Fall 2012 - 08.pdf 721Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Adrenal Lipoma With Hemorrhage A Cause of Abdominal Pain Deepali Jain, Prem Chopra, Ajay Sharma Keywords: lipoma, hemorrhage, abdominal pain INTRODUCTION N on-functional adrenal tumors are uncommon lesions; one of these is lipoma. Lipomas been described in the literature so far, to the best of authors’ knowledge (Table 1).(1-13) CASE REPORT The pain was of moderate intensity and non-radiating. There was no history of fever, nausea, or vomiting. No symptoms related to the lower urinary tract were present. The patient was diabetic - tory was noncontributory. was soft and there was no organomegaly. Ultrasonography revealed a hyperechoic well-circum- scribed lesion on the upper pole of the right kidney. Computed tomography scan showed a large well-circumscribed right-sided mass measuring 12.8 × 10 × 10 cm with fat density. Internal ar- eas of hemorrhage were seen (Figure 1). Features were suggestive of myelolipoma. Patient was planned for surgery. Laparoscopic removal of tumor was done. Grossly, tumor was well circumscribed measuring 12 × 10 × 9.5 cm. The cut surface revealed a Corresponding Author: Deepali Jain, MD; DNB Department of Pathology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India 110060 Tel: +91 986 889 5112 Fax: +91 522 264 9389 E-mail: deepalijain76@ gmail.com Received December 2010 Accepted February 2011 Departments of Pathology and Urology, Sir Ganga Ram Hospital, New Delhi, India CASE REPORT 722 | yellow colored mass with central areas of hemorrhage (Fig- - composed of lobules of mature adipose tissue with collection of foamy macrophages at places (Figures 3A and B). Large areas of hemorrhage were present throughout the tumor (Fig- ure 3C) with few clusters of hemosiderin-laden macrophages signifying old hemorrhage (Figure 3D). However, no hemat- opoietic elements were evident despite thorough sampling seen. DISCUSSION Adrenal lipomas are rare lesions. Review of the literature re- veals only 16 cases described to date (Table 1).(1-13) Lam and Lo found 4.8% of the adrenal lipomatous tumors in the 30- year period, of which 0.7% were adrenal lipomas.(6) There is male predominance (male-to-female ratio of 3:1); however, our case was a female patient. Age ranges from 35 Table 1. Summary of the reported cases of adrenal lipomas. First Author Age, y/ Gender Diameter, cm Side Presentation Treatment Remarks Lange (1) 54/M 2.5 Rt Paroxysmal hypertension Prinz(2) 73/F 3.0 Rt Incidental finding by comput- ed axial tomography scan Adrenalectomy Avinoach(3) 40/F 1.3 Rt Incidental finding at laparot- omy Sharma(4) 45/M 12.0 Rt Abdominal pain, hyperten- sion Laparoscopic removal 1-year follow-up Ghavamian(5) 50/F 8 Lt Incidental finding by CT scan Partial adrenalectomy Bilateral adrenal tuber- culosis, necrosis, and calcification Lam(6) 64/F 78/M 65/M 8.0 4.5 2.0 Rt Rt Lt Incidental finding by ultraso- nography Incidental finding at autopsy Incidental finding at autopsy Resection Calcification and ossi- fication Milathianakis(7) 39/M 20 cm/2900 g Rt Incidental finding by ultraso- nography Transperitoneal resection Giant, calcification on CT Rodríguez-Calvo(8) 70/M 45/M 1 cm 2 cm/18 g Lt Rt Incidental finding at Autopsy Incidental finding at Autopsy Pheochromocytoma in the contralateral gland Büttner(9) 50/M 1.1 RT Incidental finding at Autopsy Shumaker (10) 68/M 7.0 Lt Incidental finding by CT scan Laparoscopic left adrenal- ectomy Singaporewalla(11) 44/M 15.6 Lt Acute abdomen Resection Reteroperitoneal bleeding Shah(12) 35/M 5 Rt Pain in right loin Right adrenalectomy Gupta(13) 51/M 9 Rt Incidental finding by CT scan Laparoscopic removal Detected 3 months after nephrolithotomy Present case 55/F 12 Rt Flank pain Laparoscopic removal With internal hemor- rhage M indicates male; F, female; Rt, right; Lt, left; and CT, computed tomography. Case Report 723Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Adrenal Lipoma | Jain et al to 78 years. Most of the subjects have been reported from Eastern region of the world; however, real racial difference Right-side adrenal has been affected more commonly, includ- ing the present case.(6) Size of the tumor varies from 1 cm to 20 cm.(7) Most of the tumors have been detected incidentally. In other subjects, abdominal pain was the most frequently encountered symptom presumably due to their large size.(4) However, Milathianakis and colleagues described a case of giant lipoma of 20 cm, which was detected incidentally.(7) Our patient presented with abdominal pain presumably due to hemorrhage within the lesion. Patient may present with acute abdomen due to retroperitoneal bleeding.(11) The origin of the adrenal lipomas is not well understood. These may arise from metaplasia of either stromal cells or adrenal cortical cells.(14) Histologically, they are similar to lipomas elsewhere in the body. These are well-demarcated lesions composed of lobules of mature adipose tissue. Focal areas of (6) Histopathologic differential diagnoses are described in Table 2. Radiological and clinical differential diagnoses include more common lesions, such as myelolipoma and adrenal cor- tical adenoma with myelolipomatous metaplasia. Computed tomography and magnetic resonance imaging help in accu- - tent of adipose and hematopoietic components.(15) However, from myelolipoma due to internal hemorrhage within the tu- mor. Furthermore, the lesion did not harbor hematopoietic elements despite thorough sampling. Twelve sections were - cal presence of hematopoietic elements. Another differential diagnosis was well-differentiated lipo- sarcoma due to large size of the tumor. The absence of lipo- - coma. Surgery is adopted for large tumors because of the risk of ma- lignancy in large adrenal tumors and for the potential relief of symptoms in some patients. Currently laparoscopic surgery is the method of choice for removal of these tumors unless it is voluminous and complicated by rupture, bleeding, or sar- comatous changes.(16) Figure 1. Computed tomography scan shows a large well-cir- cumscribed fat density mass with internal areas of hemorrhage (White Arrow). Figure 2. Well-circumscribed globular mass, cut surface of which is largely yellow with areas of hemorrhage. Figure 3. (A) Histology shows lobules of mature adipose tissue (Hematoxylin and Eosin stain ×200); (B) Rim of adrenal cortex (asterisk) is seen (Hematoxylin and Eosin stain ×200); (C) Areas of hemorrhage are evident (Hematoxylin and Eosin stain ×100); and (D) Few clusters of hemosiderin-laden macrophages focally signifying areas of old hemorrhage (Hematoxylin and Eosin stain ×200). A B C D 724 | Case Report CONFLICT OF INTEREST None declared. Table 2. Histopathologic differential diagnoses of adrenal lipoma. Lesion Pathology Adrenal cortical adenoma with myelolipomatous metaplasia Gross: Small encapsulated with solid homogeneous yellow cut surface Micro: Cells of adrenal cortex intermixed with myelolipomatous areas Adrenal myelolipoma Gross: Grayish-red, with a pseudocapsule Micro: Encapsulated, and composed of various proportions of mature adipose tissue and bone marrow elements; the myeloid component is best characterized by the large megakaryocytes Well-differentiated liposarcoma Gross: Yellow, soft, and greasy, and contains lobules with white septa Micro: Adipocytic tumor with widened fibrous septa and enlarged, hyperchromatic atypical lipocytes within both the septa and fat ; S-100 immunostains for lipoblasts Adrenal pseudocyst Gross: Fibrous, well-encapsulated cyst with or without hemorrhagic adrenal tissue and calcifi- cation Micro:Wide range of histological appearances and sometimes contains intracystic mature adipose tissue Angiomyolipoma Gross: Yellow to gray, with cysts if associated with tuberous sclerosis Micro: Mixture of adipose tissue, smooth muscle cells, epithelioid cells, and blood vessels, in varying proportions, and shows at least focal immunoreactivity for HMB-45 Teratoma Gross: Solid and cystic components Micro: Various types of epithelium of ectodermal and endodermal origin, glial tissue, and mesodermal components REFERENCES 1. 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