03 24 Surgical Treatment of Adrenal Myelolipoma Original Article Introduction Adrenal myelolipomas are rare benign tumors com- posed of maturated adipose tissue and hematopoietic cells. In most cases they are small and asymptomatic. Discovered incidentally by ultrasound or computed to- mography examination, they are classified as “adrenal incidentalomas” and follow the corresponding indica- tions for surgical removal. Materials and methods We present 6 patients within a prospective study who were performed retroperitoneal endoscopic adrenalectomy (REA) between June 2007 and Janu- ary 2010 at the Second Surgical Department of UM- HAT ”Alexandrovska”, Sofia, on the occasion of adrenal gland myelolipoma. Five of the patients had unilateral pathology and one - bilateral. In the patient with bilat- eral pathology we performed a two-stage procedure – REA on the first stage and conventional contralateral adrenalectomy on the second. The demographic characteristic of patients is pre- sented in Table 1. SURGICAL TREATMENT OF ADRENAL MYELOLIPOMA G. Todorov 1 , Ts. Lukanova 1 , M. Georgiev 2 1 Second Surgical Department, Medical University, Sofia 2 Department of Urology, Medical University, Sofia Key words: endoscopic adrenalectomy, adrenal tumors, myelolipoma Contact details: G. Todorov, Second Surgical Department, Medical University, 1 Sv. Georgi Sofiiski Blvd. – 1431, e-mail: [email protected]Abstract: Objective: To evaluate the potential of different surgical techniques in the treatment of rare tumors of the adrenal glands. Material and methods: We present 6 patients within a prospective study who underwent retroperitoneal endoscopic adrenalectomy (REA) between June 2007 and January 2010 at the Second Surgical Department of UMHAT ”Alexandrovska”, Sofia, on the occasion of adrenal gland myelolipoma. Results: REA was carried out in 5 patients, while in one with bilateral myelolipomas - REA was performed followed by a conventional contralateral adrenalectomy on the 2 nd stage. The mean operative time for endoscopic surgery was 70 min - (60’-90’), with an average intraoperative blood loss of 50 ml. There were no intraoperative and postoperative complica- tions. Conclusions: Myelolipomas are rare diseases of the adrenal glands, most often discovered incidentally in imaging diag- nostics. The indications for their surgical treatment follow those of the incidentalomas. Mini-invasive techniques performed by experienced endocrine and laparoscopic team are an effective and feasible way for their removal.
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03
24
Surgical Treatment of Adrenal Myelolipoma
Original Article
Introduction
Adrenal myelolipomas are rare benign tumors com-
posed of maturated adipose tissue and hematopoietic
cells. In most cases they are small and asymptomatic.
Discovered incidentally by ultrasound or computed to-
mography examination, they are classified as “adrenal
incidentalomas” and follow the corresponding indica-
tions for surgical removal.
Materials and methods
We present 6 patients within a prospective study
who were performed retroperitoneal endoscopic
adrenalectomy (REA) between June 2007 and Janu-
ary 2010 at the Second Surgical Department of UM-
HAT ”Alexandrovska”, Sofia, on the occasion of adrenal
gland myelolipoma. Five of the patients had unilateral
pathology and one - bilateral. In the patient with bilat-
eral pathology we performed a two-stage procedure
– REA on the first stage and conventional contralateral
adrenalectomy on the second.
The demographic characteristic of patients is pre-
sented in Table 1.
SURGICAL TREATMENT OF ADRENAL MYELOLIPOMAG. Todorov1, Ts. Lukanova1, M. Georgiev2
1Second Surgical Department, Medical University, Sofia2Department of Urology, Medical University, Sofia
Key words: endoscopic adrenalectomy, adrenal tumors, myelolipomaContact details: G. Todorov, Second Surgical Department, Medical University, 1 Sv. Georgi Sofiiski Blvd. – 1431, e-mail: [email protected]
Abstract: Objective: To evaluate the potential of different surgical techniques in the treatment of rare tumors of the adrenal
glands.
Material and methods: We present 6 patients within a prospective study who underwent retroperitoneal endoscopic
adrenalectomy (REA) between June 2007 and January 2010 at the Second Surgical Department of UMHAT ”Alexandrovska”,
Sofia, on the occasion of adrenal gland myelolipoma.
Results: REA was carried out in 5 patients, while in one with bilateral myelolipomas - REA was performed followed by
a conventional contralateral adrenalectomy on the 2nd stage. The mean operative time for endoscopic surgery was 70 min
- (60’-90’), with an average intraoperative blood loss of 50 ml. There were no intraoperative and postoperative complica-
tions.
Conclusions: Myelolipomas are rare diseases of the adrenal glands, most often discovered incidentally in imaging diag-
nostics. The indications for their surgical treatment follow those of the incidentalomas. Mini-invasive techniques performed
by experienced endocrine and laparoscopic team are an effective and feasible way for their removal.
lectomy was carried out in two of the patients with
unilateral pathology. The patient with bilateral inci-
dentalomas underwent a two-stage procedure - the
first stage was total retroperitoneoscopic adrenalec-
tomy on the right, and the second - left lumbotomy
with adrenalectomy because of previous surgery in
the area – pyelolithotomy and ureterolithotomy, on
the occasion of nephrolithiasis, which considering the
10-cm size and the corresponding malignant poten-
tial, was evaluated as contraindication for mini-invasive
procedure.
The mean operative time of the endoscopic surger-
ies was 70 min - (60’-90’), with an average intraopera-
tive blood loss of 50 ml. In one case, we succeeded
to perform subtotal adrenalectomy with preservation
of apparently unchanged parenchyma of the adrenal
gland. The other required the removal of the entire
gland. Extirpation of the specimen was accomplished
by the use of “Endo-bag”, with skin excision expanded
whenever required by the size of the tumor. There
were no intraoperative and postoperative complica-
Surgical Treatment of Adrenal Myelolipoma
CT-image - a tumor formation in the right adrenal gland area, with transversal dimensions 54/74 mm; density is fat-equivalent - 60-90 HU; a capsule with irregular thickness; density does not change a�er application of contrast material
Postoperative view of the removed specimen and its macroscopic characteristics
03
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J Clin Med. 2010; 3(3):24-30
tions. Conventional adrenalectomy was performed
through lumbotomy and resection of the XII rib, while
intraoperatively were revealed multiple adhesions of
the renal capsule to the peritoneum and lumbar mus-
cle. The adrenal tumor formation was also accreted to
the tail of the pancreas. Verticalization and oral intake
in retroperitoneoscopic operations began on the 6th
postoperative hour; the mean postoperative stay was
2 days. With the conventional access this stay was ex-
tended to 6 days.
The histological diagnosis in all patients was “adrenal
myelolipoma”.
The follow up of the patients includes clinical, ul-
trasound and hormonal examinations on the 1st, 6th
and 12th postoperative months. There are no records
of recurrence or changes in the contralateral gland in
patients with unilateral pathology on the 12th month
of the follow-up. In the female patient with renin
overproduction, there was no such problem on the
6th month of the follow-up within normal potassium
levels. The man with bilateral adrenalectomy was ad-
ministered hormone replacement therapy.
Discussion
Adrenal myelolipomas are rare benign tumors com-
posed of fatty connective tissue and hematopoietic ele-
ments in different proportions. No malignant potential
of these lesions is reported in literature. Myelolipomas
are most often incidental findings (incidentalomas) of
imaging diagnostics, performed on another occasion.
They constitute about 3% of all primary adrenal tumors,
and their incidence in autopsies is 0.06% to 0.2%.1 Their
approximate share of the “incidentalomas” is 7-15%.15 My-
elolipomas are found among people aged 25-65 years,
most often affecting those aged 50-60 years2. The right
adrenal gland is more frequently involved than the left
(ratio 3:2.1) and the bilateral myelolipomas are rare.14
Our patients were in the age range 39-65 years and the
ratio right: left adrenal gland was respectively - 1.3:1. In
one case there was bilateral myelolipoma.
Far back in 1866, while exploring questions about the
biochemistry and cytology of the adrenal gland, Arnold3
reported the possibility that blood cells available from
ectopic tissue elements of bone marrow may develop
in the adrenal gland. For the first time, Gierke in 1905
represented a histological evidence of bone marrow in
the adrenal gland.4 Researchers of that time discussed
the presence of heterotopic bone tissue in the adre-
nal gland as a “pre-myeloma”. The name “myelolipoma”
was introduced in 1929 by Oberling to describe this ect-
opy.5 Etiopathogenesis of this disease remains unclear.
Experimental myeloid transformation in the adrenal
gland was induced by subcutaneous injection of extract
of anterior pituitary and metiltestosteron.19 Currently,
there are various theories about the origin and devel-
opment of the adrenal myelolipomas - development of
clusters of mesenchymal stem cells, bone marrow em-
boli, extramedullary hemopoiesis6, as the most widely
accepted is the theory of metaplasia of the reticuloen-
dothelial cells of capillaries as a result of stressful stimuli
ciency and ectopic corticotropic production.12 In one of
our cases, there was a hormonal hypersecretion featur-
ing elevated levels of aldosterone and renin in triple
upright position testing, which was normalized on the
sixth month after the operation within normal potas-
sium levels and persistent hypertension. We considered
this abnormal hormonal production as part of the pre-
sented pathology, as the contralateral gland showed no
imaging changes in the follow-up.
The clinical manifestation of myelolipomas may be
acute abdominal pain and hemorrhagic shock due to
rupture and hemorrhage from the formation, or ab-
dominal discomfort as a result of their large size. Spon-
taneous hemorrhage is more typical for tumors with
predominantly myeloid components.16
Comorbidity of myelolipomas with obesity and hyper-
tension are often reported, as in some cases the sug-
gested reason for the hypertension is the compression
of the renal artery.22,23 In our study, one of the female
patients had had a 5-year history of hypertension, and
on the postoperative follow-up the dosage of the ACE-
inhibitor taken as systemic therapy, was reduced, and
the diuretic therapy - stopped. Association with chole-
lithiasis, however, is rare, as the most probable discussed
cause is an accidental coincidence.13 In our case, the
conventional cholecystectomy is the reason for diagnos-
ing myelolipoma in one of the patients. Associated ma-
lignant pathology, such as renal cell cancer23, colon can-
cer2 etc. and simultaneous adrenal and extra-adrenal
myelolipomas have been described.24
Surgical treatment is the main therapeutic approach in
symptomatic and complicated lesions. Symptomatic tu-
Surgical Treatment of Adrenal Myelolipoma
03
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J Clin Med. 2010; 3(3):24-30
mors, growing in size, greater than 4 cm tumors, show-
ing areas of hemorrhage or necrosis tumors, as well
as those suspected for malignancy, should be removed
surgically. Conventional or endoscopic access may be
chosen depending on the size. Various techniques are
described - conventional and mini-invasive. Our opin-
ion is that when appropriate size is present, mini-in-
vasive technique is feasible for the treatment of these
tumors. In our material there are no intra-or postopera-
tive complications. Advantages, such as lesser hospital
stay, faster recovery and return to normal physical and
social activity at this stage of development of surgical
science and technology are indisputable. As described
by other authors, the laparoscopic approach may have
great results in smaller lesions (between 6-8 cm). Con-
ventional classical methods also have their indications
- both transabdominal and lumbar. Laparotomies using
subcostal or posterior access are also described.25 There
are also opposing views that surgery should not be “lib-
eralized” through using translumbar or endoscopic ac-
cesses.26 Regardless of access, strict postoperative follow-
up is mandatory. There is no described malignancy of
that pathology in literature. The 8-year follow-up period
of one of our patients, has shown no malignization, de-
spite the increase in size and expansive growth on the
imaging diagnostics. The increase in size and suspected
malignancy in imaging examinations, considering the
absence of exact criteria for imaging diagnosis of “mye-
lolipoma”, impose the same principles for removal, such
as the ones in adrenal incidentalomas.
Conclusion
Myelolipomas are rare diseases of the adrenal
glands, most often discovered incidentally in imaging
diagnostics. The indications for their surgical treatment
follow those of the incidentalomas. Mini-invasive
techniques, preformed by experienced endocrine and
laparoscopic team are an effective and feasible way for
their removal.
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