A Case-Study Report of an Indiscernible Adrenal Myelolipoma-Clinical and Histologic Features

Adrenal myelolipomas are rare, non-functional, benign tumor-like lesions of the adrenal gland. They are usually found to occur alone in one adrenal gland but not both and there may be a right sided predilection. Histological examination demonstrates variable amounts of mature adipocytes (with distended lipid vacuoles) similar to bone marrow and hematopoietic cells (including cells from myeloid, erythroid and megakaryocytic cell lines) [1,2]. The fatty component is often the predominant feature and therefore the most characteristic feature on imaging. The lesions can infrequently contain bone or show partial replacement by haemorrhage or fibrosis. Adrenal myelolipomas are usually indentified in adults, either incidentally or if complicated by haemorrhage [3]. There is no gender predilection. The tumor affects men and women equally and is most commonly found between the fifth and seventh decades of life with a mean age of 62 years. Adrenal myelolipomas can vary widely in size [4]. They are often smaller than 4cm in diameter, with the largest reported adrenal myelolipoma measuring 31x24.5x11.5cm and weighing 6kg. Most of them are small, asymptomatic and may be discovered incidentally when the region is imaged for other reasons. Larger ones (typically over 4cm in size) can present with an acute retroperitoneal haemorrhage and still others (especially when very large, causing pressure of surrounding organs or tissues) with vague mass related symptoms. Symptoms include pain in the abdomen or flank, blood in the urine, a palpable lump or high blood pressure. Some studies suggest surgical intervention if the tumor is symptomatic, growing or larger than 6cm. ultimately, the optimal treatment for myelolipoma depends on size and symptoms of the mass, and the patient’s needs [5]. Although the tumor itself is non-functioning there is a relatively high incidence (10%) of associated endocrine disorders such as the Cushing syndrome, the congenital adrenal hyperplasia (21-hydroxylase deficiency) and the Conn syndrome (primary Abstract


Introduction
Adrenal myelolipomas are rare, non-functional, benign tumor-like lesions of the adrenal gland. They are usually found to occur alone in one adrenal gland but not both and there may be a right sided predilection. Histological examination demonstrates variable amounts of mature adipocytes (with distended lipid vacuoles) similar to bone marrow and hematopoietic cells (including cells from myeloid, erythroid and megakaryocytic cell lines) [1,2]. The fatty component is often the predominant feature and therefore the most characteristic feature on imaging. The lesions can infrequently contain bone or show partial replacement by haemorrhage or fibrosis. Adrenal myelolipomas are usually indentified in adults, either incidentally or if complicated by haemorrhage [3]. There is no gender predilection. The tumor affects men and women equally and is most commonly found between the fifth and seventh decades of life with a mean age of 62 years. Adrenal myelolipomas can vary widely in size [4].
They are often smaller than 4cm in diameter, with the largest reported adrenal myelolipoma measuring 31x24.5x11.5cm and weighing 6kg. Most of them are small, asymptomatic and may be discovered incidentally when the region is imaged for other reasons. Larger ones (typically over 4cm in size) can present with an acute retroperitoneal haemorrhage and still others (especially when very large, causing pressure of surrounding organs or tissues) with vague mass related symptoms. Symptoms include pain in the abdomen or flank, blood in the urine, a palpable lump or high blood pressure. Some studies suggest surgical intervention if the tumor is symptomatic, growing or larger than 6cm. ultimately, the optimal treatment for myelolipoma depends on size and symptoms of the mass, and the patient's needs [5]. Although the tumor itself is non-functioning there is a relatively high incidence (10%) of associated endocrine disorders such as the Cushing syndrome, the congenital adrenal hyperplasia (21-hydroxylase deficiency) and the Conn syndrome (primary Abstract Adrenal myelolipomas are rare benign tumors with estimated autopsy prevalence of 0.08-0.4%. They are identified in adults, either incidentally or if complicated by haemorrhage. There is no gender predilection. They are usually found to occur alone in one adrenal gland but not both and there may be a right sided predilection. Most lesions are small and asymptomatic and may be discovered incidentally during autopsy or on imaging studies performed for other reasons. Although the tumor itself is non-functioning there is a relatively high incidence (10%) of associated endocrine disorders. Several hypotheses have been proposed as to the cause of myelolipomas but the causative process is still not clearly understood. In recent years, they have been found to be more and more frequent due to sophisticated imaging tests. The case reported below, concerns the incident of an adrenal myelolipoma measuring 6.5x6x1.4cm and weighing 32.8gr, which caused the death of a 61-year-old male. The samples undertook microscopic examination using the Hematoxylin and Eosin (H&E) staining protocol, which revealed the presence of this rare tumor in the male's adrenal gland . In these disorders, adrenal myelolipomas may contain significant amounts of adrenal cortical tissue and may become very large with continued stimulation by adrenocorticotropic hormone (ACTH), which may leads to autonomous steroid hormones production [6].

Materials & Methods
We received an adrenal gland measuring 6.5x6x1.4cm and weighing 32.8gr with its fat and a brown to red tissue fragment measuring 7.5x2.5x2.7cm and weighing 40.4gr. The tissue sections were stained with Hematoxylin and Eosin (H&E) staining technique. The procedure was: Microscopic examination from the adrenal's tissue fragment showed partial autolysis details, focal fibrosis, presence of inflammatory infiltrations, macrophages, hemosiderin granules and congested vessels with slightly thickened wall (Figure 1). Macroscopic examination in both tissue fragments revealed, in an expanded almost universal extent, the presence of mature adipocytes together with extramedullary hematopoietic details (Figure 2). There were also observed haemorrhagic infiltrations, phagocytes, hemosiderin granules and the local presence of amorphous eosinophilic material. All the findings above indicated the presence of an adrenal myelolipoma. The CT appearance is usually characteristic. The typical adrenal myelolipoma appears as an adrenal mass with fatcontaining components. The mass is usually relatively well circumscribed; however masses that are mostly fat may be difficult to separate from surrounding retroperitoneal fat

Journal of Forensic Sciences & Criminal Investigation
uptake 100% sensitivity and specificity. Whole body PET scan can show extra-adrenal involvement. The most effective imaging modality for evaluation of an adrenal mass is the contrast enhanced computed tomography (CECT). Perinephric fat allows the gland to be clearly displayed and even 1cm size tumors can be detected with 100% sensitivity [10].

Conclusion
To sum up, the case above describes an incident of an adrenal myelolipoma founded after the death of a 61-year-old male. The samples examined microscopically using the characteristic histological H&E staining protocol. Macroscopic and microscopic examination indicated a rare case of myelolipoma located in the adrenal gland.