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Special Feature
August 14, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(8):785-786. doi:10.1001/archsurg.2009.136-b
Answer: Hemorrhagic Adrenal Pseudocyst

Laparotomy was performed, and the mass was found to be retroperitoneal with identifiable tissue planes between the kidney, spleen, and pancreas. Fluid was aspirated and sent for analysis of amylase and carcinoembryonic antigen levels, which were normal. Results of an intraoperative surgical pathologic analysis suggested that the mass was benign with fluid containing blood, histiocytes, and cellular debris. The mass was resected.

Final pathologic analysis showed a large pseudocyst arising from the left adrenal gland filled with thrombus material and organized thrombus. There were adjacent arterial and venous structures, while trichrome and elastin staining suggested that the hemorrhagic pseudocyst may have arisen from a vascular malformation or aneurysm.

Most adrenal cysts are discovered incidentally on computed tomography or ultrasonography in patients with vague gastrointestinal symptoms, abdominal or back pain, or an abdominal mass.1,2Adrenal cysts are rare findings encountered more often in women between 30 and 60 years of age than in men of the same age, with a 3:1 ratio of women to men.2,3

Cysts are often classified as neoplastic (7%) or as nonneoplastic (93%).25Nonneoplastic cysts include pseudocysts (39%) and endothelial (45%), epithelial (9%), and parasitic (7%) cysts.25Pseudocysts have a fibrous wall but an absence of any endothelial or epithelial lining. They may show calcifications and septations. They are thought to be secondary to an infectious process, a previous hemorrhage or infarction, a complication of a benign or neoplastic lesion, or a cystic degeneration of an adrenal tumor.4,6Regardless of the initial event, episodes of trauma, infection, or bleeding induce collagen formation and ultimately fibrous lining.4

The etiology and potential for malignancy determine how an adrenal cyst is treated. The evaluation of an adrenal cyst should include computed tomography and a laboratory workup. Although percutaneous aspiration is an acceptable treatment option, surgical resection is best for large and complicated cysts, as well as for parasitic, functioning, and malignant cysts.57

Several approaches have been identified for surgery depending on patient comorbidities, cyst or tumor location, and surgeon preference. Because the adrenal is a fragile organ, the basic principle for all adrenalectomies is to resect the mass with minimal manipulation of the adrenal gland or, when possible, to dissect nonadrenal tissue away from the tumor to minimize contact and damage to the gland. Gentle traction can be obtained by using the kidney as a handle. Typically, a posterior, modified posterior, or laparoscopic approach is used with smaller tumors. Larger tumors may require flank, transabdominal, or thoracoabdominal approaches, but some have been removed successfully using laparoscopic approaches.13,5,6

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Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence:Lisa M. Coughlin, MD, Department of General Surgery, Forum Health/Western Reserve Care System, Northside Medical Center, 500 Gypsy Ln, Ste 200, Youngstown, OH 44505 (LCoughlinMD@gmail.com).

Accepted for Publication:March 4, 2009.

Author Contributions:Study concept and design: Coughlin and Marx. Acquisition of data: Coughlin, Hashmi, and Marx. Analysis and interpretation of data: Coughlin, Hashmi, and Marx. Drafting of the manuscript: Coughlin, Hashmi, and Marx. Critical revision of the manuscript for important intellectual content: Coughlin and Hashmi. Administrative, technical, and material support: Coughlin. Study supervision: Hashmi and Marx.

Financial Disclosure:None reported.

References
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Ansari  MSSingh  IHemal  AK Cost-reductive retroperitoneal excision of large adrenal pseudocyst: a case report and review of the literature. Int Urol Nephrol 2001;33 (2) 307- 310
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Cotran  RSKumar  VRobbins  SL Robbins Pathologic Basis of Disease. 5th ed. Philadelphia, PA WB Saunders Ltd1994;
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Rozenblit  AMorehouse  HTAmis  ES  Jr Cystic adrenal lesions: CT features. Radiology 1996;201 (2) 541- 548
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Lal  TGKaulback  KRBombonati  APalazzo  JPJeffrey  RBWeigel  RJ Surgical management of adrenal cysts. Am Surg 2003;69 (9) 812- 814
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