Adrenal haemangiomas are rare benign tumours that are usually incidentally identified (one example of an adrenal incidentaloma). Its significance mainly relates to the difficulty in differentiation from other malignant lesions.
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Epidemiology
Although these can be found at any age, they are most commonly encountered 40-70 years of age and are more common in women with a female:male ratio of approximately 2:1 3.
Clinical presentation
Adrenal haemangiomas are usually incidentally identified when the region is imaged for other reasons. On occasions, these lesions may haemorrhage 2-4. Bilateral adrenal haemangiomas have only been reported a few times 6.
Radiographic features
Plain radiograph
Usually, no abnormality can be detected, although if very large the mass or its effects on surrounding structures may be appreciable. Phleboliths or dystrophic calcification are visible in up to two-thirds of cases 5,6.
Ultrasound
Ultrasound features are non-specific demonstrating a mass of variable size and variable echotexture.
CT
Typically adrenal haemangiomas are soft tissue attenuation masses, varying in size from a few centimetres to as large as 25 cm 3. The larger masses frequently have areas of calcification representing either phleboliths or dystrophic calcification in areas of previous haemorrhage 1-3.
With administration of contrast they enhance similarly to haemangiomas elsewhere 1,3-4,6:
- heterogeneous
- mainly peripheral
- gradual filling in over time is sometimes seen, but less frequently than in the liver
- central region is often scarred and does not significantly enhance
- tending to remain isodense to the aorta on all phases
MRI
MRI is often helpful, demonstrates lesions that are 1:
-
T1
- hypointense relative to liver
- central intrinsic hyperintensity may be present due to haemorrhage
-
T2
- very hyperintense peripherally
- central scar hypointense
-
T1 C+ (Gad)
- peripheral enhancement which persists
- gradual filling is sometimes seen
Treatment and prognosis
Unfortunately, it is difficult to exclude malignancy based on imaging or even biopsy, and as such, some authors recommend all suspected adrenal haemangiomas to be excised, which is curative. Others recommend excision of only large or symptomatic tumours or those with imaging features which raise the possibility of malignancy 1,3,6.
Excision may either be traditional open adrenalectomy or laparoscopic adrenalectomy.
Differential diagnosis
Essentially the differential is that of any solid adrenal lesions, including:
- adrenal adenoma
- adrenal cortical carcinoma
- phaeochromocytoma
- neuroblastoma (in children)
- ganglioneuroma
- adrenal myelolipoma (usually has macroscopic fat)
- adrenal metastases
- adrenal abscess
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