Eur. Radiol. 7,691-694 (1997) �9 Springer-Verlag 1997

European Radiology

Case report

Adrenal cavernous hemangioma: MRI, CT, and US appearance M. MarotW, Z. Su~i~ 2 , I. Kro lo 1 , J. D i m a n o v s k i 3 , R. Klari~ 1 , Z. Ferenf:i~ 4, N. K a r a p a n d a s , N. Babi~ 1 , K. Pav lekov i~ 1

i Department of Radiology, Sestre Milosrdnice, University Hospital, Vinogradska 29, 10000 Zagreb, Croatia 2 Department of Radiology. Sveti Duh General Hospital, 10000 Zagreb, Croatia 3 Department of Urology, Sestre Milosrdmce, University Hospital, Vinogradska 29, 10000 Zagreb, Croatia 4 Department of Pathology, Sestre Milosrdnice, University Hospital, Vinogradska 29, 10000 Zagreb, Croatia 5 Department of Surgery, Sestre Milosrdnice, University Hospital, Vinogradska 29, 10000 Zagreb, Croatia

Received 25 June 1995; Revision received 18 October 1995; Accepted 31 July 1996

Abstract . Two cases of rare adrenal cavernous he- mangiomas are reported, one imaged with conven- tional X-ray techniques, US, CT, and MRI, and the other with US and CT. The CT technique clearly demonstrated calcifications and the internal structure of the lesions in both cases and peripheral rim en- hancement on the postcontrast scan in one patient. Although MRI demonstrated accurately the complex nature of the lesion, the inability to visualize the cal- cified areas do not allow to make a specific histologic diagnosis.

Key words: Adrenal gland - Neoplasms - MR - US - CT - Angioma - Genitourinary system

Introduct ion

Adrenal hemangiomas are extremely rare benign le- sions. According to Travis et al. [1] only 12 cases diag- nosed radiologically have been reported since 1955, when the first paper on the surgical treatment of adrenal hemangioma was published by Johnson and Jeppeson [2]. All the cases of adrenal hemangiomas reported prior to their paper had been found at autopsy. We pre- sent two cases imaged by CT, US, and MRI.

Case reports

Case I

A 68-year-old woman complaining of discomfort in the left abdominal region underwent sonography. A hyper- echogenic inhomogeneous mass of the right adrenal gland containing calcifications was found (Fig. 1). Plain abdominal X-ray confirmed the presence of huge calci- fied mass in the left hemiabdomen (Fig. 2).

Correspondence to: M. Marotti

A CT exam (8-ram slices; Siemens DRH, Siemens, Erlangen, Germany) demonstrated a 14-xl0-cm- large, partially solid and partially cystic left adrenal mass lesion with numerous foci of calcification (Fig. 3). The iodinated contrast media was not adminis- tered because of previous allergic reaction during an IV pyelogram.

Magnetic resonance spin-echo (TR/TE = 500/38 ms, Tl-weighted, and TR/TE = 1900/90ms; T2-weighted images, Hitachi Tokyo, Japan, MRP-20, 0.2 T) demon- strated an inhomogeneous lesion with iso- and hypoin- tense areas compared to the liver as well as signal-free areas due to calcifications (Fig. 4 A).

The T2-weighted images showed a heterogeneously mixed signal intensity lesion with areas of an extremely high signal, areas of medium signal, and signal-free ar- eas (Fig.4 B).

The coronal view showed caudal displacement of the kidney and cranial displacement of the spleen with pre- served fat plains (Fig. 5).

The surgical specimen consisted of a yellowish en- capsulated, tumor measuring 14 x 10 x 10 in size, weigh- ing 800 g, yellow and friable when transected, with foci of calcifications and hemorrhagic areas in the subcapsu- lar area (Fig. 6). The adrenal gland was attached as an appendage along the tumor capsule.

Histologically, there were endothelium-lined blood- filled areas, necrosis and calcifications, with adrenal tis- sue found under the tumor capsule. The postoperative course was uneventful and the patient was released from the hospital 11 days after the surgical procedure.

Case 2

In a 60-year-old woman a preoperative workup for an unrelated disease (halux valgus) revealed a left upper abdominal palpable mass. Urography demonstrated soft tissue mass in the left adrenal bed. A C T scan (Sie- mens DRH, 8-mm noncontrast slices) demonstrated an 8- x 6- x 5-cm-large inhomogeneons tumor of the left

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Fig. L Sonography of the left upper abdo- men. Calcified mass lesion (arrow) with wide acoustic shadowing. Cranially dis- placed spleen (s)

Fig.2. Plain X-ray of the abdomen. Huge calcification in the left upper abdomen (ar- rows)

Fig,3. Abdominal CT demonstrating a rounded, sharply defined inhomogeneous adrenal mass lesion (large arrowheads) with mulhple calcifications (small arrowheads)

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Fig.4. a Magnetic resonance Tl-weighted spin-echo (TR/TE 500/ 38 ms) transverse image demonstrating an inhomogeneous mass lesion of medmm signal intensity (arrowheads)�9 Calcifications are much less pronounced (arrow) than on CT. b Magnetic resonance T2-weighted (TR/TE 1900/90 ms) transverse image demonstrating inhomogeneous high-signal-intensity areas (arrowheads) which correspond well to the blood-filled vascular areas and necrosis seen in the pathologic specimen (see Fig. 6)

Fig.5. Magnetic resonance, frontal view. A huge mass lesion (ar- rowheads) displacing spleen (s) cranially and kidney (k) caudally

Fig.6. Surgical specimen. Blood-filled vascular spaces (arrow- heads). Calcifications and necrosis (c)

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adrenal gland with small calcification not seen on urog- raphy (Fig,7A). After IV administration of a contrast medium (80 ml Telebrix 300, Byk Gulden, Konstanz, Germany single bolus), enhancement at the periphery of the lesion and a central nonenhancement area were observed (Fig. 7 B).

Ultrasound demonstrated an inhomogeneous solid lesion with a small calcified focus. The surgical specimen consisted of a yellowish-red, encapsulated soft oval- shaped tumor measuring 9 x 7.5 x 5 cm in size and 150 g in weight. Transection revealed a necrotic, blood- filled central area of 7 cm in diameter.

The histologic finding was the same as in the first case, with endothelium-lined blood-filled areas, necro- sis, and calcification. Adrenal tissue was found under the tumor capsule (Fig. 8).

D i s c u s s i o n

With the introduction of US and CT, adrenal hemangi- omas, previously identified post mortem, are currently diagnosed also radiologically. Most of them are diag- nosed during workup for unrelated symptoms. Heman- giomas of the adrenal gland are extremely rare nonfunc- tioning tumors, Plaut [3] found one case in 10000 autop- sies. The most frequent are cavernous hemangiomas fol- lowed by capillary hemangiomas and hemangioperi- cytomas. Regressive tumor changes, such as necrosis, calcifications, and fibrosis, are common. Because there are no symptoms of adrenal hemangiomas, they are usu- ally diagnosed clinically after reaching a size larger than 10 cm in diameter [4].

The US findings of one of our patients (Case 1) dif- fered from those reported in the literature [5-8] show- ing extensive calcification which made it impossible to

693

F i g . 7 . a Precontrast CTimage of the left adrenal tumor lesion with a calcified fo- cus (arrowhead). b Postcontrast CT im- age showing a peripheral enhancement (arrowheads) and a central nonen- hanced area

Fig.8. Adrenal tissue incorporated pe- ripherally in the necrotic tumor (hema- toxylin and eosin x 100); with wide, en- dothelium lined spaces (arrow) filled with erythrocytes (arrowhead)

demonstrate either the solid or the cystic parts of the tu- mor. The US findings of our other patient (case 2) was in accord with other reports.

Noncontrast CT demonstrated cystic areas of a pre- dominantly solid tumor with a large central calcification which did not differ from those observed in previously re- ported cases [6, 8-10], although the calcification in our case was more pronounced (case 1; Figs. 2 and 3). Of all reported hemangiomas, 70 % contain calcifications [5].

The postcontrast CT of case 2 (Fig.TB) resemble those reported by Derchi et al. [8] and Guerin et al. [10] showing peripheral enhancement. Derchi et al. [8] claimed that it could be of diagnostic importance in the differentiation of adrenal hemangiomas from other ad- renal lesions [8].

The MRI Tl-weighted image demonstrated a rela- tively inhomogeneous lesion of mixed medium signal in- tensity comparable to that of the liver, suggesting the so- lid nature of the lesion. The two medium-intensity foci present in the periphery on Tl-weighted images were believed to represent areas of hemorrhage. In our case, Tl-weighted images did not show good correlation with pathologic findings as suggested by Honig et al. [11], because they underestimated the amount of calcifi- cation present.

The MRI T2-weighted images demonstrated accu- rately the complex nature of the lesion (Fig. 8) with ar- eas of necrosis, blood-filled vascular spaces, and hemor- rhage which exhibit high signal intensity (Fig.5). Cen- trally placed low-intensity region correlated well with calcifications and fibrous septa.

The T2-weighted images correspond well to previ- ously reported cases represented by Honig et al. [11] and Hamrick-Turner et al. [12], with the turnout of high signal intensity on long TR spin-echo images with low- intensity septa which radiate peripherally.

Differential diagnosis includes adrenal carcinoma, which should at that size probably invade surrounding organs, pheochromocytoma, and neuroblastoma. When adrenal calcified lesions are detected by CT, metastases and tuberculosis also should be considered as differen- tial diagnoses. Our two cases confirm the results of Der- chi et al. [8] that contrast-enhanced CT characteristics and visualization of calcified loci may suggest the diag- nosis, at least in patients with large adrenal lesions.

The MRI detection of tumor calcification was inade- quate on both T1 and T2 sequences. The lack of visual-

694

ization of the calcified areas in the tumor by MRI does not allow a specific diagnosis. Therefore, in the cases presented, MRI had no diagnostic value.

References

1. Travls WD, Oertel J, Lack EE (1990) Miscellaneous tumors and tumefactive lesions of the adrenal gland. In: Lack EE (ed) Pa- thology of the adrenal glands. Churchill Livingstone, New York, pp 362-364

2. Johnson CC, Jeppesen FB (1955) Hemangioma of the adrenal. J Urol 74:573

3. Plaut A (1962) Hemangiomas and related lesions of the adrenal gland. V~rchows Arch Path Anat 335:345

4. Salup R, Finegold R, Borochovitz D, Boehnke M, Posner M (1992) Cavernous hemangioma of the adrenal gland. J Urol 147:110

5. Vargas AD (1980) Adrenal hemangioma. Urology 16:389

M. Marottl et al.: Adrenal cavernous hemangioma

6. Orringer RD, Lynch JA, McDermott W (1983) Cavernous he- mangioma of the adrenal gland. J Surg Oncol 22:106

7. Lee WJ, Weinreb J, Kumari S, Phillips G, Pochaczevsky R, Pil- lari G (1982) Adrenal hemangioma. J Comput Assist Tomogr 6:392

8. Derchi LE, Rapacclm GL, Banderali A, Danza FM, Grillo F (1989) Ultrasound and CT findings in two cases of hemangioma of the adrenal gland. J Comput Assist Tomogr 13:659

9. Nakagawa N, Takahashl M, Maeda K, Fujimura N, Yufu M (1986) Case report: adrenal hemangioma coexisting with malig- nant hemangioendothelioma. Clin Radiol 37:97

10. Guerin E, Babin C, Lchujeur C, Lucas G, Barret F (1988) He- mangiome de la surrenale. Apropos d un cas. J Radiol 69:57

11. Honig SC, Klavans MS, Hyde C, Siroky MB (1991) Adrenal he- mangioma: an unusual adrenal mass deliniated with magnetic resonance imaging. J Urol 146:400

12. Hamrick-Turner JE, Abbltt PL, Allen BC, Fowler JE Jr, Crans- ton PE, Harrison RB (1993) Adrenal hemangioma: MR find- ings with pathologic correlation 17:503

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The book aims at covering the whole scope of neuro-oncology. To this end, it is divided into two sections: Basic principles and Spe- cific brain tumors. In the first section on basic principles, a variety of contributions deal with prerequisites for the understanding of biology as well as diagnosis and treatment of tumors of the CNS. Each author provides the reader with an extensive survey of his topic. Chapters on tumor epidemiology, pathogenesls, immunolo- gy, genetics, and metabolism are followed by clinical contributions, including neuro-opthalmology, which cover diagnostics, chemo- therapy, radiation therapy and surgery. The section concludes with an outlook on future therapy options and with a chapter on the special features of pediatric neuro-oncology.

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