What is the recommended treatment for a 2.6 cm myelolipoma of the adrenal gland?

Management of 2.6 cm Adrenal Myelolipoma

A 2.6 cm adrenal myelolipoma with radiographic features consistent with myelolipoma and no symptoms requires only repeat imaging in 6-12 months, with no further follow-up needed if the lesion remains stable. 1

Initial Management Algorithm

Confirm Diagnosis with Imaging Characteristics

• Myelolipomas are diagnosed by their characteristic appearance on CT showing macroscopic fat content (negative Hounsfield units in fatty components), which distinguishes them from other adrenal masses 1, 2
• Once radiographically confirmed as myelolipoma, no biopsy is needed as these are benign tumors composed of mature adipose tissue and hematopoietic elements 3, 4

Size-Based Decision Making

• At 2.6 cm, this lesion falls well below the 4 cm threshold where most guidelines recommend more intensive surveillance 2, 5
• Myelolipomas of any size without symptoms can be managed conservatively with imaging surveillance 1
• The American Urological Association specifically states that small masses containing macroscopic fat (myelolipomas) do not require additional follow-up after initial characterization 2, 5

Surveillance Protocol

First Follow-Up Imaging

• Repeat imaging at 6-12 months to establish stability 1
• If the lesion is unchanged at 6-12 months, no further follow-up is required 1

Growth Rate Thresholds

• If growth is <3 mm/year (or <1 cm/year), no further imaging or intervention is needed 1, 2
• If growth exceeds 1 cm in 1 year, consider adrenalectomy due to risk of complications 1

When Surgery Is Indicated

Absolute Indications for Adrenalectomy

• Development of symptoms (flank pain, abdominal discomfort) 1, 3, 4
• Rapid growth >1 cm per year 1
• Size >6 cm due to increased risk of spontaneous rupture and life-threatening hemorrhage 3, 6, 7
• Inability to definitively distinguish from malignancy on imaging 6

Surgical Approach

• Laparoscopic adrenalectomy is preferred for smaller, contained lesions 1
• Simple excision is curative; radical surgery is unnecessary for myelolipoma 8

Critical Pitfalls to Avoid

Do Not Over-Treat Small Asymptomatic Lesions

• Myelolipomas are benign, hormonally inactive tumors that do not require surgery when small and asymptomatic 3, 4, 8
• Most myelolipomas remain stable or grow very slowly 3

Do Not Skip Initial Hormonal Evaluation

• Although myelolipomas themselves are non-functioning, initial hormonal screening should still be performed to exclude coexisting functional adrenal pathology 2, 4
• Approximately 5% of radiologically benign incidentalomas have subclinical hormone production 2

Recognize High-Risk Features Requiring Surgery

• Symptomatic myelolipomas should be resected without delay, especially those causing pain, as this indicates tumor bulk, necrosis, or impending hemorrhage 3, 4, 6
• Giant myelolipomas (>6 cm) are at high risk of spontaneous rupture with hemorrhage and cardiovascular shock 3, 6, 7

Special Considerations

Patient-Specific Factors

• Obesity and hypertension are frequently associated with adrenal myelolipomas 3, 8
• Younger patients (<40 years) may warrant closer surveillance due to higher baseline malignancy risk in this age group, though myelolipomas remain benign 2

Cost-Effectiveness

• For a 2.6 cm asymptomatic myelolipoma, observation is both clinically appropriate and cost-effective compared to surgery 6
• Surgery becomes cost-effective when lesions are symptomatic or when diagnostic uncertainty exists 6