Large sized bilateral adrenal myelolipoma with spontaneous retroperitoneal hemorrhage: a case series

Adrenal myelolipomas are rare, benign adrenal tumors typically discovered incidentally. Histologically, it comprises mature adipose tissue and normal hematopoietic elements (erythroid, myeloid, and megakaryocytic precursors). Although often asymptomatic, larger tumors may present with mass effect, retroperitoneal hemorrhage, or spontaneous rupture requiring surgical intervention.

Both patients, a 51-year-old male and a 57-year-old female, presented with left-sided flank pain and imaging findings of large left adrenal masses (>10 cm) with retroperitoneal hemorrhage. Hormonal assays were negative, ruling out functional adrenal tumors. In both cases, laparoscopic adrenalectomy was attempted but converted to open surgery due to tumor size, friability, and intraoperative challenges. Bilateral adrenal myelolipoma and dense adhesion with the tail of the pancreas and splenic hilum was present in the first case.

Spontaneous rupture of large-sized adrenal myelolipoma occurs, primarily in tumors >10 cm, leading to hemorrhagic events. Imaging, particularly CT and MRI, aids diagnosis, revealing characteristic fat-rich lesions. Management depends on size, symptoms, and imaging findings. Tumors <10 cm are typically treated laparoscopically, while larger or invasive ones require open surgery. The prognosis is excellent, with minimal follow-up needed for most cases. For large tumors, periodic ultrasounds and clinical reviews are advised post-surgery.

Most cases of adrenal myelolipomas are small, unilateral, and non-adherent to adjacent structures, but some may be bilateral, large, or adherent to nearby organs, leading to symptoms and intraoperative challenges. This case series emphasizes the complications associated with large adrenal myelolipomas and underscores the importance of careful evaluation, planning, and surgical approach.