Marie Catherine Lee, General Surgery Resident, Department of Surgery, Lenox Hill Hospital, New York, NY; Mitchell I. Chorost, Chief of GI Surgical Oncology, Maimonides Medical Center, Brooklyn, NY; Jonathan Earle, Pathology Resident, Department of Pathology, Lenox Hill Hospital, New York, NY
Marie Catherine Lee, MD
General Surgery Resident
Department of Surgery
Lenox Hill Hospital
New York, NY
Mitchell I. Chorost, MD
Chief of GI Surgical Oncology
Maimonides Medical Center
Jonathan Earle, MD
Department of Pathology
Lenox Hill Hospital
New York, NY
Adrenal hematoma is a rare diagnosis for large adrenal masses. We report the case of an 82-year-old woman with a large, palpable left upper quadrant mass, which was found to be of adrenal origin. Her biochemical workup showed no evidence of catecholamine or endocrine function. The lesion was surgically removed, and a path?ology examination determined thatit was a large, chronic hematoma of unknown etiology. We review the workup and treatment of large adrenal masses.
An 82-year-old woman, native of Trinidad, was found to have a large, palpable, asymptomatic left upper quadrant abdominal mass on routine physical examination by her primary care physician. The patient, a former nurse, had been in good health and reported no recent weight change, trauma, fever, rash, headaches, appetite changes, or changes in bowel and bladder habits. She also had no chest pain, palpitations, dysuria, polyuria, or abdominal distention.
The patient had a medical history of hypertension, diverticulosis, and mild iron-deficiency anemia. Her hypertension was well controlled with daily oral atenolol, and she was taking a daily multi?vitamin. The patient's surgical history included an open cholecystectomy about 40 years earlier and excision of a large, benign, left chest wall mass about 50 years before her current presentation. She reported no tobacco or alcohol use, and her only significant family history was hypertension and diabetes.
The patient was a thin, somewhat pale, Hispanic woman who looked young for her age. Her physical examination was relatively unremarkable, except for the abdominal mass. Her abdomen was soft and flat, with active bowel sounds on auscultation. She had a well-healed right upper quadrant scar and a left lower chest scar. On palpation, a large, firm, nontender mass was easily detected in the left upper quadrant. The mass was round and nonpulsatile on examination.
A computed tomography (CT) scan of her abdomen and pelvis resulted in a presumed diagnosis of splenomegaly (Figure 1). The spleen itself appeared normal, although it abutted a left upper quadrant mass measuring 12.0 x 10.2 cm, which was contiguous with the tail of the pancreas and the upper pole of the left kidney. The mass was round and well-circumscribed, with a well-defined capsule. The left adrenal gland was not visualized nor was there evidence of ascites or lymphadenopathy.
A workup of the adrenal mass was initiated. A complete blood count showed hemoglobin of 10.0 g/dL and hematocrit of 30.7%, consistent with the patient's long-standing history of anemia. Co?ag?ulation studies were unremarkable. Her serum chemistry was normal: sod?ium, 137 mmol/L; potassium, 4.1 mmol/L; chlo?ride, 100 mmol/L; bicarbonate, 27 mmol/L; blood urea nitrogen, 9 mmol/L; creatinine, 1.0 mg/dL; and glucose, 97 mg/dL. Serum aldosterone and renin levels were within normal limits. Urinary cortisol, free catecholamines, vanillymandelic acid (VMA), and metanephrines were also normal, ruling out a pheochromocytoma. Because of the size of the mass, the patient was referred to the surgery clinic for further evaluation and treatment.
Based on the size of the growth and the unremarkable chemical workup, it was recommended that the patient have the mass removed, and a left adrenalectomy was planned. Using an extended left subcostal incision, a transabdominal approach was taken to remove the mass. On exploration, a large, firm, purplish, well-encapsulated, round lesion was easily and cleanly dissected free from the stomach, spleen, left kidney, and pancreatic tail. Intraoperative measurement determined the mass to be 14 cm (Figure 2). A very thin rim of normal-appearing adrenal tissue was noted in the anterior inferior capsule. The encapsulated lesion was sent intact for pathologic evaluation.
Despite intraoperative blood loss of less than 150 cc, the patient was given a one-unit blood transfusion because of a postoperative hematocrit of 28.2%. Sub?sequent blood counts and laboratory values were within normal limits. She had an unremarkable recovery after the transfusion, and the nasogastric tube and Foley catheter were removed on postoperative day 1. By postoperative day 2, the patient was on a regular diet. A steroid taper was prescribed, and she was discharged to home on postoperative day 4.
On pathologic examination, the mass was described as a 15 x 13-cm, well- encapsulated hematoma with heterogeneous areas of calcification and liquefaction. The collection was enveloped in a fine rim of adrenal tissue, devoid of malignant histology. The final pathology report determined it was a massive chronic intra-adrenal hematoma with obliteration of the normal gland, and no evidence of malignancy.
The workup of an adrenal mass is quite extensive. The differential diagnosis includes adrenal incidentaloma, pheochromocytoma, adrenocortical carcinoma, angiomyolipoma, and collision tumor. The first determination to be made is whether the mass is functioning or nonfunctioning. Functional tumors may cause Cushing's disease from hypercortisolemia, hyperaldosteronemia, and Conn's syndrome, or they may be virilizing tu?mors from steroid overproduction. Pheo?chro?mo?cytoma is also a primary concern when evaluating functional adrenal mass?es because of the potential hazards of massive catecholamine release.1 Nonfunctioning tumors vary significantly in ap?pearance and presentation.2
The evaluation of an adrenal mass begins with a complete blood count and a basic serum chemistry workup, including sodium, chloride, potassium, bicarbonate, and glucose levels. Further testing should be performed based on clinical examination and the initial laboratory evaluation; serum levels may be meas?ured to rule out hyperaldosteronemia, Cushing's disease, or pheochromocytoma. Specific testing should be undertaken to rule out particular adrenal pathologies. Serum aldosterone and renin levels should be checked when there is suspicion of hyperaldosteronemia. This diagnosis is confirmed with a captopril suppression test, in which captopril, an angiotensin-converting enzyme (ACE) inhibitor, is administered to the supine patient. ACE is an intermediary in the feedback cycle regulating renin-an?gio?tensin-aldosterone release, which is initiated by changes in blood pressure detected in nephrons. ACE converts angio?tensin I into angiotensin II; in?creased angiotensin II stimulates aldosterone release. Because of this, the patient's aldosterone and renin levels are checked serially for several hours following captopril administration. In patients with an aldosterone-producing mass, the expected drop in serum aldosterone and renin levels will not occur. The patient's position is noted during the test because an abrupt rise from sitting to standing may induce an appropriate release of aldosterone, resulting in a subsequent transient hypotension, falsely elevating the measured aldosterone level.
Cushing's syndrome often results from adrenal hyperplasia or a hyperfunctioning adrenal mass. In addition to ob?taining the requisite patient history (including any history of exogenous steroid use) and conducting a physical examination, diagnosis may be confirmed by ob?taining 24-hour urinary free cortisol, urine chemistries, urine 17-hydroxy-steroids, and plasma adrenocorticotrophic hormone (ACTH). Patients of?ten have abnormalities on routine serum chem?istries, such as hypergly?cemia, hyperlipidemia, hypo?ka?lemia, and metabolic alkalosis. Both low-dose and high-dose de?x?ame?thasone tests are used to differentiate ACTH-dependent from ACTH-independent stimulators of ad?renal cortical activity.
Pheochromocytoma may also present as an adrenal mass and poses a particular challenge to surgeons. In addition to having routine screening labs, patients should be checked for 24-hour urinary metanephrines, VMA, and catecho?la?mines, all of which are biochemical products in the synthesis of endogenous catecholamines. In cases of suspected pheochromocytoma, a meta-iodobenzylguanidine (MIBG) scan may be used to localize the tumor. Selective venous sampling of each adrenal gland is sometimes used to localize nonvisualized masses, but this is uncommon.
Imaging is of utmost importance in the preoperative workup of an adrenal mass. CT scanning is the initial imaging standard for adrenal masses. Magnetic resonance imaging (MRI) can also be useful because many of the nonfunctional adrenal tumors have distinct radiologic appearances.3 One reported case of a large adrenal hematoma presenting as a mass was diagnosed using MRI, al?though this is a rare occurrence and an unusual diagnosis.4 Of special note, our patient underwent a percutaneous CT-guided biopsy of her adrenal mass, which was inconclusive, but this practice is generally discouraged due to the potential risk of an undetected pheochromocytoma. Percutaneous manipulation of an undiagnosed adrenal pheochromocytoma may cause a massive catecholamine response and induce a hypertensive crisis, dysrhythmias, or even death.5
Surgical excision is currently recommended for all adrenal masses larger than 5 cm, as well as for all types of functioning tumors. The incidence of malignancy in adrenal masses is significantly higher for lesions larger than 4 cm in diameter. For this reason, adrenal masses larger than 3 cm but smaller than 5 cm are monitored closely for changes in size, and patients should be advised to consider surgical excision. Laparoscopic ad?renalectomy has been shown to have definite advantages for patients amenable to such treatment. Decreased postoperative pain and shorter hospital stays and recovery times are documented benefits of laparoscopic adrenalectomy for nonfunctioning and benign tumors smaller than 5 cm. Early studies appear to have similar outcomes for laparoscopic ad?rena?lectomy for malignancy, but more recent reports warn that very large tumors and pheo?chromocytomas of all sizes may not be appropriate for laparoscopic excision even in the hands of very experienced la?p?aroscopic surgeons.6-8
Intra-adrenal hematomas are generally associated with trauma, infection, or bleeding diatheses. Ascending infections, classically gonococcal, were a common source of adrenal hemorrhage in the past, although the incidence of Friderichsen-Waterhouse syndrome has decreased significantly with advances in antibiotics and greater awareness of sexually transmitted diseases. A few isolated reports of similar pathology exist in the literature, where a massive adrenal tumor is found to be a hematoma within a normal gland. The treatment has been variable, ranging from observation to surgical excision.4,8-10 Because of the large and increasing size of our patient's mass, resection was a straightforward clinical decision. Our patient was seen in the surgery clinic for follow-up and had no complications; she was referred to a hematology clinic for further workup, and we suspect that her ongoing anemia may resolve with time.
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