|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 29-30
Combined adrenal and mediastinal cystic lesion
K. V. S Hari Kumar1, KP Shijith2, Vijay Dutta3
1 Department of Endocrinology, Command Hospital, Chandimandir, Panchkula, Haryana, India
2 Department of Radiology, Command Hospital, Chandimandir, Panchkula, Haryana, India
3 Department of Pulmonology, Command Hospital, Chandimandir, Panchkula, Haryana, India
|Date of Web Publication||12-Dec-2014|
K. V. S Hari Kumar
Departments of Endocrinology, Command Hospital, Chandimandir, Panchkula 134 113, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar KH, Shijith K P, Dutta V. Combined adrenal and mediastinal cystic lesion
. J Assoc Chest Physicians 2015;3:29-30
Cystic lesions of the adrenal grand are rarely seen in the clinical practice and often pose a diagnostic dilemma. The difficulties in the diagnosis are further compounded by the presence of another cyst at a different anatomical location.  We present a young adult with incidentally discovered cystic lesions on either side of the diaphragm in the right adrenal gland and posterior mediastinum.
A 32-year-old male patient presented with nonspecific pain abdomen for 1 week duration. Clinical examination was not contributory and he was given a course of antacids and prokinetic agents. Ultrasonography abdomen revealed a cystic lesion over right adrenal and he was referred to our center. The patient denied history of weight gain, palpitations, and never recorded high blood pressure in the past. Other history was not contributory. Examination revealed normotensive individual with no neurocutaneous markers and positive findings. Computed tomography (CT) scan of the abdomen revealed the presence of a well-defined lobulated cystic lesion seen between the medial and lateral limbs of the right adrenal gland [Figure 1]. Similar lesion is seen in the left hemithorax in left lower dorsal paravertebral region without intraspinal extension. The lesion showed small calcification specks without post-contrast enhancement.
|Figure 1: Coronal (a) and axial (b and c) computed tomography (CT) scan abdomen showing the cystic lesion of right adrenal (black arrow) and the posterior mediastinum (white arrow)|
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His investigations revealed normal hematological and biochemical parameters. Serum cortisol was 0.5 μg/dL after overnight dexamethasone (normal <1.8 μg/dL) and 24 h urine metanephrines was normal. Serology for the Echinococcal antigen (5.7 IU/ml, normal <10) and the entire tumor marker screen (CA 19-9, CA-125, alpha-fetoprotein (AFP), and carcinoembryonic antigen (CEA) was negative. The patient did not give consent for the aspiration of the cyst for diagnostic purpose. However, the characteristics of the cyst and the location lead us to the most probable diagnosis of lymphangioma. In view of the asymptomatic nature of the cysts, we did not consider the option of therapeutic removal and the patient is under regular follow-up for further monitoring.
Cystic adrenal lymphangiomas are rare benign lesions and are reported in about 60 patients only till date. Lymphangiomas are the result of developmental malformations of the lymphatic system and are common in the neck and axilla.  They are rarely seen in the chest and abdomen as observed in our case. Adrenal lymphangioms are diagnosed incidentally and the symptoms are related to the structural alterations rather than functional changes. The differential diagnosis of adrenal cystic lesions involves hydatid cyst, lymphangioma, cystic metastases, and pheochromocytoma with cystic changes.  Our patient had no features to suggest other etiologies except for lymphangioma. Lack of confirmation by the histopathology is the main limitation of our report.
The unusual feature in our patient is the combination of an abdominal and intrathoracic lymphangioma. The concurrent existence of thoracic and abdominal lesions suggests the systemic lymphatic origin of the tumor.  The treatment of lymphangiomasis complete surgical excision whenever required. Indications for surgeryinclude large, symptomatic cyst, complicated, functional cyst, and all cysts with probable features of malignancy. Our patient did not have any indications for the surgical removal and hence, we plan to follow conservatively.
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