Laparoscopic adrenalectomy for a giant adrenal teratoma: A case report and review of the literature

Abstract

Introduction and importance: Teratomas typically are benign gonadal neoplasms, arising from more than one embryonic germ layer. Extragonadal teratomas are rare and primary adrenal teratomas more so, with few documented cases. We present one such case, diagnosed via CT, resected via laparoscopic adrenalectomy, and confirmed on histology. To the best of our knowledge, this is the first case documented in the Caribbean.

Case presentation: A 38-year-old obese female with restrictive lung disease presented with right back/flank pain due to a non-functional 10.5 cm right adrenal mass on CT, likely a giant myelolipoma. Further radiologic review suggested this was instead a mature adrenal teratoma. She underwent a laparoscopic adrenalectomy and histology confirmed a mature adrenal teratoma.

Clinical discussion: Most adrenal tumours are incidentalomas and are usually benign adenomas. Primary adrenal teratomas account for 1 % of teratomas and 0.13 % of adrenal tumours. They may be mature or immature; the latter carries a greater risk of malignancy. Benign adrenal teratomas are typically non-functional and commonly mistaken for myelolipomas on imaging. Adrenalectomy is required due to the risk of malignant transformation. The laparoscopic approach depends on size, localized tissue invasion and technical considerations, but offers advantages for the patient if possible.

Conclusions: Though uncommon, preoperative radiologic diagnosis of an adrenal teratoma is possible and should be completely resected after a functional workup. A laparoscopic adrenalectomy is preferred once this can be done safely, even when very large, with surgical and oncologic outcomes equivalent to an open approach combined with the known advantages of laparoscopic surgery.

Keywords: Adrenal; Case report; Laparoscopic adrenalectomy; Mature; Myelolipoma; Teratoma.

Fig. 1

A - Axial and B - sagittal abdominopelvic CECT demonstrating a well-defined right adrenal gland mass containing predominantly fat density, as well as intra-lesional mural soft-tissue and rim-like peripheral calcification.

Fig. 2

Adrenal tumour in-tact prior to dissection (A) with liver superiorly (B).

Fig. 3

Adrenal tumour (A) and its relations to the inferior vena cava (B), right renal vein (C) and liver (D).

Fig. 4

Tumour bed post-resection showing liver (A), upper pole of right kidney (B), inferior vena cava (C) and right renal vein (D) all intact after complete excision of the tumour.

Fig. 5

A - Squamous epithelium-lined soft tissue with sebaceous units; and B - dense fibrosis with bone and bone marrow with maturing trilineage haematopoiesis (top left) and unremarkable adrenal gland parenchyma (bottom right).