Presentation
A&E referral for lumbar spine tenderness following fall downstairs, query fracture
Patient Data
No previous imaging available for comparison.
No fracture. Normal sagittal alignment.
Rounded density (78 mm) projected overlying the left upper quadrant, with flecks of calcification.
Of uncertain etiology, ultrasound referral is advised for further assessment.
Between the spleen and the upper pole of the left kidney there is a thick-walled heterogeneous mass measuring 6.4 cm X 7.3 cm there is some suspicion of vascularity but this is difficult to confirm.
The rest of the upper abdominal organs appear normal in shape and size.
A cursory look at the pelvic organs does not reveal any obvious gynecological pathology.
The urinary bladder outlines normally.
The lesion cannot be adequately specified with ultrasound, urgent CT abdomen and pelvis is recommended.
A large heterogeneous mass likely arising from the left adrenal gland measuring 78 x 58 mm contains fat and calcification suggestive of myelolipoma.
Bulky left ovary. No suspicious lesion was detected in the liver, spleen, kidneys, pancreas, right adrenal, bowel loops or pelvis. No significant abdominal or pelvic lymphadenopathy. No free fluid or collection. Lower lung sections are unremarkable. No suspicious bony lesion.
Histology report
Sections from the left adrenal gland show an encapsulated tumor, comprising nests and cords lined by uniform polygonal cells with clear vacuolated to amphophilic cytoplasm. The lesional cells are embedded in extensive fibrohyaline stromal tissue with patchy fat metaplasia and dystrophic calcification. The lesional cells are positive for AE1/AE3, Synaptophysin and Melan A and negative for S100, chromogranin, Gata 3, EMA, CK7, CK20, inhibin, or CDX2. Mitotic figures are not easily identifiable. No necrosis or invasion is found. The Ki67 index is <1%. The lesional cells generally display minimal cytologic atypia, but in places, the atypia is more significant, but given the very low proliferative index, the nuclear pleomorphism is likely due to degenerative type atypia. Overall features are consistent with an adrenal cortical adenoma. Congo red is negative for amyloid. Prominent fibrohyaline change probably represents extensive degenerative change, with subsequent fat (lipomatous) metaplasia and calcification. There is no evidence of malignancy.
Left adrenal gland - adrenal cortical adenoma with extensive hyaline change.
Case Discussion
The patient was asymptomatic. Given the lesion size and patient age the decision was made to undergo to have an adrenalectomy.
CT imaging characteristics were suggestive of an adrenal myelolipoma. Upon resection, the lesion was sent for histology and was confirmed to be an adrenal cortical adenoma.
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