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Adrenal Hemangioma: An Unusual Adrenal Mass Delineated with Magnetic Resonance Imaging
0022-534 7/91/1462-0400$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 146, 400-402, August 1991 Printed in U.S.A.
Case Reports ADRENAL HEMANGIOMA: AN UNUSUAL ADRENAL MASS DELINEATED WITH MAGNETIC RESONANCE IMAGING STANTON C. HONIG, M. SCOTT KLAVANS, CHARLES HYDE AND MIKE B. SIROKY From the Departments of Urology and Radiology, Veterans Affairs Medical Center, Boston, Massachusetts
ABSTRACT
Adrenal hemangioma should be included in the differential diagnosis of any large calcified adrenal mass. We report to our knowledge the eighth surgically removed lesion and describe its appearance on magnetic resonance imaging. This imaging includes features seen in hemangiomas elsewhere, in particular a het�rogeneous mass with enhancing peripheral high intensity foci on Tl images. KEY WORDS:
adrenal glands, hemangioma, magnetic resonance imaging
Hemangiomas are well circumscribed tumors comprised of closely adjacent vascular channels of varying size that are lined with a single layer of endothelium. Most commonly found in the liver, they have also been described at various genitourinary sites, including the prostate,1 ureter,2 bladder3 and perineum.4 To our knowledge, we describe case 8 of hemangioma of the adrenal gland removed surgically since the first surgical case reported in 1955.5 Fewer than 20 cases have been reported in the literature.5-10 CASE REPORT
A 73-year-old man presented to the emergency room in urinary retention and he underwent catheterization. Medical history included hypertension controlled with hydrochlorothi azide and clonidine, and severe chronic obstructive pulmonary disease. Physical examination revealed a well developed man with a palpable nontender abdominal mass and an enlarged prostate without nodularity. The patient manifested no clinical signs of adrenal hyperfunction. All admitting laboratory values were within normal limits, including blood urea nitrogen (15 mg./dl., normal range 7 to 24 mg./dl.) and serum creatinine (0.9 mg./dl., normal range 0. 7 to 1.7 mg./dl.). Hormonal studies did not reveal evidence of adrenal medullary or cortical hyper function. Urinalysis showed a specific gravity of 1.023, pH 6.0, trace protein and no white or red blood cells. As part of an evaluation of the upper urinary tract before prostatectomy, an excretory urogram (IVP) was performed (fig. 1), revealing a normal collecting system on the right side and a large mass on the left side. The mass depressed but did not distort the caliceal system and contained multiple small calcifications. A contrast enhanced computerized tomogram (CT, fig. 2) confirmed the presence of the mass but could not determine whether the mass was renal or suprarenal. Renal ultrasound revealed the mass to be suprarenal in origin. Magnetic resonance imaging (MRI) confirmed the mass to be separate from and superior to the kidney (fig. 3). MRI was performed in sagittal, coronal and axial planes. Imaging included Tl weighted images (with and without gadolinium, Gd) and T2 weighted images. On Tl weighted images there was a large suprarenal mass with areas of high signal intensity indicating focal hemorrhage. Peripheral high signal intensity lesions that enhance with Gd are compat ible with venous sinuses. On T2 weighted images there was marked signal heterogeneity (believed to be due to calcifica tions, hemorrhage and necrosis). The patient was explored via a left thoracoabdominal inci sion. The mass was well encapsulated and was easily separated from the upper pole of the left kidney. The blood supply entered the mass posteromedially from the aorta. The mass was re moved in toto without untoward incident. Convalescence was uneventful and the patient was discharged from the hospital
FIG. 1. IVP demonstrates large soft tissue mass with calcifications depressing but not distorting collecting system.
Accepted for publication January 18, 1991.
FIG. 2. CT scan of heterogeneous, calcified suprarenal mass 400
401
HONIG AND ASSOCIATES
FIG. 3. MRI. A, Tl sagittal images show heterogeneous suprarenal mass, isointense with liver. B, Tl coronal images after injection of Gd DTPA show peripheral high signal foci (arrows) with enhancement representing venous sinuses.
multiple arteries and veins. There was evidence of recent and old organized thrombi (fig. 4). There were large areas of necrosis but no evidence of dysplastic or neoplastic changes. DISCUSSION
FIG. 4. Large adrenal mass shows normal adrenal tissue (arrow) with evidence of extensive calcification and thrombosis.
11 days postoperatively. Transurethral resection of the prostate was done 2 weeks postoperatively. Pathology. The ovoid pink mass weighed 600 gm. (fig. 4). On gross examination the mass was well encapsulated with some patchy yellow areas. The adrenal cortex and medulla were identified at the superior pole of the mass. Microscopically, the mass was composed of large cavernous sinuses connected to
We found 7 previous reports in the literature of a surgically removed hemangioma of the adrenal gland, the largest weighing 6,000 gm.8 All cases were discovered incidentally during routine physical examination or evaluation for hypertension (see table). None of the tumors was functioning. Of the cases 75% involved patients in the seventh decade. Although in all cases the mass was first appreciated on an IVP, the radiological studies that best delineated the suprarenal origin of the mass were those able to image the gland in a coronal plane, that is ultrasonog raphy and MRI. Calcifications on plain abdominal films were noted in 7 of 8 cases. Arteriography was performed in 3 cases of adrenal heman gioma.8 The typical findings are dilated, crowded vessels that fill large irregular, well defined sinusoidal spaces and retain contrast agents for as long as 20 seconds. However, as in the liver, these findings are only suggestive and not pathognomonic of a hemangioma.11 CT shows a large adrenal mass with calci fications.10 MRI has assumed an increasing importance in the radio graphic evaluation of adrenal masses.12 On Tl weighted images the adrenals appear as areas of moderate signal intensity, isointense with the liver. Pathological processes affect the signal in characteristic patterns but these are rarely pathog nomonic. For example, adrenal metastases are typically isoin tense to hypointense on Tl and hyperintense on T2 images. Adrenocortical carcinomas are typically hyperintense on Tl and T2 images. However, low signal intensity in some cases has been reported. MRI is exquisitely sensitive to hemorrhage, which affects the signal in a complex manner that is dependent on the chronicity of the hemorrhage. MRI is insensitive to
Hemangioma of adrenal gland Reference
Age (yrs.)
Presentation
Calcification
IVP
Angiogram
MRI
Johnson and Jeppesen' Weiss and Schulte' Rothberg et al8 Ruebel' Vargas9 Lee et al1° Present study
46 70 72 74 75 76 59 73
Hypertension Retention Hypertension Hematuria Prostatism Abdominal calcification Abdominal calcification Retention
No information Yes Yes No Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes
No No Yes Yes No Yes No No
No No No No No No No Yes
402
ADRENAL HEMANGIOMA
calcifications, which have no signal and appear as signal voids. exploration and removal of the lesion are still necessary for To our knowledge, the appearance of an adrenal hemangioma definitive diagnosis. on MRI has not been reported previously. Cavernous heman REFERENCES giomas of the liver are notable for a long T2 relaxation time 1. Sundarasivarao, D., Banerjea, S., Nageswararao, A. and Rao, N. (hyperintense signal). The signal is heterogeneous due to areas V.: Hemangioma of the prostate: a case report. J. Urol., 110: 10 of thrombosis and slow venous flow. The Tl image is isoin 708, 1973. tense to hypointense with respect to normal liver. After admin 2. Uhlir, K.: Hemangioma of the ureter. J. Urol., 110: 647, 1973. istering Gd-diethylenetriaminepentaacetic acid (Gd-DTPA), 3. Esguerra, A., Carvajal, A. and Mouton, H.: Pelvic arteriography in high intensity foci appear in the periphery on Tl images. Many the diagnosis of hemangioma of the bladder. J. Urol., 109: 609, 1973. of the features of liver hemangiomas were seen in this case. The adrenal was predominantly isointense with the liver. The 4. Redman, J. F., Bissada, N. K. and Williams, E. W.: Cavernous hemangioma presenting as a perinea! mass in a man. J. Urol., correlation with pathological findings was good. Areas of ne 112: 766, 1974. crosis and hemorrhage were identified on Tl sequences, and C. C. and Jeppesen, F. B.: Hemangioma of the adrenal. focal calcifications were suggested on Tl and T2 sequences. 5. Johnson, J. Urol., 74: 573, 1955. The peripheral signals that enhanced with Gd must be vascular 6. Weiss, J. M. and Schulte, J. W.: Adrenal hemangioma: a case and certainly represent venous sinuses. Enhancement with Gd report. J. Urol., 95: 604, 1966. is the finding most characteristic of a hemangioma. 7. Ruebel, A. A.: Adrenal hemangioma. Urology, 2: 289, 1973. Ruling out carcinoma in a nonfunctioning adrenal mass 8. Rothberg, M., Bastidas, J., Mattey, W. E. and Bernas, E.: Adrenal hemangiomas: angiographic appearance of a rare tumor. Radiol preoperatively remains difficult. Our preoperative diagnosis ogy, 126: 341, 1978. was a nonfunctioning adrenocortical carcinoma. Calcifications 9. Vargas, A. D.: Adrenal hemangioma. Urology, 16: 389, 1980. are present in benign and malignant lesions. Larger heman giomas are easily confused with adrenal carcinomas or pheo 10. Lee, W. J., Weinreb, J., Kumari, S., Phillips, G., Pochaczevsky, R. and Pillari, G.: Case report. Adrenal hemangioma. J. Comput. chromocytomas. Radiological features suggestive of heman Assist. Tomogr., 6: 392, 1982. gioma are calcification and delayed filling with contrast me 11. Abrams, R. M., Beranbaum, E. R. and Santos, J. S.: Angiographic dium on angiography. The MRI finding of a mass with a features of cavernous hemangioma of the liver. Radiology, 92: heterogeneous signal characterized by foci of high intensity 308, 1969. that enhance after Gd administration is, based on our experi 12. Glazer, G. M.: MR imaging of the liver, kidneys, and adrenal glands. Radiology, 166: 303, 1988. ence, confirmation that the lesion is a hemangioma. However,
Vol. 146, 400-402, August 1991 Printed in U.S.A.
Case Reports ADRENAL HEMANGIOMA: AN UNUSUAL ADRENAL MASS DELINEATED WITH MAGNETIC RESONANCE IMAGING STANTON C. HONIG, M. SCOTT KLAVANS, CHARLES HYDE AND MIKE B. SIROKY From the Departments of Urology and Radiology, Veterans Affairs Medical Center, Boston, Massachusetts
ABSTRACT
Adrenal hemangioma should be included in the differential diagnosis of any large calcified adrenal mass. We report to our knowledge the eighth surgically removed lesion and describe its appearance on magnetic resonance imaging. This imaging includes features seen in hemangiomas elsewhere, in particular a het�rogeneous mass with enhancing peripheral high intensity foci on Tl images. KEY WORDS:
adrenal glands, hemangioma, magnetic resonance imaging
Hemangiomas are well circumscribed tumors comprised of closely adjacent vascular channels of varying size that are lined with a single layer of endothelium. Most commonly found in the liver, they have also been described at various genitourinary sites, including the prostate,1 ureter,2 bladder3 and perineum.4 To our knowledge, we describe case 8 of hemangioma of the adrenal gland removed surgically since the first surgical case reported in 1955.5 Fewer than 20 cases have been reported in the literature.5-10 CASE REPORT
A 73-year-old man presented to the emergency room in urinary retention and he underwent catheterization. Medical history included hypertension controlled with hydrochlorothi azide and clonidine, and severe chronic obstructive pulmonary disease. Physical examination revealed a well developed man with a palpable nontender abdominal mass and an enlarged prostate without nodularity. The patient manifested no clinical signs of adrenal hyperfunction. All admitting laboratory values were within normal limits, including blood urea nitrogen (15 mg./dl., normal range 7 to 24 mg./dl.) and serum creatinine (0.9 mg./dl., normal range 0. 7 to 1.7 mg./dl.). Hormonal studies did not reveal evidence of adrenal medullary or cortical hyper function. Urinalysis showed a specific gravity of 1.023, pH 6.0, trace protein and no white or red blood cells. As part of an evaluation of the upper urinary tract before prostatectomy, an excretory urogram (IVP) was performed (fig. 1), revealing a normal collecting system on the right side and a large mass on the left side. The mass depressed but did not distort the caliceal system and contained multiple small calcifications. A contrast enhanced computerized tomogram (CT, fig. 2) confirmed the presence of the mass but could not determine whether the mass was renal or suprarenal. Renal ultrasound revealed the mass to be suprarenal in origin. Magnetic resonance imaging (MRI) confirmed the mass to be separate from and superior to the kidney (fig. 3). MRI was performed in sagittal, coronal and axial planes. Imaging included Tl weighted images (with and without gadolinium, Gd) and T2 weighted images. On Tl weighted images there was a large suprarenal mass with areas of high signal intensity indicating focal hemorrhage. Peripheral high signal intensity lesions that enhance with Gd are compat ible with venous sinuses. On T2 weighted images there was marked signal heterogeneity (believed to be due to calcifica tions, hemorrhage and necrosis). The patient was explored via a left thoracoabdominal inci sion. The mass was well encapsulated and was easily separated from the upper pole of the left kidney. The blood supply entered the mass posteromedially from the aorta. The mass was re moved in toto without untoward incident. Convalescence was uneventful and the patient was discharged from the hospital
FIG. 1. IVP demonstrates large soft tissue mass with calcifications depressing but not distorting collecting system.
Accepted for publication January 18, 1991.
FIG. 2. CT scan of heterogeneous, calcified suprarenal mass 400
401
HONIG AND ASSOCIATES
FIG. 3. MRI. A, Tl sagittal images show heterogeneous suprarenal mass, isointense with liver. B, Tl coronal images after injection of Gd DTPA show peripheral high signal foci (arrows) with enhancement representing venous sinuses.
multiple arteries and veins. There was evidence of recent and old organized thrombi (fig. 4). There were large areas of necrosis but no evidence of dysplastic or neoplastic changes. DISCUSSION
FIG. 4. Large adrenal mass shows normal adrenal tissue (arrow) with evidence of extensive calcification and thrombosis.
11 days postoperatively. Transurethral resection of the prostate was done 2 weeks postoperatively. Pathology. The ovoid pink mass weighed 600 gm. (fig. 4). On gross examination the mass was well encapsulated with some patchy yellow areas. The adrenal cortex and medulla were identified at the superior pole of the mass. Microscopically, the mass was composed of large cavernous sinuses connected to
We found 7 previous reports in the literature of a surgically removed hemangioma of the adrenal gland, the largest weighing 6,000 gm.8 All cases were discovered incidentally during routine physical examination or evaluation for hypertension (see table). None of the tumors was functioning. Of the cases 75% involved patients in the seventh decade. Although in all cases the mass was first appreciated on an IVP, the radiological studies that best delineated the suprarenal origin of the mass were those able to image the gland in a coronal plane, that is ultrasonog raphy and MRI. Calcifications on plain abdominal films were noted in 7 of 8 cases. Arteriography was performed in 3 cases of adrenal heman gioma.8 The typical findings are dilated, crowded vessels that fill large irregular, well defined sinusoidal spaces and retain contrast agents for as long as 20 seconds. However, as in the liver, these findings are only suggestive and not pathognomonic of a hemangioma.11 CT shows a large adrenal mass with calci fications.10 MRI has assumed an increasing importance in the radio graphic evaluation of adrenal masses.12 On Tl weighted images the adrenals appear as areas of moderate signal intensity, isointense with the liver. Pathological processes affect the signal in characteristic patterns but these are rarely pathog nomonic. For example, adrenal metastases are typically isoin tense to hypointense on Tl and hyperintense on T2 images. Adrenocortical carcinomas are typically hyperintense on Tl and T2 images. However, low signal intensity in some cases has been reported. MRI is exquisitely sensitive to hemorrhage, which affects the signal in a complex manner that is dependent on the chronicity of the hemorrhage. MRI is insensitive to
Hemangioma of adrenal gland Reference
Age (yrs.)
Presentation
Calcification
IVP
Angiogram
MRI
Johnson and Jeppesen' Weiss and Schulte' Rothberg et al8 Ruebel' Vargas9 Lee et al1° Present study
46 70 72 74 75 76 59 73
Hypertension Retention Hypertension Hematuria Prostatism Abdominal calcification Abdominal calcification Retention
No information Yes Yes No Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes
No No Yes Yes No Yes No No
No No No No No No No Yes
402
ADRENAL HEMANGIOMA
calcifications, which have no signal and appear as signal voids. exploration and removal of the lesion are still necessary for To our knowledge, the appearance of an adrenal hemangioma definitive diagnosis. on MRI has not been reported previously. Cavernous heman REFERENCES giomas of the liver are notable for a long T2 relaxation time 1. Sundarasivarao, D., Banerjea, S., Nageswararao, A. and Rao, N. (hyperintense signal). The signal is heterogeneous due to areas V.: Hemangioma of the prostate: a case report. J. Urol., 110: 10 of thrombosis and slow venous flow. The Tl image is isoin 708, 1973. tense to hypointense with respect to normal liver. After admin 2. Uhlir, K.: Hemangioma of the ureter. J. Urol., 110: 647, 1973. istering Gd-diethylenetriaminepentaacetic acid (Gd-DTPA), 3. Esguerra, A., Carvajal, A. and Mouton, H.: Pelvic arteriography in high intensity foci appear in the periphery on Tl images. Many the diagnosis of hemangioma of the bladder. J. Urol., 109: 609, 1973. of the features of liver hemangiomas were seen in this case. The adrenal was predominantly isointense with the liver. The 4. Redman, J. F., Bissada, N. K. and Williams, E. W.: Cavernous hemangioma presenting as a perinea! mass in a man. J. Urol., correlation with pathological findings was good. Areas of ne 112: 766, 1974. crosis and hemorrhage were identified on Tl sequences, and C. C. and Jeppesen, F. B.: Hemangioma of the adrenal. focal calcifications were suggested on Tl and T2 sequences. 5. Johnson, J. Urol., 74: 573, 1955. The peripheral signals that enhanced with Gd must be vascular 6. Weiss, J. M. and Schulte, J. W.: Adrenal hemangioma: a case and certainly represent venous sinuses. Enhancement with Gd report. J. Urol., 95: 604, 1966. is the finding most characteristic of a hemangioma. 7. Ruebel, A. A.: Adrenal hemangioma. Urology, 2: 289, 1973. Ruling out carcinoma in a nonfunctioning adrenal mass 8. Rothberg, M., Bastidas, J., Mattey, W. E. and Bernas, E.: Adrenal hemangiomas: angiographic appearance of a rare tumor. Radiol preoperatively remains difficult. Our preoperative diagnosis ogy, 126: 341, 1978. was a nonfunctioning adrenocortical carcinoma. Calcifications 9. Vargas, A. D.: Adrenal hemangioma. Urology, 16: 389, 1980. are present in benign and malignant lesions. Larger heman giomas are easily confused with adrenal carcinomas or pheo 10. Lee, W. J., Weinreb, J., Kumari, S., Phillips, G., Pochaczevsky, R. and Pillari, G.: Case report. Adrenal hemangioma. J. Comput. chromocytomas. Radiological features suggestive of heman Assist. Tomogr., 6: 392, 1982. gioma are calcification and delayed filling with contrast me 11. Abrams, R. M., Beranbaum, E. R. and Santos, J. S.: Angiographic dium on angiography. The MRI finding of a mass with a features of cavernous hemangioma of the liver. Radiology, 92: heterogeneous signal characterized by foci of high intensity 308, 1969. that enhance after Gd administration is, based on our experi 12. Glazer, G. M.: MR imaging of the liver, kidneys, and adrenal glands. Radiology, 166: 303, 1988. ence, confirmation that the lesion is a hemangioma. However,