JBR–BTR, 2008, 91: 90-91.

BILATERAL ADRENAL MYELOLIPOMAS

K. Civrilli, N. Damry, R. Steppé, A. Efira, J. Mathieu1

Key-word: Myelolipoma

Background: A 28-year-old male patient presented with bilateral inguinal adenopathies, painful
at the left. His medical history revealed a treated pulmonary tuberculosis. At the time of presen-
tation chest radiography was normal. Except for the inguinal adenopathies, physical examina-
tion was unremarkable. Laboratory tests showed hypokalemia, inflammation and anemia.

B C

A B
1A

Fig. 1B 1C
1. Department of Radiology, University Hospital Brugmann, Brussels, Belgium 2A 2B
 BILATERAL ADRENAL MYELOLIPOMAS — CIVRILLI et al
Work-up
CT scan of the abdomen (Fig. 1), unenhanced CT
scan at inguinal level (A) shows bilateral inguinal
adenopathies, more prominent on the left side.
Unenhanced CT scan at upper abdominal level (B)
demonstrates the presence of bilateral adrenal
masses with central areas of fat density. Contrast-
enhanced CT scan at upper abdominal level (C)
shows pronounced enhancement at the periphery
of the adrenal masses bilaterally.
MRI at upper abdominal level (Fig. 2) includes an
axial T1-weighted image (A) which shows high sig-
nal intensity centrally in both the adrenal masses,
more pronounced at the left side and a fat-sup-
pressed T1-weighted image (B) demonstrating
complete signal void in the central part of the
adrenal masses.
Imaging findings consist of multiple intra-
abdominal lymph nodes, bilateral adrenal masses
and inguinal lymph nodes. The left inguinal lymph
nodes presented as a necrotic mass. Biopsy of the
left inguinal nodes was diagnostic for a malignant
non-Hodgkin lymphoma with large B-cells.
Radiological diagnosis
Based on CT- and MR-imaging findings (fat den-
sity on CT scan, high intensity on T1-WI and
absence of signal on fat suppressed MR-images)
the presence of coexistent bilateral adrenal
myelolipomas, as incidental finding, was suggest-
ed. Follow-up after chemotherapy over a two-year
period, revealed that the inguinal lymph nodes had
disappeared, but the bilateral adrenal masses
remained unchanged, thereby confirming the initial
radiological diagnosis.
Discussion
Adrenal myelolipoma is a rare benign neoplasm
composed of myeloid, erythroid, and fatty elements
with occasional calcifications. The incidence varies
from 0,08 to 0,4% at autopsy. The male-to-female
ratio is 1:1 and the lesions most commonly occur in
the fifth to seventh decade of life. Most lesions are
small and asymptomatic, discovered incidentally at
autopsy or on imaging studies performed for other
reasons. Tumor size varies from several millimetres
to larger than 30 cm. Most myelolipomas are unilat-
eral but show no predilection to one particular side,
they are hormonally nonfunctional and do not
undergo malignant transformation.
The imaging appearance of myelolipomas is
based on the fat content of the lesion: thus they
appear echogenic at US, with low attenuation at CT
scan. The presence of pure fat within an adrenal
91
lesion at CT is diagnostic of a myelolipoma, and no
further work-up is required.
With MR-imaging, the fatty portion of the lesion
is hyperintense on T1-weighted images. This is non-
specific and can also be seen in any lesion that con-
tains hemorrhage. Therefore, it is necessary to per-
form a frequency-selective fat-suppressed T1-
weighted sequence and compare it with the non-
fat-suppressed T1-weighted sequence. The fatty
portion of the lesion should lose signal on the fat-
suppressed sequence, and is diagnostic of a
myelolipoma.
In the presented case, the patient had no symp-
toms related to the adrenal masses, although their
substantial size and mass-effect exerted on the
kidneys. They were bilateral, nonfunctional and
contained no calcifications nor hemorrhagic areas.
As they met the CT and MRI diagnostic criteria
for adrenal myelolipoma, the radiologist felt confi-
dent about the diagnosis, thereby avoiding biopsy
of these lesions.
The differential diagnosis that might have been
considered includes retroperitoneal liposarcoma,
adrenal lymphoma, adrenal metastases and adrenal
adenoma. The hyperintense aspect on T1-weighted
in-phase MR-images, excluded adrenal lym-
phomas and metastases, that both have low signal
on T1-weighted in-phase MR-images. There was no
evidence of liposarcoma, because the sclerosing
components of liposarcoma are predominantly of
muscle-density although fatty components also
may be present.
Adrenal adenomas show only minor enhance-
ment following administration of gadolinium,
whereas the myelolipomas enhance strongly.
To our knowledge, there are very few other reports
of patients, presenting a combination of bilateral
adrenal myelolipomas and non Hodgkin lymphoma.
CT and/or MRI are very useful for the differential
diagnosis and can obviate the need for biopsy.
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