Benign combined myelolipoma and adrenocortical adenoma with mild autonomous cortisol secretion in an adrenal incidentaloma: A case report
Adrenal incidentalomas are increasingly being identified because of the widespread use of cross-sectional imaging.1 We present a unique case of co-occurrence of two distinct adrenal tumors: a myelolipoma and a mild autonomous cortisol secreting (MACS) adrenocortical adenoma.A 67-year-old woman was r...
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| Main Authors: | , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-07-01
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| Series: | Clinical Medicine |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1470211825000879 |
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| Summary: | Adrenal incidentalomas are increasingly being identified because of the widespread use of cross-sectional imaging.1 We present a unique case of co-occurrence of two distinct adrenal tumors: a myelolipoma and a mild autonomous cortisol secreting (MACS) adrenocortical adenoma.A 67-year-old woman was referred to the endocrine clinic for evaluation of an incidental adrenal nodule identified on a computed tomography (CT) scan performed as part of a targeted lung health check. She had a background of chronic back pain, irritable bowel syndrome (IBS) and a 50 pack-year smoking history. Physical examination and history did not reveal signs of Cushing’s syndrome, hyperaldosteronism or catecholamine excess, and there were no identifiable metabolic comorbidities linked to elevated cortisol levels, such as diabetes, hypertension or dyslipidemia.Endocrine evaluation revealed an abnormal overnight dexamethasone suppression test (ODST), with a post-test cortisol level of 97 nmol/L (<50), indicating MACS. ACTH was normal at 15 ng/L. Both the 24-h urinary cortisol and plasma metanephrines were found to be within normal limits. A dedicated adrenal scan showed heterogeneous enhancement with areas of macroscopic fat, but did not demonstrate contrast washout, raising suspicion of a lesion that could be more than a simple adenoma. The varying attenuation values complicated the differentiation between benign and malignant pathologies.1,2Given the size (≥4 cm), atypical imaging features and biochemical evidence of mild autonomous cortisol secretion, the case was discussed at the adrenal multidisciplinary team (MDT) meeting, where laparoscopic left adrenalectomy was strongly recommended because of the uncertain nature of the mass and risk of malignancy.2The patient underwent uneventful laparoscopic adrenalectomy under perioperative steroid cover because of the potential risk of adrenal crisis. Postoperatively, the patient recovered well, a short Synacthen® test confirmed adequate adrenal function, allowing for discontinuation of hydrocortisone. Histopathology of the adrenal tissue revealed a benign combined myelolipoma with adrenocortical adenoma, with no evidence of malignancy. A repeat overnight dexamethasone suppression test showed normal results, confirming the resolution of autonomous cortisol secretion. She was subsequently discharged from the clinic. Discussion: Adrenal myelolipomas are rare, benign tumours comprising mature adipose tissue and haematopoietic tissue. They are usually discovered incidentally and are typically non-functional. Given their benign nature and often asymptomatic presentation, adrenal myelolipomas are generally considered low-risk lesions. By contrast, adrenocortical adenomas are also benign tumours of the adrenal cortex, but they can be either functional or non-functional.3 In this case, the adrenocortical adenoma had MACS, which has been associated with an increased risk for hypertension, hyperglycaemia, obesity, dyslipideamia, vertebral fractures, adverse cardiovascular events and mortality.4 This underscores the importance of comprehensive endocrine evaluation for appropriate diagnosis and management.The simultaneous presence of an adrenocortical adenoma with MACS and a myelolipoma in the same adrenal gland is rare, with very few documented cases in the literature. This scenario illustrates the complexities of adrenal pathology and emphasises the importance of a MDT approach in addressing such cases. |
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| ISSN: | 1470-2118 |