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March 16, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(3):283-284. doi:10.1001/archsurg.2008.583-b

Answer: Adrenal Myelolipoma

The patient underwent a diagnostic laparoscopy that revealed a mass of 6.0 × 5.0 × 2.5 cm arising from the right adrenal gland. An uncomplicated laparoscopic right adrenalectomy was performed. Pathologic examination showed the tumor mass was composed of mature adipocytes with interspersed hematopoietic marrow containing immature myeloid and erythroid precursors, mature granulocytes, and megakaryocytes, consistent with an adrenal myelolipoma. The patient tolerated the procedure well without complications, and his abdominal pain has completely resolved.

Adrenal myelolipomas are rare, benign, nonfunctioning tumors composed of mature adipose tissue and scattered hematopoietic elements. Ultrasonography, CT, and MRI are effective in diagnosing adrenal myelolipomas in more than 90% of cases, with CT being the most sensitive diagnostic imaging modality.1Most are asymptomatic and identified incidentally during radiologic studies. The prevalence of an adrenal incidentaloma at autopsy is less than 1% for patients younger than 30 years, but increases to 7% in patients aged 70 years or older.2Differential diagnosis of a fatty adrenal mass includes teratoma, lipoma, liposarcoma, and angiomyolipoma. The incidence of adrenal myelolipomas is 0.03% at autopsy.2Although usually small (<5 cm), they can reach massive size and become symptomatic. Adrenal myelolipomas have been reported to present with abdominal and flank pain, palpable mass, or hematuria that are predominantly the result of tumor necrosis or hemorrhage. While hormonally inactive, these tumors have been reported to coexist with hormonally active conditions such as pheochromocytoma, Cushing syndrome, and congenital adrenal hyperplasia resulting from 21-hydroxylase deficiency.3Extraadrenal myelolipomas have also been reported to occur in approximately 15% of cases, with approximately 50% occurring in the presacral area and the remainder in the thorax, retroperitoneum, pelvis, kidneys, liver, and stomach.3

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system ( Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery( 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.

Correspondence:Celia M. Divino, MD, Department of Surgery, The Mount Sinai School of Medicine, 1 Gustave L. Levy Pl, Box 1259, New York, NY 10029 (

Accepted for Publication:August 8, 2008.

Author Contributions:Study concept and design: Connor, Craig, Buch, and Divino. Acquisition of data: Connor, Craig, Buch, and Divino. Analysis and interpretation of data: Connor, Craig, Buch, and Divino. Drafting of the manuscript: Connor, Craig, Buch, and Divino. Critical revision of the manuscript for important intellectual content: Connor, Craig, Buch, and Divino. Administrative, technical, and material support: Connor, Craig, Buch, and Divino.

Financial Disclosure:None reported.

Daneshmand  SQuek  ML Adrenal myelolipoma: diagnosis and management.  Urol J 2006;3 (2) 71- 74PubMedGoogle Scholar
Lau  JBalk  ERothberg  M  et al.  Management of Clinically Inapparent Adrenal Mass: Evidence Report/Technology Assessment No. 56.  Rockville, MD Agency for Healthcare Research and Quality2002;AHRQ Publication No. 02-E014
Patel  VGBabalola  OAFortson  JKWeaver  WL Adrenal myelolipoma: report of a case and review of the literature.  Am Surg 2006;72 (7) 649- 654PubMedGoogle Scholar