Category: Adrenal Disorders
To highlight a case of an adrenal mass radiologically consistent with a myelolipoma and biochemical evidence of hypercortisolism. This case underscores the need for biochemical hormone evaluation of all incidental adrenal masses.
A complete clinical evaluation of a 70 year-old male with an incidentally found large left adrenal mass was performed.
Consistent with obesity, facial plethora, thinning of skin with easy bruising, and dorsocervical fat pads.
CT abdomen showed a 6.6 x 5.1 cm left adrenal mass, consistent with a myelolipoma.
Bone density scan was normal.
Abnormal dexamethasone test, with a cortisol 8.32 μg/dl and elevated 24 hr urine free cortisol level of 51.7 mcg/24 hrs (4 – 50 mcg/24 hrs).
Baseline ACTH was 10 pg/ml (6 – 50 pg/ml), Cortisol: 11.37 μg/dl (6 – 18.4 μg/dl) and DHEAs: 33 mcg/dl (24 – 244 mcg/dl).
Plasma metanephrines, aldosterone and renin were normal.
Patient had symptoms of worsening fatigue, weakness, and weight gain. He had a history of hypertension, hyperlipidemia, obesity, coronary artery disease, and stroke. Due to worsening type 2 diabetes, Empagliflozin was recently added to his regimen of Metformin, Glipizide, and Pioglitazone. Given overt biochemical hypercortisolism with worsening metabolic profile, he is planned for a laparoscopic left adrenalectomy.
Adrenal incidentalomas are increasingly identified in individuals undergoing abdominal CT scans. Of these, myelolipomas comprise 6-16% of cases. Current guidelines recommend biochemical evaluation of these incidentally found adrenal masses unless noted to be an obvious myelolipoma. Myelolipomas have historically been categorized as benign, non-functional, hormonally inactive lesions based on their composition of mature adipocytes and trilinear hematopoietic cells. However, as shown in our case and other reports as well, adrenal myelolipomas can be associated with endocrine dysfunction.
This is thought to be due to the presence of concomitant adrenal adenomas or other adrenal collision tumors, such as pheochromocytomas, adrenocortical carcinomas or ganglioneuromas, which may not be detectable on imaging alone.
Conclusion : This case illustrates the importance of performing a full biochemical evaluation of adrenal incidentalomas, even if imaging is consistent with myelolipoma. Although functionality of myelolipomas is rare, endocrine dysfunction associated with myelolipomas is underestimated. If functionality is found to be present, such as in our case with hypercortisolism, it may affect surgical management.
University of Florida
I am currently a second year fellow at University of Florida, Gainesville, FL in the division of Endocrinology, Diabetes and Metabolism. I completed my internal medicine residency at New York Methodist Hospital/Weill Cornell Medical College (New York Presbyterian Brooklyn Methodist Hospital) in Brooklyn, NY.
University of Florida
I am currently in my second year of fellowship in the department of Endocrinology, Diabetes and Metabolism at University of Florida. I completed internal medicine training at University of Illinois at Peoria.
Robert H Hux MD Professor of Surgery
Univerity of Florida College of Medicine
Dr. Sarosi is the Vice-Chairman for Education, and Surgery residency program director at the University of Florida College of Medicine. He is the Robert H. Hux MD Professor of Surgery. In addition, he is the Assistant Chief of the Surgical Service and Director of Surgical Quality at the North Florida/ South Georgia VAMC.
Prior to joining the faculty at the University of Florida, Dr. Sarosi was on the faculty at The University of Texas Southwestern Medical School in Dallas, Texas where he worked at both Parkland Memorial Hospital and The North Texas VA Medical Center. Dr. Sarosi is a graduate of Harvard Medical School and received his surgical training at the University of Michigan Medical Center, where he also completed a two-year Gastrointestinal Surgery Research Fellowship.
Dr. Sarosi’s primary research focus is esophageal diseases including gastroesophageal reflux disease and esophageal adenocarcinoma. He is currently an Investigator on an NIH funded trial examining surgical simulation and safety, and a Site Investigator on a VA CSP trial examining post-operative transfusion strategies in high cardiac risk surgical patients. He is the author of 78 journal articles and 22 book chapters.
Dr. Sarosi is an active surgical educator. He is currently a Director of the American Board of Surgery and a Director of the American Board of Plastic Surgery. He is the Vice Chairman of the ACS/ APDS/ ASE Residency Prep Curriculum and is the course director of the UF Residency Prep course.
Dr. Sarosi is a member of the ACS, AAS, SUS, AVAS, APDS SSAT, Halsted Society ASA and SSA and has served on or chaired numerous committees in these organizations. He is currently on the editorial boards of the Surgery, the American Journal of Surgery, and has previously served on the editorial board of the Journal of Surgical Research.
University of Florida
Hans K. Ghayee, DO, FACP, is an endocrinologist at the University of Florida and the Malcom Randall VA Medical Center in Gainesville, FL. His clinical interests are in evaluating patients with adrenal disorders as well as neuroendocrine tumors. Dr. Ghayee's research currently involves translational studies that serve as a basis for understanding basic mechanisms of adrenal tumor function as well as searching for new therapeutic targets for patients with these disorders.