PSEUDOTUMOR JOY G. PAUL,
OF ADRENAL
GLAND
M.D.
STANLEY
BROSMAN,
DONALD
RHODES,
M.D. M.D.*
From the Department of Surgery, Division of Urology, Harbor General Hospital, Torrance, California
- A sixty-two-year-old male underwent medical evaluation because of hypertension. A suprarenal mass was detected on pyelography and subsequently confirmed by tomography, angiography, sonography, and adrenal venography. In spite of these positive diagnostic studies surgical exploration revealed a normal adrenal gland surrounded by densejbroadipose tissue which appeared to account for the pseudotumor.
ABSTRACT
Even though adrenal lesions are uncommon, most urologists look for these abnormalities when reviewing excretory urograms. We report our experience with a patient in whom an extensive evaluation for an adrenal tumor led to a surprising surgical experience. Case Report A sixty-two-year-old Spanish-speaking Cuban immigrant was admitted for evaluation of hypertension. Physical examination was unremarkable except for moderate obesity and an elevated blood pressure of 150/100 mm. Hg. Several estimations of serum electrolytes, creatinine, urinary vanilmandelic acid, with ketosteroids were within normal limits. Rapid sequence excretory pyelography revealed equal and prompt visualization of both kidneys without any significant disparity in renal size. An adrenal mass was noted on the left side which was later confirmed by a tomogram of that area (Fig. 1A and B). The mass measured 3 by 4 cm. and was ahnost the same density as that of the kidney. Aortic flush and left renal angiography were interpreted as being consistent with a mass in the left suprarenal area (Fig. 1C). There was no hypervascularity or neovascularity to suggest neoplasm. *Present address: tion, Santa Barbara,
112
Santa Barbara California.
Medical
Clinic Founda-
Adrenal venography was interpreted as clearly demonstrating a mass lesion of the left adrenal gland. The central vein was slightly displaced medially, and the capsular veins were seen draped around the mass (Fig. 1D). There was moderate dilatation and tortuosity of the tributaries draining the central portion of the mass. Although sonography was technically difficult, an area of sonar lucency was described in the region of the upper pole of left kidney. A-mode sonography was also compatible with a cystic (3 cm.) lesion in this area (Fig. 2). On the basis of these diagnostic studies the patient was believed to have a left adrenal adenoma or a cystic lesion of the adrenal gland. We elected to operate on the patient with the intention of performing an adrenalectomy. The left suprarenal gland was approached by making a flank incision through the bed of the eleventh rib. The area of the adrenal gland was examined, and the apparent mass involving the adrenal was dissected and removed. The upper pole of the kidney was completely normal. The pathologist opened the “tumor” specimen and found a normal-appearing adrenal gland surrounded by normal fibroadipose tissue. This gross observation was later confirmed by microscopic study. The surgical area was carefully reexamined, and no other tumors were found. There was a slight thickening of the tail of the pancreas which was
UROLOGY
/
JANUARY 1976
/
VOLUME
VII, NUMBER
1
FIGURE 1. Intravenous pyelogram (A) and tomogram (B) showing mass lesion of left adrenal gland. (C) Aortogram revealing displacement of adrenal arteries. (D) Adrenal venogram showing draping of mass by displaced capsular veins and tortuous tributaries draining central portion of mass.
FIGURE
raphy
2.
(A
showing
and B) B-mode and A-mode sonogcystic lesion (a) above left kidney.
A
UROLOGY
/ JANUARY 1976 / VOLUME
VII, NUMBER
1
113
biopsied but showed no abnormalities. The patient’s postoperative course was complicated by a pancreatocutaneous fistula which subsequently healed. His blood pressure remained unchanged. Comment The presence of most nonfunctioning adrenal tumors is discovered as an incidental finding in patients having excretory urograms. Occasionally a large tumor can be detected on a scout film of the abdomen, particularly if calcification is present. Once such a lesion is considered, a variety of diagnostic studies are available to establish or disprove the diagnosis. The absence of hypokalemic systemic alkalosis and the presence of normal urinary vanilmandelic acid concentrations usually exclude the presence of a functioning aldosteronoma or pheochromocytoma. Normal plasma cortisol and urinary ketosteroid levels generally exclude the possibility of a functioning cortical tumor. Radiologic study of the adrenal glands has rapidly developed in recent years. Tomography has been useful in establishing the presence or can be absence of adrenal tumors. 1 Arteriography helpful in distinguishing between malignant and benign lesions,2 but its routine use is limited because of technical difficulties in selectively studying all of the arteries particularly those of the right adrenal gland. Adrenal venography has been shown to be a safe procedure and very effective in visualizing has the both adrenal glands. 3 This procedure added advantage of permitting collection of blood specimens to measure hormone excretion. Adrenal tumors as small as 0.7 cm. can be detected by the displacement of normal veins which partially encircle the tumor and by the presence of dilated capsular veins.4 Ultrasound imaging is gaining popularity as a safe, noninvasive procedure. Normal adrenal glands do not visualize as discreet structures. Birnholz5 reported the value of sonography in 5 patients with adrenal masses more than 3 cm. in diameter.
114
In spite of a complete evaluation with the conclusive preoperative diagnosis of adrenal tumor, our patient had a normal gland. After retrospective analysis of the radiologic studies the conclusions were the same. Our explanation is that the fibroadipose tissue surrounding the adrenal gland can permit the semblance of a tumor and that the adrenal glands can occasionally have this unusual appearance. Dr. Keith Waterhouse’ told us of an identical situation in one of his patients, and there may be others with adrenal “pseudotumor.” Variation in the position of other structures such as the spleen and pancreas may give the impression of an adrenal or renal mass. Retroperitoneal tumors such as neurofibromas, teratomas, leiomyomas, and the like can also be mistaken for adrenal lesions. Ordinarily, radiologic diagnostic studies will differentiate between these and true adrenal tumors. Pseudotumor of the adrenal gland represents an unusual entity in which the radiologic findings are falsely positive for tumor as a result of the envelopment of a normal adrenal gland with abundant fibroadipose tissue and the aberrant course of the adrenal veins. 1009 West Carson Street Torrance, California 90509 (DR. BROSMAN) References 1. PICKERING,R. S.,etal.: Excretory urographic localization of adrenal cortical tumors and pheochromocytomas, Radiology 114: 345 (1975). 2. MCNULTY, J. G., et al.: Angiographic diagnosis of benign adrenal adenoma, Am. J. Roentgenol. 104: 386 (1968). 3. REUTER, S. R., BLAIR,A. J.,SCHTEINGART, D. E., and BOOKSTEIN, J. J.: Adrenal venography, J. Radiol. 89: 805 (1967). MITTY, H. A., NICOLIS, G. L., and GABRILOVE, L.: Adrenal venography, Am. J. Roentgenol. 119: 564 (1973). BIRNHOLZ, J. C. : Ultrasound imaging of adrenal mass lesions, Radiology 109: 163 (1973). WATERHOUSE, K. : Personal communication, 1974. MADAYAG, M., et al. : Renal and suprarenal pseudotumors caused by variations of the spleen, Radiology 105: 43 (1972). 8. NAFTEL, W., et al. : Pseudocyst of pancreas simulating a renal neoplasm, Urology 5: 417 (1975).
UROLOGY
/ JANUARY1976
/ VOLUMEVII,
NUMBER1
OF ADRENAL
GLAND
M.D.
STANLEY
BROSMAN,
DONALD
RHODES,
M.D. M.D.*
From the Department of Surgery, Division of Urology, Harbor General Hospital, Torrance, California
- A sixty-two-year-old male underwent medical evaluation because of hypertension. A suprarenal mass was detected on pyelography and subsequently confirmed by tomography, angiography, sonography, and adrenal venography. In spite of these positive diagnostic studies surgical exploration revealed a normal adrenal gland surrounded by densejbroadipose tissue which appeared to account for the pseudotumor.
ABSTRACT
Even though adrenal lesions are uncommon, most urologists look for these abnormalities when reviewing excretory urograms. We report our experience with a patient in whom an extensive evaluation for an adrenal tumor led to a surprising surgical experience. Case Report A sixty-two-year-old Spanish-speaking Cuban immigrant was admitted for evaluation of hypertension. Physical examination was unremarkable except for moderate obesity and an elevated blood pressure of 150/100 mm. Hg. Several estimations of serum electrolytes, creatinine, urinary vanilmandelic acid, with ketosteroids were within normal limits. Rapid sequence excretory pyelography revealed equal and prompt visualization of both kidneys without any significant disparity in renal size. An adrenal mass was noted on the left side which was later confirmed by a tomogram of that area (Fig. 1A and B). The mass measured 3 by 4 cm. and was ahnost the same density as that of the kidney. Aortic flush and left renal angiography were interpreted as being consistent with a mass in the left suprarenal area (Fig. 1C). There was no hypervascularity or neovascularity to suggest neoplasm. *Present address: tion, Santa Barbara,
112
Santa Barbara California.
Medical
Clinic Founda-
Adrenal venography was interpreted as clearly demonstrating a mass lesion of the left adrenal gland. The central vein was slightly displaced medially, and the capsular veins were seen draped around the mass (Fig. 1D). There was moderate dilatation and tortuosity of the tributaries draining the central portion of the mass. Although sonography was technically difficult, an area of sonar lucency was described in the region of the upper pole of left kidney. A-mode sonography was also compatible with a cystic (3 cm.) lesion in this area (Fig. 2). On the basis of these diagnostic studies the patient was believed to have a left adrenal adenoma or a cystic lesion of the adrenal gland. We elected to operate on the patient with the intention of performing an adrenalectomy. The left suprarenal gland was approached by making a flank incision through the bed of the eleventh rib. The area of the adrenal gland was examined, and the apparent mass involving the adrenal was dissected and removed. The upper pole of the kidney was completely normal. The pathologist opened the “tumor” specimen and found a normal-appearing adrenal gland surrounded by normal fibroadipose tissue. This gross observation was later confirmed by microscopic study. The surgical area was carefully reexamined, and no other tumors were found. There was a slight thickening of the tail of the pancreas which was
UROLOGY
/
JANUARY 1976
/
VOLUME
VII, NUMBER
1
FIGURE 1. Intravenous pyelogram (A) and tomogram (B) showing mass lesion of left adrenal gland. (C) Aortogram revealing displacement of adrenal arteries. (D) Adrenal venogram showing draping of mass by displaced capsular veins and tortuous tributaries draining central portion of mass.
FIGURE
raphy
2.
(A
showing
and B) B-mode and A-mode sonogcystic lesion (a) above left kidney.
A
UROLOGY
/ JANUARY 1976 / VOLUME
VII, NUMBER
1
113
biopsied but showed no abnormalities. The patient’s postoperative course was complicated by a pancreatocutaneous fistula which subsequently healed. His blood pressure remained unchanged. Comment The presence of most nonfunctioning adrenal tumors is discovered as an incidental finding in patients having excretory urograms. Occasionally a large tumor can be detected on a scout film of the abdomen, particularly if calcification is present. Once such a lesion is considered, a variety of diagnostic studies are available to establish or disprove the diagnosis. The absence of hypokalemic systemic alkalosis and the presence of normal urinary vanilmandelic acid concentrations usually exclude the presence of a functioning aldosteronoma or pheochromocytoma. Normal plasma cortisol and urinary ketosteroid levels generally exclude the possibility of a functioning cortical tumor. Radiologic study of the adrenal glands has rapidly developed in recent years. Tomography has been useful in establishing the presence or can be absence of adrenal tumors. 1 Arteriography helpful in distinguishing between malignant and benign lesions,2 but its routine use is limited because of technical difficulties in selectively studying all of the arteries particularly those of the right adrenal gland. Adrenal venography has been shown to be a safe procedure and very effective in visualizing has the both adrenal glands. 3 This procedure added advantage of permitting collection of blood specimens to measure hormone excretion. Adrenal tumors as small as 0.7 cm. can be detected by the displacement of normal veins which partially encircle the tumor and by the presence of dilated capsular veins.4 Ultrasound imaging is gaining popularity as a safe, noninvasive procedure. Normal adrenal glands do not visualize as discreet structures. Birnholz5 reported the value of sonography in 5 patients with adrenal masses more than 3 cm. in diameter.
114
In spite of a complete evaluation with the conclusive preoperative diagnosis of adrenal tumor, our patient had a normal gland. After retrospective analysis of the radiologic studies the conclusions were the same. Our explanation is that the fibroadipose tissue surrounding the adrenal gland can permit the semblance of a tumor and that the adrenal glands can occasionally have this unusual appearance. Dr. Keith Waterhouse’ told us of an identical situation in one of his patients, and there may be others with adrenal “pseudotumor.” Variation in the position of other structures such as the spleen and pancreas may give the impression of an adrenal or renal mass. Retroperitoneal tumors such as neurofibromas, teratomas, leiomyomas, and the like can also be mistaken for adrenal lesions. Ordinarily, radiologic diagnostic studies will differentiate between these and true adrenal tumors. Pseudotumor of the adrenal gland represents an unusual entity in which the radiologic findings are falsely positive for tumor as a result of the envelopment of a normal adrenal gland with abundant fibroadipose tissue and the aberrant course of the adrenal veins. 1009 West Carson Street Torrance, California 90509 (DR. BROSMAN) References 1. PICKERING,R. S.,etal.: Excretory urographic localization of adrenal cortical tumors and pheochromocytomas, Radiology 114: 345 (1975). 2. MCNULTY, J. G., et al.: Angiographic diagnosis of benign adrenal adenoma, Am. J. Roentgenol. 104: 386 (1968). 3. REUTER, S. R., BLAIR,A. J.,SCHTEINGART, D. E., and BOOKSTEIN, J. J.: Adrenal venography, J. Radiol. 89: 805 (1967). MITTY, H. A., NICOLIS, G. L., and GABRILOVE, L.: Adrenal venography, Am. J. Roentgenol. 119: 564 (1973). BIRNHOLZ, J. C. : Ultrasound imaging of adrenal mass lesions, Radiology 109: 163 (1973). WATERHOUSE, K. : Personal communication, 1974. MADAYAG, M., et al. : Renal and suprarenal pseudotumors caused by variations of the spleen, Radiology 105: 43 (1972). 8. NAFTEL, W., et al. : Pseudocyst of pancreas simulating a renal neoplasm, Urology 5: 417 (1975).
UROLOGY
/ JANUARY1976
/ VOLUMEVII,
NUMBER1
