Surgery for symptomatic bilateral giant adrenal cyst: Functional preservation vs oncological appropriateness

Background: Adrenal cysts are uncommon and generally asymptomatic, thus often discovered only incidentally. In the case described here, two giant bilateral adrenal cysts were diagnosed in an emergency setting based on the onset of acute compressive symptoms. Only after a complete diagnostic workup aimed at excluding any suspicion of malignancy, the patient underwent elective and adrenal-preserving surgery. Case description: A 26-year-old man was hospitalized in the emergency room for abdominal pain and dyspepsia. The ultrasound (US) scan showed two giant masses of both the adrenals. The workup allowed a diagnosis of nonfunctioning giant adrenal cysts, one with evidence of intracystic bleeding. Bilateral surgery was indicated and, on both sides, a wide resection of the cyst wall was performed laparoscopically, trying to preserve the adrenal function. At follow-up, the patient shows no evidence of recurrent disease. Conclusion: Despite an acute onset of compressive symptoms that led the patient to hospitalization in an emergency setting, the symptoms of the patient were cured at first. A correct and thorough subsequent workup was then performed that allowed to make a diagnosis of bilateral giant adrenal cysts without any sign of malignancy. This diagnosis indicated a bilateral adrenal-sparing decompressive procedure that, after follow-up, resulted in long-term cure. Clinical significance: A correct imaging played a key role in planning the treatment since it could exclude any suspicion of malignancy, thus allowing to indicate a “functional” approach aimed at avoiding a lifelong and difficult-to-manage substitutive therapy in a young patient.