Vol. 95, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1966 by The Williams & Wilkins Cc.
ADRENAL HKVIANGIO~VIA: A CASE REPORT JEROME M. WEISS
JOHN W. SCHULTE
From the Division of Urology, University of California Medical Center, San Francisco, California
Ten cases of adrenal hemangioma have been described in the literature. In 1955, Johnson and Jeppesen1 presented an excellent review of the subject and described the first adrenal hemangioma to be removed surgically (the others had been found at autopsy). Our report is of the surgical removal of another of these rare lesions. CASE REPORT
A 70-year-old white man entered Fort Miley Veterans Administration Hospital on February 8, 1965 with acute urinary retention. Except for symptoms of prostatism that had progressively worsened over the previous 5 years, he had no history or symptoms of urinary tract disease and had been in excellent health with no serious medical or surgical illnesses. About 10 to 15 years prior to admission he had been struck on his right flank
FIG. 1. Excretory urogram shows calcific adre-
FIG. 2. A, arteriogram shows single artery approaching mass from superior direction. Two vessels that appear to arise from renal artery do not go to adrenal mass. B, angionephrotomogram outlining adrenal mass.
by a limb that he had been cutting from a walnut tree. This was followed by flank swelling and pain but the injury did not prevent him from continuing his work and there was no associated gross hematuria. Accepted for publication July 23, 1965. 1 Johnson, C. C. and Jeppesen, F. B.: Hemangioma of the adrenal. J. Urol., 74: 573-577, 1955.
The patient was normotensive (110/60 mm. Hg) and displayed none of the signs of hyperadrenalism. There were no abdominal bruits. A urinalysis revealed excessive amounts of blood cells and rods. Result of the phenolsulfonphthalein dye excretion test was 45 per cent in 1 hour by catheter collection. The serum. creatinine 604
value was 1.2 mg. per cent and serum electrolytes were normal. On February 11 a simple perineal prostatectomy was done for a 55-gm. benign hyperplastic gland. The convalescence was uneventful. Unfortunately, routine excretory urograms were not obtained until 5 clays postoperatively. These showed a large right calcific suprarenal mass which was depressing the kidney (fig. 1). Arteriograms and angionephrotomograms confirmed the presence of a solid mass above the right kidney which did not appear to be excessively vascularizecl (fig. 2). The preoperative diagnosis was a non-hormonal adrenal tumor.
FIG. 3. Gross specimen of adrenal hemangioma
On February 25 a right transthoracic extraperitoneal adrenalectomy was clone. The adrenal mass was easily freed from the superior pole of the kidney. It was supplied by a single artery approaching it from above. The blue-black dumbbell-shaped mass rn.easurecl 11 by 7 by 6 cm. and weighed 276.5 gm. (fig. 3). The cut surface had a rim of thickened adrenal cortex with a central encapsulated necrotic core of white to yellow-green tissue containing calcification (fig. 4). Microscopically, there was cortical hyperplasia with massive central hemorrhage and necrosis-containing areas of cavernous hemangioma (fig. 5). The patient had an unevent-
hemangioma; cut surface
FIG. 5. Microscopic section shows hyperplastic adrenal cortex (right) with calcifications, and hemangiomatous channels (left).
WEISS AND SCHULTE
ful convalescence and was discharged from the hospital after 1 week. DISCUSSION
The adrenal hemangioma herein reported was asymptomatic and was discovered on routine excretory urography. Previous flank trauma may have been the etiologic factor responsible for the hemorrhage. The pathologic features parallel those of the mass reported by Johnson and Jeppesen which exhibited adrenal hyperplasia. 1 These authors postulated that the hyperplasia was secondary to the increased hemangiomatous blood supply. The adrenal hemangioma removed in our case is the largest reported (11 by 7 by 6 cm.); in the case reported by Johnson and Jeppesen the mass was 6.5 by 4 by 3 cm. Other authors found associated hemangiomas involving the liver, ovaries, uterus and skull. There are 2 reports of bilateral adrenal involve-
ment as well as two of malignant hemangioblastomas. It is possible that some cases of adrenal hemangioma have been misdiagnosed. Adderley and associates feel that some acute hemorrhagic cysts may in actuality be hemangiomas that have been completely destroyed by the bleeding. 2 SUMMARY
Routine excretory urograms of a 70-year-old white man with a previous history of flank trauma revealed a right adrenal mass. On surgical removal, the mass was a large organized hematoma arising from a cavernous hemangioma. The patient had no signs of hyperadrenalism or urological disorders other than progressive prostatism for which he was treated surgically. The case is presented because of its rarity. It is suggested that some acute hemorrhagic adrenal cysts may actually have their origin in such a lesion. 2 Adderley, C.H., Grime, R. T. and Whitehead, R.: Adrenal cysts. Brit. J. Surg., 42: 389-394, 1955.