Adrenal Myelolipoma Management
For adrenal myelolipoma, no treatment or follow-up imaging is required regardless of size, as these are definitively benign tumors with characteristic fat content on CT imaging. 1
Diagnostic Confirmation
Myelolipomas are readily identified by their characteristic macroscopic fat content on CT imaging, which is diagnostic and distinguishes them from other adrenal masses. 1 The presence of fat within the lesion on imaging definitively establishes the diagnosis without need for biopsy. 1
Initial Hormonal Evaluation
Despite the benign radiologic appearance, a one-time hormonal evaluation is required before finalizing the management plan, as approximately 5% of radiologically benign incidentalomas have subclinical hormone production requiring treatment. 2 This includes:
- 1 mg overnight dexamethasone suppression test for autonomous cortisol secretion 2
- Plasma or 24-hour urinary metanephrines to exclude pheochromocytoma 2
- Aldosterone-to-renin ratio only if hypertension and/or hypokalemia present 2
Conservative Management Approach
Once hormonal evaluation confirms non-functionality, patients with myelolipomas do not require further follow-up imaging or functional testing, regardless of size. 1 This recommendation from the National Comprehensive Cancer Network and American College of Radiology is based on the definitively benign nature of these tumors with no malignant potential. 1
Research data supports this conservative approach, showing that among 15 patients followed for an average of 3.2 years without surgery, 13 remained asymptomatic despite variable tumor growth patterns. 3 While some tumors increased in size and others decreased or remained stable, size and growth rate did not correlate with symptom development. 3
Surgical Indications
Surgery is reserved exclusively for symptomatic tumors causing pain or mass effect. 1 Specific indications include:
- Persistent or severe abdominal/flank pain directly attributable to the mass 3, 4
- Acute presentation with hemorrhage (more likely in tumors >4 cm) 4
- Coexisting functional adrenal pathology requiring intervention 3
For growing lesions (>5 mm/year), adrenalectomy should be considered after repeating functional work-up. 5 Before surgery, complete hormonal re-evaluation including pheochromocytoma screening is mandatory to prevent intraoperative hypertensive crisis. 5
When surgery is indicated, minimally invasive laparoscopic or retroperitoneoscopic adrenalectomy should be performed when feasible, with 6 cm as a cutoff for considering open rather than laparoscopic approach. 5
Critical Pitfalls to Avoid
- Never perform adrenal biopsy - the diagnosis is made on imaging characteristics alone, and biopsy is potentially harmful and not informative. 6, 2
- Do not skip initial hormonal evaluation - undiagnosed pheochromocytoma can cause life-threatening hypertensive crisis during any procedure. 2
- Avoid indefinite surveillance imaging - once the diagnosis is confirmed and hormonal evaluation is negative, no follow-up imaging is needed unless symptoms develop. 1