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Anastomosing Hemangioma Arising From the Adrenal Gland
Images in Clinical Urology Anastomosing Hemangioma Arising From the Adrenal Gland Michael Ross, Anthony Polcari, Maria Picken, Howard Sankary, and John Milner
Figure 1. Unenhanced axial computed tomography image showing a heterogeneous low-density mass (white arrow) in the right retroperitoneum, abutting the right adrenal gland and lacking diffuse calcification, suggesting the mass was not cavernous hemangioma.
Figure 2. Contrast-enhanced coronal computed tomography image showing a heterogeneous, 3.3 ⫻ 3.7-cm, right adrenal mass, discrete from the kidney (K). The mass had peripheral enhancement (white arrow), central cysts (black arrow), and adjacent fat stranding.
A
drenal hemangiomas are rare, nonfunctional vascular tumors. Of the 60 reported cases from published studies, nearly all have been of the cavernous subtype. Cavernous hemangiomas are characterized histologically by enlarged blood-filled vascular channels that erode and displace normal tissue. Characteristic computed tomography findings include low-attenuation centrally, patchy peripheral enhancement, and diffuse calcification.1-4 Anastomosing hemangiomas are distinguished from their cavernous counterparts by the anastomosing sinusoidal-like pattern of tightly packed capillary channels. The imaging findings for this novel subtype have not yet been described. We report the first case of anastomosing hemangioma of adrenal origin. A 49-year-old, asymptomatic, Hispanic man with endstage renal disease presented for a renal transplant evaluation. Renal ultrasonography showed bilateral renal
Figure 3. Anastomosing hemangioma (left side) adjacent to adrenal cortex (AC). Tightly packed capillary channels with focal anastomosing sinusoidal pattern are visible (white arrows). Hematoxylin-eosin stain, original magnification ⫻250.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Loyola University Medical Center, Maywood, IL Reprint requests: Michael Ross, M.D., Department of Urology, Loyola University Medical Center, Maywood, IL 60153. E-mail: [email protected] Submitted: April 7, 2012, accepted (with revisions): May 23, 2012
cysts and a complex cystic structure adjacent to the right kidney. Follow-up abdominal computed tomography with 2.5-mm slices and coronal reformatting was obtained for additional characterization. Noncontrast-enhanced images revealed a 3.7-cm, right adrenal mass without calci-
© 2012 Elsevier Inc. All Rights Reserved
0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.05.032
e27
fication (Fig. 1). Contrast-enhanced images demonstrated heterogeneity with central cystic spaces and peripheral enhancement concerning for adrenal malignancy (Fig. 2). The functional workup, including a complete metabolic panel and 24-hour urinary cortisol/ vanillymandelic acid/metanephrine determination, was negative. Given his end-stage renal disease, renal cysts, and desire for a kidney transplant, the patient underwent uneventful laparoscopic radical nephrectomy/adrenalectomy. The gross pathologic examination showed a red-tan, nonencapsulated, hemorrhagic, 2.0-cm mass arising from the adrenal cortex and extending into the right kidney. On microscopic examination, tightly packed capillary channels with a focal anastomosing sinusoidal pattern were seen. The vascular channels were lined by bland endothelial cells (Fig. 3). These features confirmed anastomosing hemangioma of adrenal origin. Adrenal hemangioma is a rare, benign, vascular tumor with fewer than 60 reported cases. Of these, cavernous
e28
hemangiomas have predominated.1,2 To date, anastomosing hemangiomas have only been described in the kidney, testis, and ovary.5,6 The present case represents the first case of anastomosing hemangioma arising within the adrenal gland. References 1. Alexander JK, Nikolaidis P, Casalino DD. Adrenal gland hemangioma. J Urol. 2011;186:2415-2416. 2. Matsuda D, Iwamura M, Baba S. Cavernous hemangioma of the adrenal gland. Int J Urol. 2009;16:424-424. 3. Thiele JW, Bodie B. Adrenal hemangioma. Surgery. 2001;129:373374. 4. Oh BR, Jeong YY, Ryu SB, et al. A case of adrenal cavernous hemangioma. Int J Urol. 1997;4:608-610. 5. Montgomery E, Epstein JI. Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma. Am J Surg Pathol. 2009;33:1364-1369. 6. Kryvenko ON, Gupta NS, Meier FA, et al. Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis. Am J Clin Pathol. 2011;136:450-457.
UROLOGY 80 (3), 2012
Figure 1. Unenhanced axial computed tomography image showing a heterogeneous low-density mass (white arrow) in the right retroperitoneum, abutting the right adrenal gland and lacking diffuse calcification, suggesting the mass was not cavernous hemangioma.
Figure 2. Contrast-enhanced coronal computed tomography image showing a heterogeneous, 3.3 ⫻ 3.7-cm, right adrenal mass, discrete from the kidney (K). The mass had peripheral enhancement (white arrow), central cysts (black arrow), and adjacent fat stranding.
A
drenal hemangiomas are rare, nonfunctional vascular tumors. Of the 60 reported cases from published studies, nearly all have been of the cavernous subtype. Cavernous hemangiomas are characterized histologically by enlarged blood-filled vascular channels that erode and displace normal tissue. Characteristic computed tomography findings include low-attenuation centrally, patchy peripheral enhancement, and diffuse calcification.1-4 Anastomosing hemangiomas are distinguished from their cavernous counterparts by the anastomosing sinusoidal-like pattern of tightly packed capillary channels. The imaging findings for this novel subtype have not yet been described. We report the first case of anastomosing hemangioma of adrenal origin. A 49-year-old, asymptomatic, Hispanic man with endstage renal disease presented for a renal transplant evaluation. Renal ultrasonography showed bilateral renal
Figure 3. Anastomosing hemangioma (left side) adjacent to adrenal cortex (AC). Tightly packed capillary channels with focal anastomosing sinusoidal pattern are visible (white arrows). Hematoxylin-eosin stain, original magnification ⫻250.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Loyola University Medical Center, Maywood, IL Reprint requests: Michael Ross, M.D., Department of Urology, Loyola University Medical Center, Maywood, IL 60153. E-mail: [email protected] Submitted: April 7, 2012, accepted (with revisions): May 23, 2012
cysts and a complex cystic structure adjacent to the right kidney. Follow-up abdominal computed tomography with 2.5-mm slices and coronal reformatting was obtained for additional characterization. Noncontrast-enhanced images revealed a 3.7-cm, right adrenal mass without calci-
© 2012 Elsevier Inc. All Rights Reserved
0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.05.032
e27
fication (Fig. 1). Contrast-enhanced images demonstrated heterogeneity with central cystic spaces and peripheral enhancement concerning for adrenal malignancy (Fig. 2). The functional workup, including a complete metabolic panel and 24-hour urinary cortisol/ vanillymandelic acid/metanephrine determination, was negative. Given his end-stage renal disease, renal cysts, and desire for a kidney transplant, the patient underwent uneventful laparoscopic radical nephrectomy/adrenalectomy. The gross pathologic examination showed a red-tan, nonencapsulated, hemorrhagic, 2.0-cm mass arising from the adrenal cortex and extending into the right kidney. On microscopic examination, tightly packed capillary channels with a focal anastomosing sinusoidal pattern were seen. The vascular channels were lined by bland endothelial cells (Fig. 3). These features confirmed anastomosing hemangioma of adrenal origin. Adrenal hemangioma is a rare, benign, vascular tumor with fewer than 60 reported cases. Of these, cavernous
e28
hemangiomas have predominated.1,2 To date, anastomosing hemangiomas have only been described in the kidney, testis, and ovary.5,6 The present case represents the first case of anastomosing hemangioma arising within the adrenal gland. References 1. Alexander JK, Nikolaidis P, Casalino DD. Adrenal gland hemangioma. J Urol. 2011;186:2415-2416. 2. Matsuda D, Iwamura M, Baba S. Cavernous hemangioma of the adrenal gland. Int J Urol. 2009;16:424-424. 3. Thiele JW, Bodie B. Adrenal hemangioma. Surgery. 2001;129:373374. 4. Oh BR, Jeong YY, Ryu SB, et al. A case of adrenal cavernous hemangioma. Int J Urol. 1997;4:608-610. 5. Montgomery E, Epstein JI. Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma. Am J Surg Pathol. 2009;33:1364-1369. 6. Kryvenko ON, Gupta NS, Meier FA, et al. Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis. Am J Clin Pathol. 2011;136:450-457.
UROLOGY 80 (3), 2012