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Adrenal cysts: an emerging condition

Nature Reviews Endocrinology volume 19, pages 398–406 (2023)Cite this article

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Abstract

Adrenal cysts are rare lesions representing approximately 1–2% of adrenal incidentalomas. The majority of these rare lesions are benign. Rarely, phaeochromocytomas and adrenal malignant masses can present as cystic lesions and can occasionally be difficult to distinguish from benign cysts. Histologically, adrenal cysts are subdivided into pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. The radiological appearance of an adrenal cyst is generally similar to that of cysts in the kidney. They are thus well demarcated, usually rounded, with a thin wall and homogenous internal structure, low attenuating (<20 Hounsfield Units) on CT, low signalling on T1-weighted MRI sequences and high signalling on T2-weighted MRI sequences, and anechoic or hypoechoic on ultrasonography. Benign adrenal cysts have a slight female predominance and are usually diagnosed between the ages of 40 and 60. Most adrenal cysts are asymptomatic and are detected incidentally, although very large adrenal cysts can lead to mass effect symptoms, with surgery required to alleviate the symptoms. Thus, conservative management is usually recommended for asymptomatic cysts. However, when uncertainty exists regarding the benign nature of the cyst, additional work-up or follow-up is needed. The management of an adrenal cyst should preferably be discussed at an adrenal multidisciplinary team meeting.

Key points

  • Adrenal cysts are rare lesions representing around 1–2% of adrenal incidentalomas.

  • Most adrenal cystic lesions are benign but, rarely, phaeochromocytomas and adrenal malignant masses can present as cystic lesions.

  • The radiological appearance of a benign adrenal cyst is generally similar to that of cysts in the kidney.

  • The management of an adrenal cyst should preferably be discussed at an adrenal multidisciplinary team meeting and hormonal screening is recommended.

  • Most benign adrenal cysts are asymptomatic and are detected incidentally, but very large benign adrenal cysts can lead to mass effect symptoms, requiring surgery to alleviate the symptoms.

  • Conservative management is usually recommended for an asymptomatic benign adrenal cyst; however, when its benign nature is unclear, follow-up CT or MRI, PET, steroid profiling, or adrenalectomy should be considered.

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Fig. 1: Histopathological features of adrenal pseudocyst.
Fig. 2: Histopathological features of adrenal endothelial (vascular) cyst.
Fig. 3: Differential diagnoses of adrenal cystic lesions.
Fig. 4: Transverse CT and MRI images of benign adrenal cysts.
Fig. 5: Proposed flowchart for the clinical management of patients with adrenal cysts.

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Authors and Affiliations

  1. Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden

    Jan Calissendorff & Henrik Falhammar

  2. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

    Jan Calissendorff & Henrik Falhammar

  3. Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden

    C. Christofer Juhlin

  4. Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden

    C. Christofer Juhlin

  5. Department of Surgical Sciences, Radiology & Molecular Imaging, Uppsala University, Uppsala, Sweden

    Anders Sundin

  6. Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Irina Bancos

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Nature Reviews Endocrinology thanks Henrik Olsen; Hironobu Sasano Sasano; Carla Scaroni, who submitted a co-report with Alessandro Mondin; and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Calissendorff, J., Juhlin, C.C., Sundin, A. et al. Adrenal cysts: an emerging condition. Nat Rev Endocrinol 19, 398–406 (2023). https://doi.org/10.1038/s41574-023-00835-2

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