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title: "Adrenal Cyst"
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docid: "c5d717a3-3d6e-4e86-9efe-1ad0ec14740f"
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authors:
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- key: "c3463c5c-31d3-4489-bbfe-6b895abdb86d"
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value: "Mitchell Tublin, MD"
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breadcrumbs:
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-
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name: "Genitourinary"
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slug: "genitourinary"
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treeNodeId: "bd0eb4fe-d465-4faa-a3b7-526e8f01802d"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "e82a3e55-c0be-4ed1-acd6-b03ae9167c31"
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-
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name: "Adrenal"
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slug: "adrenal"
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treeNodeId: "d3b85dea-43cb-4be3-b103-902e38d0336e"
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-
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name: "Benign Neoplasms"
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slug: "benign-neoplasms"
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treeNodeId: "eeebc0ba-f71a-4ae6-8daf-525d0d18fa16"
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-
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name: "Adrenal Cyst"
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slug: "adrenal-cyst"
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treeNodeId: null
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category: "Genitourinary"
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documentVersionId: "c0408d4e-b577-4561-89ba-5fd1d7888eaf"
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imageCount: 14
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lastUpdated: "09/09/21"
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pageDescription: "Adrenal Cyst"
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pageKeywords: "Genitourinary, Diagnosis, Adrenal, Benign Neoplasms, Adrenal Cyst"
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pageTitle: "Adrenal Cyst | STATdx"
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enhancedTitle: "Adrenal Cyst"
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type: "DX"
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references: true
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breadcrumbs:
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- "Genitourinary"
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- "Diagnosis"
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- "Adrenal"
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- "Benign Neoplasms"
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- "Adrenal Cyst"
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---
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# KEY FACTS
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- ## Imaging
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- "Adrenal cyst" is descriptive term, not pathological diagnosis
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- True adrenal cysts
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- Majority are endothelial cysts (lymphangiomas)
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- Epithelial cysts exceedingly rare
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- Simple, or minimally complex, adrenal cyst, thin rim calcification, no enhancement
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- Pseudocysts
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- Prior hemorrhage inferred
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- Nonenhancing but complex contents and wall calcification
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- Relevant history (extraadrenal malignancy, rapid growth), biochemical evaluation (cortisol, metanephrines): Consider underlying adrenal neoplasm
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- Enhancing soft tissue components may suggest adrenal mass hemorrhage and pseudocyst formation
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- Parasitic (echinococcal) cyst
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- Rare outside endemic areas
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- Typically in setting of generalized echinococcus
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- ## Top Differential Diagnoses
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- Adrenal adenoma
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- CECT: Enhancing mass without visible wall or peripheral calcifications
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- Gastric diverticulum
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- Air-, fluid-, or contrast-filled mass with no enhancement of contents
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- Adrenal myelolipoma
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- Macroscopic fat
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- Necrotic adrenal tumor
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- Complex wall with heterogeneous contents
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- Retroperitoneal bronchogenic cyst
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- ## Clinical Issues
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- No treatment required usually
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- Imaging surveillance performed, although intensity and length of follow-up not defined
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- Biochemical evaluation (cortisol, metanephrines) routinely performed to exclude underlying adrenal neoplasm
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- Surgical resection for complex cyst with enhancing components, or symptomatic cyst
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- ## Diagnostic Checklist
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- Complicated cyst has high attenuation, thick enhancing wall, &/or septations
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# TERMINOLOGY
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- ## Definitions
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- "Adrenal cyst" is descriptive term, not pathological diagnosis
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- Can mean true cyst, pseudocyst, or cystic mass
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Well-defined, nonenhancing, water-density adrenal mass ± calcifications
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- ### Location
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- Suprarenal
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- Unilateral > bilateral (8-10% of cases)
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- ### Size
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- < 5 cm (50%), up to 20 cm
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- ## CT Findings
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- ### NECT
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- Unilocular or multilocular mass
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- Well-defined, round to oval, homogeneous mass usually with water (0 HU) or near-water density
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- Higher- or mixed-attenuation mass (hemorrhage, intracystic debris, crystals)
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- Wall usually very thin
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- ↑ wall thickness, up to 3 mm for complex cysts
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- Calcifications
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- Rim-like or nodular (51-69%)
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- Centrally in intracystic septation (19%)
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- Punctate within intracystic hemorrhage (5%)
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- ### CECT
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- No central enhancement ± wall enhancement
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- Coronal reformats helpful to determine organ of origin if large cyst
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- ## MR Findings
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- ### T1WI
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- Homogeneous, hypointense mass
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- Hyperintense mass (hemorrhage)
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- ### T2WI
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- Hyperintense mass
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- ## Ultrasonographic Findings
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- Simple or septated suprarenal cyst
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- Shadowing from calcification
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- Real-time examination helpful to differentiate adrenal cyst from adjacent (renal, pancreatic) cyst
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- ## Imaging Recommendations
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- ### Best imaging tool
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- CECT or MR; US for confirmation
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# DIFFERENTIAL DIAGNOSIS
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- [Adrenal Adenoma](/document/adrenal-adenoma/e2916d86-5f9f-4dd3-9576-1a7b89d8dda0)
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- NECT: Lipid-rich adenoma (< 10 HU) mimics adrenal cyst
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- Peripheral or septal calcification favors adrenal cyst
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- CECT: **Enhancing mass** without visible wall or peripheral calcifications
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- Assess washout kinetics to diagnose lipid-poor adenoma
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- MR: Signal suppression at out-of-phase, chemical-shift imaging
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- US: Solid adrenal lesion
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- [Gastric Diverticulum](/document/gastric-diverticulum/eeb101f0-8bdf-4771-b44a-fe6e73b3a463)
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- May simulate left adrenal cyst
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- Air-, fluid-, or contrast-filled suprarenal mass
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- No enhancement
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- Normal adjacent adrenal gland
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- [Adrenal Myelolipoma](/document/adrenal-myelolipoma/5813a554-06a4-4696-af71-7ce50693039d)
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- Fat (not fluid) attenuation mass
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- ## Necrotic Adrenal Tumor
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- Primary (pheochromocytoma or carcinoma) or metastatic
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- Clinical history, biochemical evaluation, lesion complexity suggest correct diagnosis
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- Enhancing soft tissue components
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- ## Retroperitoneal Bronchogenic Cyst
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- Rare, benign, suprarenal fluid or soft tissue attenuation lesion
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- Adjacent to but separate from adrenal gland
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- ## Renal Cyst
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- Coronal MR/CT or US useful to determine organ of origin of large, retroperitoneal cystic lesions
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Congenital (endothelial, epithelial) cysts
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- Acquired (post hemorrhagic, inflammatory) pseudocysts
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- Cystic, hemorrhagic degeneration of underlying adrenal neoplasm
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- ## Staging, Grading, & Classification
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- Accepted classification scheme
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- Pseudocyst
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- Most common type of cystic adrenal lesion in surgical series
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- No epithelial or endothelial lining: Fibrous cyst wall
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- Potentially as complication of prior trauma or hemorrhage though history of such often not elicited
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- May be associated with underlying adrenal neoplasm (pheochromocytoma, adrenal carcinoma, myelolipoma)
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- Attenuation and complexity at imaging varies depending upon hemorrhagic component
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- Wall and septal calcification common
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- Endothelial cyst
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- Subtypes: Lymphangiomatous and hemangiomatous
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- True cyst: Endothelial lining
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- Originate from preexisting vascular malformation or obstructed, ectatic lymphatic channels
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- Thin rim calcification typical
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- Epithelial cyst
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- Extremely rare: No acinar structures within normal adrenal gland
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- Mesothelial origin suggested (mesothelial cells potentially incorporated within adrenal gland during embryogenesis)
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- Parasitic (hydatid) cyst
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Typically asymptomatic
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- Larger cysts may be symptomatic
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- Abdominal pain
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- Hemorrhage
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- Clinical history (malignancy, hypertension) elicited
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- May indicate cystic degeneration of underlying adrenal neoplasm (e.g., metastasis, pheochromocytoma)
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- Diagnosis
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- Usually incidental finding at imaging
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- Endocrine-biochemical evaluation performed to exclude underlying functional adrenal tumor
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- ## Demographics
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- ### Age
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- Any, though patients 20-50 years of age most common
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- ### Sex
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- M:F = 1:3
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- ### Epidemiology
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- Uncommon entity: Autopsy incidence 0.064-0.18%
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- Accounts for 1% of incidental adrenal lesions in large imaging series
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- ## Natural History & Prognosis
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- Complications
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- Hypertension, infection, rupture, hemorrhage
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- Excellent prognosis for vast majority of incidental, benign adrenal cysts
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- Prognosis for pseudocysts secondary to adrenal neoplasm depends upon tumor histology
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- ## Treatment
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- No treatment required usually
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- Imaging follow-up typically performed
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- Intensity and length of surveillance not defined
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- Cysts may enlarge over time
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- Endocrine evaluation (cortisol, metanephrine, etc.) performed
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- Surgical resection if symptomatic, underlying adrenal neoplasm
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- Laparoscopic resection preferred
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Complicated cyst may suggest underlying adrenal neoplasm
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- Clinical history, biochemical evaluation, and prior imaging helpful
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- ## Image Interpretation Pearls
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- Simple adrenal cyst: Scant septation, no enhancement, thin rim calcification
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- Likely benign endothelial cyst or pseudocyst
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- Coronal imaging helpful to determine organ of origin (and exclude exophytic renal or pancreatic cyst)
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- Complicated cyst: High attenuation, thick enhancing wall, &/or septations
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- Complexity may suggest underlying adrenal neoplasm and secondary pseudocyst
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2a5b237c-1238-48d3-9b6c-f76846cba1cb
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## References
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# Selected References
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1. [Wang F et al: CT and MRI of adrenal gland pathologies. Quant Imaging Med Surg. 8(8):853-75, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30306064%5Bpmid%5D)
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1. [Lattin GE Jr et al: From the radiologic pathology archives: adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics. 34(3):805-29, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24819798%5Bpmid%5D)
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1. [Kyoda Y et al: Adrenal hemorrhagic pseudocyst as the differential diagnosis of pheochromocytoma--a review of the clinical features in cases with radiographically diagnosed pheochromocytoma. J Endocrinol Invest. 36(9):707-11, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23563219%5Bpmid%5D)
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1. [Ricci Z et al: Adrenal cysts: natural history by long-term imaging follow-up. AJR Am J Roentgenol. 201(5):1009-16, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24147471%5Bpmid%5D)
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1. [Saadai P et al: The pathological features of surgically managed adrenal cysts: a 15-year retrospective review. Am Surg. 79(11):1159-62, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24165250%5Bpmid%5D)
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1. [Sebastiano C et al: Cystic lesions of the adrenal gland: our experience over the last 20 years. Hum Pathol. 44(9):1797-803, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23618356%5Bpmid%5D)
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1. [El-Hefnawy AS et al: Surgical management of adrenal cysts: single-institution experience. BJU Int. 104(6):847-50, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19389014%5Bpmid%5D)
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1. [Chien HP et al: Adrenal cystic lesions: a clinicopathological analysis of 25 cases with proposed histogenesis and review of the literature. Endocr Pathol. 19(4):274-81, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18972224%5Bpmid%5D)
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1. [Song JH et al: The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR Am J Roentgenol. 190(5):1163-8, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18430826%5Bpmid%5D)
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1. Elsayes KM et al: Adrenal masses: MR imaging features with pathologic correlation. Radiographics. 24 Suppl 1:S73-86, 2004
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1. [Guo YK et al: Uncommon adrenal masses: CT and MRI features with histopathologic correlation. Eur J Radiol. 62(3):359-70, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17532488%5Bpmid%5D)
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1. [Sanal HT et al: Imaging features of benign adrenal cysts. Eur J Radiol. 60(3):465-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16962278%5Bpmid%5D)
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1. [Akçay MN et al: Hydatid cysts of the adrenal gland: review of nine patients. World J Surg. 28(1):97-9, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=14639487%5Bpmid%5D)
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1. [Elsayes KM et al: Adrenal masses: MR findings with pathologic correlation. RadioGraphics 24: S73-86; 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15486251%5Bpmid%5D)
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1. [Kawashima A et al: Imaging of nontraumatic hemorrhage of the adrenal gland. Radiographics. 19(4):949-63, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10464802%5Bpmid%5D)
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1. [Neri LM et al: Management of adrenal cysts. Am Surg. 65(2):151-63, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=9926751%5Bpmid%5D)
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1. [Otal P et al: Imaging features of uncommon adrenal masses with histopathologic correlation. Radiographics. 19(3):569-81, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10336189%5Bpmid%5D)
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1. [Kawashima A et al: Spectrum of CT findings in nonmalignant disease of the adrenal gland. Radiographics. 18(2):393-412, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9536486%5Bpmid%5D)
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1. [Tung GA et al: Adrenal cysts: imaging and percutaneous aspiration. Radiology. 173(1):107-10, 1989](http://www.ncbi.nlm.nih.gov/pubmed/?term=2675177%5Bpmid%5D)
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## Images
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### Selected Images
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*Axial CECT in a 28-year-old woman with abdominal pain shows an incidental left adrenal cystic lesion <img src='img/arrows/WS.png'/>. Note thin cyst septation <img src='img/arrows/WC.png'/>, a finding characteristic of endothelial adrenal cyst.*
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*Axial CECT in a 28-year-old woman with abdominal pain shows an incidental left adrenal cystic lesion <img src='img/arrows/WS.png'/>. Note thin cyst septation <img src='img/arrows/WC.png'/>, a finding characteristic of endothelial adrenal cyst.*
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*Longitudinal US in the same patient confirms an anechoic left suprarenal-adrenal cyst <img src='img/arrows/BS.png'/>. The simple appearance of the cyst and the lack of additional relevant clinical history (malignancy, HTN, etc.) prompted surveillance rather than resection for this incidental, benign endothelial cyst.*
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*Longitudinal US in the same patient confirms an anechoic left suprarenal-adrenal cyst <img src='img/arrows/BS.png'/>. The simple appearance of the cyst and the lack of additional relevant clinical history (malignancy, HTN, etc.) prompted surveillance rather than resection for this incidental, benign endothelial cyst.*
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*Axial NECT in a 71-year-old woman shows a 4-cm, complex cystic right adrenal mass <img src='img/arrows/WC.png'/> containing coarse calcifications. Adrenalectomy (performed given lesion complexity and size) confirmed hemorrhagic pseudocyst.*
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*Axial NECT in a 71-year-old woman shows a 4-cm, complex cystic right adrenal mass <img src='img/arrows/WC.png'/> containing coarse calcifications. Adrenalectomy (performed given lesion complexity and size) confirmed hemorrhagic pseudocyst.*
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*Axial T2 FS MR in a 54-year-old woman with left flank pain shows a 7-cm, complex cystic right adrenal mass with a low-signal hemosiderin ring <img src='img/arrows/WS.png'/>. A pseudocyst was resected. Signal intensity of pseudocysts varies depending on the age of hemorrhage.*
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*Axial T2 FS MR in a 54-year-old woman with left flank pain shows a 7-cm, complex cystic right adrenal mass with a low-signal hemosiderin ring <img src='img/arrows/WS.png'/>. A pseudocyst was resected. Signal intensity of pseudocysts varies depending on the age of hemorrhage.*
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*Sagittal US in a 35-year-old woman shows a > 10-cm right suprarenal cyst <img src='img/arrows/WS.png'/>. Real-time examination and a follow-up MR (not shown) confirmed simple extrarenal-adrenal cyst that was subsequently resected. An epithelial cyst (a rare subtype of adrenal cysts) was shown at histology.*
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*Axial CECT in a 51-year-old woman shows an incidental, peripherally calcified left adrenal cyst <img src='img/arrows/WS.png'/>. Coarse calcification suggests a pseudocyst. Pseudocysts may be due to prior trauma/hemorrhage, but this history is often absent.*
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*Axial CECT in a hypertensive 36-year-old woman shows a peripherally enhancing, septated, 7-cm left adrenal pheochromocytoma <img src='img/arrows/WS.png'/>. Enhancing soft tissue should prompt testing for an underlying adrenal neoplasm.*
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*Axial CECT in a 72-year-old man with pancreatitis shows peripancreatic infiltration <img src='img/arrows/WS.png'/> and a 3-cm adrenal pseudocyst <img src='img/arrows/WC.png'/>. The pseudocyst resolved on follow-up CT. Imaging surveillance is advocated for asymptomatic, probable pseudocysts.*
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*Staging CECT in a 66-year-old man with metastatic lung carcinoma shows large, bilateral, necrotic adrenal metastases <img src='img/arrows/WS.png'/>. The clinical history and an enhancing rind <img src='img/arrows/WC.png'/> prevent an erroneous diagnosis of benign adrenal cysts.*
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*Axial CECT of a 62-year-old man shows a 2-cm, incidental left suprarenal lesion <img src='img/arrows/WC.png'/>. Location adjacent to the left crus <img src='img/arrows/WO.png'/> and separate from the left adrenal <img src='img/arrows/WS.png'/> indicates a retroperitoneal bronchogenic cyst, a mimic of adrenal cyst.*
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### Additional Images
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*Sagittal US shows a sonolucent mass above the right kidney that proved to be an adrenal cyst.*
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*Axial T2 MR shows a high-signal left adrenal cyst <img src='img/arrows/WS.png'/>.*
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*Axial CECT shows a nonenhancing water density right adrenal cyst.*
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*Sagittal reformation of CECT shows a nonenhancing right adrenal cyst <img src='img/arrows/WS.png'/>.*
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