The Pathological Features of Surgically Managed Adrenal Cysts: A 15-year Retrospective Review PAYAM SAADAI, M.D.,* SHALINI ARORA, M.D.,*†ALEXANDER J. GREENSTEIN, M.D., M.P.H.,* MICHAEL LEWIS, M.D.,‡ CELIA M. DIVINO, M.D.,* RICHARD A. PRINZ, M.D.,§k KAARE WEBER, M.D.*{ From the Departments of *Surgery and ‡Pathology, The Mount Sinai Medical Center, New York, New York; the †Department of Surgery, Elmhurst Hospital Center, New York, New York; the §Department of Surgery, Rush University Medical Center, Chicago, Illinois; the kDepartment of Surgery, North Shore University Health System, Evanston, Illinois; and the {Department of Surgery, White Plains Hospital, White Plains, New York Adrenal cysts are rare. Most are benign but some may contain malignancy. There are no estab- lished guidelines for their surgical management. The purpose of this study was to determine the pathological findings and likelihood of malignancy in hormonally inactive adrenal cysts after adrenalectomy. Using the pathology registries at two centers, we identified patients who un- derwent excision of an adrenal cyst between 1994 and 2009. Hormonally active cysts including pheochromocytomas were excluded. Charts were reviewed for patient demographics, pre- sentation, surgical management, and postoperative course. Of 551 adrenalectomy specimens, 15 (2.7%) contained an inactive adrenal cyst or cystic component. Cysts were more likely to be in women (67%) and right-sided (73%). Three patients (20%) were symptomatic from their lesion. Laparoscopic adrenalectomy was performed in nine patients (60%). Pathology revealed eight hemorrhagic cysts, four lymphangiomas, one hemangioma, one epithelial cyst, and one metastatic pulmonary adenocarcinoma. Laboratory and radiographic workup are essential in determining whether adrenal cysts have hormonal function or a solid tissue component before adrenalectomy. Although nonfunctional adrenal cysts may contain malignancy, most are benign. It is reasonable to observe asymptomatic, nonfunctioning, benign-appearing adrenal cysts in patients in whom follow-up can be ensured. A N INCREASING NUMBER of adrenal masses are di- agnosed incidentally during imaging studies performed for other indications. 1 These ‘‘clinically inapparent’’ masses are generally referred to as ad- renal incidentalomas, and their management has been the topic of much discussion. Current guidelines presented in a National Institutes of Health consensus statement recommend surgical excision of adrenal incidentalomas if the mass is greater than 4 cm, has features suspicious for malignancy on imaging, or if there is evidence of hormonal hypersecretion. 1, 2 Adrenal incidentalomas that do not fit this criteria are followed clinically with laboratory evaluation for hormonal overproduction and imaging to determine growth of the lesion. Adrenal cysts are a subtype of adrenal masses. The classification of adrenal cysts includes not only pseudocysts, but also epithelial cysts, endothelial cysts, and, rarely, parasitic cysts. 3, 4 Although most are benign, especially pure epithelial cysts, some may harbor malignancy. 4–6 Because of the rarity of adrenal cysts, it is unclear whether the treatment recommen- dations for adrenal incidentalomas should be extrap- olated to include the subset of lesions that are cystic. As the resolution of abdominal imaging techniques continues to improve, the prevalence of clinically in- apparent adrenal cysts will only increase. Better guidelines are therefore needed as to which adrenal cysts require surgical excision and which can be managed conservatively. The purpose of this study was to review the cases of patients with hormonally in- active adrenal cysts who were managed by adrenal- ectomy to determine the indications for excision, the operative management, the postsurgical pathological findings, and the subsequent patient course. Methods The medical records of all patients found to have pathologically evident cysts after adrenalectomy were Presented as a poster at the Pacific Coast Surgical Association 83rd Annual Meeting, Napa, CA, February 18, 2012. Address correspondence and reprint requests to Payam Saadai, M.D., The Mount Sinai Medical Center, 5 E. 98th Street, 15th Floor, Box 1259, New York, NY 10029. E-mail: payam.saadai@ mountsinai.org. 1159