A 49 years old lady presented to the Urology clinic in KIMS PBMH with dull aching left flank pain and dyspepsia for the last 3 months. She was attended by Dr. Sumanta Mishra, an expert urology specialist She was diabetic for 2 years on oral hypoglycemic and hypertensive for the last 5 years on medications. She had LSCS 16 years back and attained menopause 2 years back. She doesn’t have palpitation, headache, dizziness, pedal edema, or any recent weight loss or weight gain. She had central obesity with a BMI of 37. On examination, her systemic blood pressure was 160/90 mm of Hg, pulse 80/min, and no abdominal mass palpable.
Her ultrasound abdomen showed a well-defined brightly echogenic lesion measuring 82x92x117mm is seen in the left adrenal region. Her blood investigations including serum electrolytes were normal. Contrast-enhanced CT scan with adrenal protocol showed a Large retroperitoneal mixed density lesion of size 9.8x 7.3x 9.5 cm noted in the anatomical side of left adrenal gland displacing left kidney downwards. The lesion contains a gross fat density area with some soft tissue density area suggestive of adrenal myelolipoma. The right adrenal was normal. Her endocrine evaluation was done to rule out secreting tumors including pheochromocytoma. All hormonal evaluations including 24 hours urinary metanephrines and normetanephrine, serum cortisol, DHEA, serum aldosterone, and renin levels were within normal limits.
Based on radiological features and hormonal evaluation she was diagnosed with left adrenal myelolipoma. After proper counseling, the patient about the treatment plan laparoscopic left adrenalectomy was planned.
Standard three-port was placed by Hasson’s technique in the right lateral decubitus position and adrenal approached by the transperitoneal route. The key steps of surgery were identifying and controlling the adrenal vein while safeguarding the renal hilar vessels along with the spleen and pancreatic tail. The adrenal mass of 11 x 9 x 9 cm was excised and retrieved by a Pfannenstiel incision. The patient was discharged on 3rd post-operative day.
Our patient had such a giant AML and presented with features of pressure effect due to mass. Her hypertensive status and central obesity warranted hormonal evaluation which was normal and helped confirm the diagnosis. Although this is a benign lesion, surgery is needed in large symptomatic cases and suspicion of malignancy. AMLs doesn’t recur after surgical excision with recurrence-free survival rate up to 12 years being reported [