in our case). In rare circumstances patients may present with a tender mass or acute abdominal pain due to infection, rupture or intra-cystic haemorrhage [4].

Abdominal ultrasound is safe and inexpensive, and can detect adrenal masses more than 2 cm in diameter; however, it can not always measure the adrenal mass and characterise its morphology accurately. In contrast, MRI allows better characterization of the mass and its anatomical site [5].

Treatment of adrenal masses depends on the size and the related symptoms. Most small and asymptomatic adrenal lesions are benign and don’t need surgical intervention. Surgical excision is required for adrenal lesions which are increasing in size, symptomatic, functional or suspicious for malignancy [6].

Conclusion:
Adrenal pseudocysts are rare, especially when infected or very large. Radiological and clinical findings are nonspecific, so further assessment by histopathological examination is needed for definitive diagnosis. Surgical excision is the best diagnostic and therapeutic method for suspicious or symptomatic lesions [7].
Differential Diagnosis List
Adrenal pseudocyst
Simple adrenal cyst
Adrenal hemorrhage
Cystic lymphangioma
Cystic neuroblastoma
Final Diagnosis
Adrenal pseudocyst
Case information
URL: https://eurorad.org/case/10112
DOI: 10.1594/EURORAD/CASE.10112
ISSN: 1563-4086
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