CYSTS OF THE ADRENAL GLAND VWITH CASE REPORT *

DEzXr L. Rzm{ANx, M-D., and WITi1-TA L. GuTrON, MD.

(From the Department of Pathology, School of Medicine, University of Marylaxd,
Baltimore I, Md.)
In the past 20 years only four papers on adrenal cysts have appeared
in American literature. As there is a scarcity of material on this sub-
ject, this report is believed to be justified.
The mechanism by which adrenal cysts are formed does not coincide
with the manner in which true retention or inclusion cysts are de-
veloped. They result usually from ectasia of pre-existing vessels ' or
cystic degeneration of hematomas or adenomas.2 Therefore, they are
better called pseudocysts.
A classification of these lesions by Levison 3 includes true glandular
cysts, cystic adenomas, cystic lymphangiomas, pseudocysts, and
echinococcus cysts. The first two classes are excluded from this paper
because satisfactory reports and descriptions were not found in the
literature. Echinococcus cysts of the adrenal gland are exceedingly
rare. From a study of i,617 cases of echinococcosis by Barnett,4 it was
shown that the adrenal gland is involved in much less than 0.5 per cent.
Dew,5 in his exhaustive monograph, cited only a single case of echino-
coccus disease involving the adrenal gland and in this the lesion occu-
pied a position in the capsule.
It also has been suggested that cysts of the adrenal glands are of a
secondary nature. According to Rabson and Zimmerman,' cystic
lymphangiomas of the adrenal gland should be classed more accurately
as lymphangiectasias. They concluded that lymphangiomas and hem-
angiomas are rare in the suprarenal body and that hamartomas are
the most common cystic lesions seen in the adrenal gland. In this cate-
gory the cases of Ballance 6 and of Rabson and Zimmerman may be in-
cluded. Degeneration of hematomas resulting in pseudocyst formation
was exemplified by the cases of Iglitsyn,2 Pearse,7 and most probably
by that of Levison.3
Cysts of the suprarenal gland manifest themselves clinically in in-
sidious and varied ways. That in the case of Rabson and Zimmerman 1
and the one recorded in this paper were found at autopsy and had ap-
parently caused no disturbances during life. In the case reported by
Ballance,6 the patient, a 49-year-old white female, complained of sense
of pressure, "indigestion," and back pain which passed around to the
epigastrium. This complaint had existed for 5 years. The cyst in this
case was externally palpable. Acute abdominal pain, shock, and palp-
* Received for publication, May I5, I946.
479
480 REIMANN AND GUYTON

able tumor which became apparent over a 3-day period were seen in a
case reported by Pearse.7 An erroneous diagnosis of "gallstones" and
"pleurisy" had been made in this case. Levison'I3 patient manifested
a pluriglandular syndrome which led to impressions of parathyroid and
thyroid dysfunctions.
The gross appearance of adrenal cysts varies as does the pathogene-
sis. Those cysts resulting from ectasia of lymph channels consist of
numerows locules that contain clear or milky fluid. The compartments
reportedly may vary from i to 13 mm.- Cysts measuring 23 by 15 cm.
and containing i Y4 liters of fluid have been reported.6 The walls of the
lymphangiectatic cysts are delicate and smooth.
The hematocysts have irregularly pigmented walls which may con-
tain foci of calcareous material.3 This is true whether the hematocysts
develop in normal adrenal gland or adenomatous areas. Cysts of this
type may contain bloody or reddish brown fluid. Ballance 6 cited the
case of Doran in which the cyst contained 250 cc. of bloody fluid and
that of Hartwell in which the cyst contained 3 liters of reddish brown
fluid.
The following case is an example of lymphangiectasia of the adrenal
gland. REPORT OF CASE

M. R. (U. H. no. 86984), was a white female, 58 years of age, who was admitted
with complaints of generalized abdominal pain, nausea, and vomiting of 8 days'
duration. Physical and roentgenologic examinations of the abdomen led to a
correct diagnosis of periappendicular abscess with partial intestinal obstruction.
The chemical findings in the blood were normal with the exception of a decreased
plasma chloride level and moderate hypoproteinemia. There was no clinical evi-
dence of endocrinopathy.
Operative drainage of the abscess was undertaken. Postoperatively, the patient
continued to suffer the effects of peritonitis. Treatment with penicillin and sulfona-
mide compounds effected no improvement. The patient died on the I4th postopera-
tive day.
The findings at autopsy were consistent with the clinical diagnosis.
The cystic right adrenal gland could in no way be related to the ante-
mortem condition of the patient. The left adrenal gland was normal.
The right suprarenal body measured 7 by 2.4 cm. Cysts were ex-
ternally apparent. On section the medulla was seen to contain smooth-
walled cysts which ranged from I to I3 mm. in diameter. The fluid
within the cysts was clear when fresh but became opaque and jelly-like
in io per cent formaldehyde. There was no gross evidence of hemor-
rhage. The cysts had obviously distended the overlying cortex. Out-
side the walls of the larger cysts bits of compressed adrenal cortex were
seen.
Microscopically, the cysts appeared as widely dilated spaces lined by
 CYSTS OF THE ADRENAL GLAND 481

endothelium and filled with acellular, eosinophilic albuminous precipi-

tate. Connective tissue separated the cysts. Calcareous deposits were
present in the fibrous areas. The surrounding adrenal cortex showed
pressure atrophy. In the better preserved portions of the cortex, glo-
merular, fascicular, and reticular zones could be discerned. The corti-
cal cells were pale, granular, shrunken, and poor in lipoid material.
SUMARY
Cysts of the adrenal glands are exceedingly rare. The most com-
monly reported types are hematocysts and lymphangiectatic cysts. A
case of lymphangiectatic cysts of the right adrenal gland is reported.
REFERENCES
i. Rabson, S. M., and Zimmerman, E. F. Cystic lymphangiectasia of the adrenal.
Arch. Path., 1938, 26, 869-872.
2. Iglitsyn, N. M. [Blood cysts of suprarenals.] Kkirwgiya, I937, no. i, II5-
121.
3. Levison, P. A case of bilateral adrenal cysts. Endocrinology, 1933, 17, 372-376.
4. Bamett, L. Hydatid cysts: their location in the various organs and tissues of
the body. Australan & New Zealand J. Surg., I942-43, 12, 240-248.
S. Dew, H. R. Hydatid Disease, Its Pathology, Diagnosis and Treatment. The
Australasian Medical Publishing Co., Ltd., Sydney, 1928, p. 406.
6. Ballance, H. A. Cyst of the right supraenal capsule removed by operation.
Brit. M. J., 1923, I, 926-928.
7. Pearse, H. E. Cysts of the adrenals: report of a case. Tr. West. S. A., I9I6,
26, 329-336.

[Ilustrations folo]
 DESCRIPTION OF PLATE

PLATE 8o
FIG. i. This photograph shows cross sections of the lymphangiectactic cystic
adrenal. The largest cyst is seen in the upper pole of the adrenal gland pictured
on the left. Many smaller cysts filled with mucinous material are seen in the
midportion, and normal adrenal cortex is seen in the lower portion of the
same section.
FIGS. 2 and 3. Endothelium-lined spaces filled with precipitated albuminous mate-
rial are shown with recognizable adrenal cortex. Hematoxylin and eosin stain.
X Ioo.

482
 _i.fe:ti*;.J'
AMEmCAN JOURNAL OF PATHOLOGY. VOL. XII PLATE 80

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Reimann and Guyton Cysts of the Adrenal Gland

483