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Adrenal hemangiomas are rare benign tumors that are usually incidentally identified (one example of an adrenal incidentaloma). Its significance mainly relates to the difficulty in differentiation from other malignant lesions.
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.
Adrenal hemangiomas are usually incidentally identified when the region is imaged for other reasons. On occasions, these lesions may hemorrhage 2-4. Bilateral adrenal hemangiomas have only been reported a few times 6.
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 features are non-specific demonstrating a mass of variable size and variable echotexture.
Typically adrenal hemangiomas are soft tissue attenuation masses, varying in size from a few centimeters 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 hemorrhage 1-3.
With administration of contrast they enhance similarly to hemangiomas elsewhere 1,3-4,6:
- 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 is often helpful, demonstrates lesions that are 1:
- hypointense relative to liver
- central intrinsic hyperintensity may be present due to hemorrhage
- 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 hemangiomas to be excised, which is curative. Others recommend excision of only large or symptomatic tumors or those with imaging features which raise the possibility of malignancy 1,3,6.
Excision may either be traditional open adrenalectomy or laparoscopic adrenalectomy.
Essentially the differential is that of any solid adrenal lesions, including: