Introduction

Adrenal cysts are uncommon lesions and are mostly silent clinically.1 It is often misdiagnosed as adrenal haemorrhage or adrenal malignancy. We hereby report a rare case of adrenal cyst.

Case Report

A thirty-five year old woman presented with a persistent pain in the lower abdomen and feeling of giddiness. She had no bowel, bladder and menstrual complaints. On per abdomen examination no lump was palpable.

On USG scan examination; there was a presence of 10 x 6.5 cm complex Left ovarian mass with solid internal components (Figs. 1,2). The right adnexa showed focus of posterior acoustic shadowing. There was another cystic lesion 15 x 12 cm with no internal echoes seen, displacing the left kidney infero-medially.

The findings were confirmed on CT-Scan (Figs. 3,4).

24 hours urinary VMA level was normal.

She was subjected to Right Oopherectomy, Left ovarian cystectomy and aspiration of the Left adrenal cyst through 9th Inter costal space; when 400 ml of clear fluid was drained. Cytological examination of fluid, revealed it to be having alkaline pH, with presence of proteins (4+) and sugar (1+).

Post operative USG scan of the patient three months hence revealed refilling of the cyst. In view of persistent pain, she was subjected to surgery, when excision of the cyst was done. Histopathology confirmed the diagnosis of adrenal cyst (Figs. 5,6).

Discussion

Adrenal cysts are rare though their true

Fig. 1 :Usg of adrenal cyst-2.	Fig. 2 :USG of adrenal cyst.

incidence is probably higher than reported. This observation is due to the more frequent diagnosis of asymptomatic incidental cysts noted on imaging studies.2 Adrenal cysts may occur at any age, but most are found in the 3rd and 4th decades of life.3 In some series, a female preponderance of about 3 : 1 has been noted for unknown reason.4

Fig. 3 : CT scan of adrenal cyst-1.	Fig. 4 : CT scan of adrenal cyst-2.

Adrenal cysts are usually asymptomatic and many are discovered at autopsy. Symptoms, if present, are related to size and position of the lesion and can include dull flank pain, gastrointestinal disturbances, or the finding of a palpable mass. They seldom cause adrenal hypofunction, Cushing’s syndrome, or phaeochromocytoma. Patients may present with acute abdominal findings if intracystic haemorrhage or rupture occurs.5 In our case the probable cause of giddiness could be due to hypoglycaemia following adrenal insufficiency, though we could not confirm it.

Fig. 5 : HP of adrenal cyst-4.	Fig. 6 : HP of adrenal cyst-6-BMP.

Adrenal cysts vary greatly in size from microscopic to more than 50 cm in diameter and may contain up to 11 liters of fluid. Small adrenal cysts are clinically silent, while cysts of large size can cause displacement and compression of adjacent organs. Smaller cysts are usually incidentally found during the evaluation of unrelated abdominal conditions. Symptoms that derive from vascular adrenal cysts are usually associated with large cysts, presumably due to compression of surrounding viscera, and include pain and vague gastrointestinal complaints. There is no predilection for the right or left gland and the reported bilateralism is 8%. All age groups are affected; the highest incidence is in the 5th and 6th decades. There is a 2:1 female predominance.

Cystic adrenal masses can be classified into neoplastic and non-neoplastic aetiologies. The distinction between malignant and benign adrenal cysts can be difficult. Cysts of neoplastic aetiology occur as a result of necrosis and cystic degeneration within both benign and malignant tumours. Non-neoplastic cysts have been conventionally divided into four categories: endothelial (45%), haemorrhagic or pseudocystic (39%), epithelial (9%) and parasitic (7%).6 Haemorrhagic (pseudocystic) cysts consist of a hyalinized fibrous capsule containing nests of entrapped adrenal cortical cells and amorphous cyst contents composed of a mixture of serum, blood and fibrin. Dilated, thin walled vascular channels lined by flattened cells are usually present within the fibrous capsule and the adjacent adrenal gland. It is thought that haemorrhage is secondary to trauma or some toxic or infectious process.7 The endothelial variant is composed of a fibrous wall focally lined on its inner aspect by flattened cells resembling normal endothelium.8 The lining of endothelial cysts stains intensively for collagen type IV but shows only focal, weak staining for Factor VIII-related antigen. The endothelial variant of adrenal vascular cyst is slightly more common than the haemorrhagic variant and is thought to arise from a preexisting vascular hamartoma of blood vessel or lymphatic nature.

Clinically, the differential diagnosis of adrenal cysts is extensive and includes any lesion that can present as an upper abdominal mass. This includes adrenal neoplasms; hepatic cysts and haemangiomas; cystic renal cortical adenomas and carcinomas; Wilms’ tumour; pancreatic, mesenteric and urachal cysts; retroperitoneal tumours; polycystic kidneys; and hydronephrosis. The pathologic differential diagnosis includes parasitic cysts (hydatid cysts) and epithelial cysts.

The treatment options available are aspiration and surgical excision. Surgical excision is indicated in the presence of symptoms, endocrine abnormalities (even when sub clinical), complications, suspicion of malignancy and/or large size (> 5 cm). Reports of laparoscopic surgical excision are also available.9

References

1. Huang SP, Chen CC, Li CC, Wu WJ, Chou YH, Huang CH. Adrenal cyst—a case report. Kaohsiung J Med Sci 2001; 17 (3) : 156-60.
2. Milsten MS, Minielly JA, Van Schoyck P, Forrest JB. Abdominal pain secondary to a lymphangiomatous cyst of the adrenal: Case report and review of litterature. J Oklahama State Med Assoc 1994; 87 : 225-7.
3. Foster D. Adrenal cysts: Review of literature and report of case. Arch Surg 1966; 92 : 131-43.
4. Asbeshouse GA, Goldstein RB, Asbeshouse BS. Adrenal cysts: Review of literature and report of three cases. J Urol 1959; 81 : 711-9.
5. Stewart JOR, Lester JG. Ruptured adrenal cyst. Post Grad Med J 1962; 38 : 709-11.
6. Danza FM, De Marinis L, Mancini A, Valentini AL, Summaria V, Conte G, Camaioni M, Fiumara C. Adrenal gland cysts: Our experience. Minerva Chir 1993; 48 (21-22) : 1325-30.
7. Cunningham MD. Hemorrhagic adrenal cyst- A Case Report. Journal of the American Osteopathic Association.Vol. 93; 5 : 619.
8. Cotran RS, Kumar V, Robbins SL. Robbins Pathologic Basis of Disease. 5th ed. Philadelphia, W. B. Saunders, 1994: pp. 1161.
9. Koksoy, Ferda N, Yucel, Osman, Celik, Atilla, Igdem, Aysenur Akyildiz. Laparoscopic Management of a Giant Adrenal Cyst: Case Report. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques. 2001; 11 (6) : 379-81.

+Department of Radiology; *Department of Surgery; **Department of Pathology; BARC Hospital, Chembur, Mumbai.