Chin J Radiol 2004; 29: 371-375 371

A 63-year-old female suffered from pain over leftupper quadrant of abdomen. Ultrasound examina-tions disclosed a heterogeneous echogenic lesionmeasuring 6x6 cm, at the upper pole of the leftkidney. Non-contrast computed tomography (CT)scan revealed a left suprarenal tumor with lowattenuation but peripheral enhancement of thislesion was shown after administration of contrastmedium. Magnetic resonance (MR) imaging con-firmed the tumor mass arising from the left adrenalgland with progressive centripetal enhancementafter administration of contrast medium. Aftertumor resection, the pathologic result was anadrenal hemangioma.

Key words: Adrenal gland, CT; Adrenal gland,MR; Adrenal gland, neoplasms; Hemangioma

Hemangiomas of the adrenal gland are extremelyuncommon, and most tumors are found incidentally. Itaffects people between the ages of 50 to 70 years.Women are affected twice as often as men according tothe previous reported cases. Bilateral involvement hasbeen reported twice [1]. Histologically, these tumorsconsist of dilated, endothelial-lined, blood-filledchannels within the adrenal parenchyma [2]. At micro-scopic analysis, hemangiomas are classified ascavernous, capillary, sclerosing types and heman-giopericytoma. We present the CT and MR imagingmanifestations of an adrenal hemangioma.

CASE REPORT

A 63-year-old female suffered from intermittentdull pain over the left upper quadrant (LUQ) ofabdomen for 3 days. Physical examination revealedknocking tenderness over LUQ. The patient had ahistory of hypertension with medical treatment for 10years. She underwent cholecystectomy 2 years previ-ously. Laboratory tests including blood urea nitrogenand serum creatinine were all within normal range.Adrenal hormonal studies including 24-hour urinevanillymandelic acid, plasma aldosterone and plasmacortisol were all within normal range too. Plainabdominal radiography, ultrasound, CT, and MRimaging of the abdomen were taken for the patient.

Plain abdominal radiographs demonstrated asubtle soft-tissue density in the left suprarenal region,without calcification. Ultrasound examination (LOGIQ500, GE Medical Systems, Milwaukee, Wis.) using a3.5 MHz convex transducer disclosed a heteroge-neously echogenic lesion measuring 6 × 6 cm, at theupper pole of the left kidney. Nonenhanced CT(LightSpeed Plus, GE Medical Systems, Milwaukee,Wis.) scans showed a low-attenuated mass in the leftsuprarenal region. Peripheral enhancement of thislesion was found after administration of 100 mlcontrast medium (Ultravist, Schering AG, Berlin,

Reprint requests to: Dr. Jinn-Ming ChangDepartment of Radiology, Chi-Mei Medical Center.No. 901, Chung Hwa Road, Yung-Kang, Tainan 710,Taiwan, R.O.C.

CT and MR Imaging Manifestation of AdrenalHemangioma: a case reportMING-TSUNG WANG

1 WEN-SHENG TZENG2 CHEE-WAI MAK

2 JYH-CHING CHEN1 JINN-MING CHANG

2

DAVID LU3

Department of Radiology1, Kaohsiung Military General HospitalDepartment of Radiology2, Pathology3, Chi-Mei Medical Center

Germany) intravenously (Fig. 1). MR imagingconfirmed that the mass was superior to and separatedfrom the left kidney (Fig. 2). The T1-weighted images(spin echo: TR/TE, 450 ms/14 ms) revealed a hetero-geneously low signal intensity mass with a very highintensity at the central portion at the left adrenalregion. This lesion became heterogeneously hyperin-tense in T2-weighted images (fast spin echo:8571/82.9) with fat saturation. In the chemical shiftimaging, no apparent change of the signal intensitycould be identified in this lesion in comparison to theopposed phase images with in-phase ones. Afteradministration of 10 ml contrast medium, early andheterogeneous enhancement of the peripheral portionin this lesion (Fig. 3) was identified.

The patient underwent left adrenalectomy. Atsurgery, a tan-brownish ovoid tumor measuring 5.5 ×5.0 × 4.0 cm3 and weighing 6.0 grams was removed.Histological examination showed the tumor wasvascular and well-circumscribed. The bulk of the masscontained variable cystic spaces filled with bloodyfluid and red cells. Toward the periphery, numeroussmall papillary structures containing hyaline corescovered by benign-looking endothelial cells werefound, which was characteristic for hemangiomas(Fig. 4). The external surface was generally smooth,with some attached fat tissue and a portion of normal-looking adrenal tissue measuring 2.5 × 1.2 × 0.5 cm3

located inferior to the tumor.

DISCUSSION

Hemangiomas are benign tumors, showing apropensity for liver, brain and skin involvement andrarely involve the adrenal glands. Most hemangiomashave been incidental findings since the patient usuallyhas no symptom. The exceptions have been in thosecases in which the patient initially presents with alarge, palpable, abdominal mass, flank pain, or hyper-tension of unknown cause.

Rothberg et al. [3] reported round calcificationwith translucent centers, typical of phleboliths, to bepathognomonic of adrenal gland hemangiomas. Honiget al. [4] reported calcification on plain abdominalfilms of adrenal hemangioms were noted in 6 of 7cases, not all of whom were with phleboliths. Wesupposed that phleboliths are frequently seen inadrenal hemangiomas but not without exception. Otheradrenal tumors that commonly have calcification arecarcinoma (30% of case) and adrenal cyst (15%) [5].Calcification are also occasionally observed inpheochromocytomas, teratomas, and adenomas. Atnonenhanced CT scans show a hypoattenuating mass

with necrotic areas and peripheral enhancement afterintravenous administration of contrast material.Nonenhanced T1-weighted MR images show hetero-geneous low signal intensity and nonenhanced T2-weighted MR images show marked high signalintensity except in the central fibrotic areas. Theenhancement pattern is the same as that seen at CT[6]. The peripheral signals that enhanced with

CT and MR Imaging manifestation of Adrenal Hemangioma372

Figure 1. Peripheral and septum-like enhancement of thelesion is identified in the left suprarenal region in theaxial CT scan after injection of contrast material.

Figure 2. Coronal T2-weighted fast spin-echo with fatsaturation MR image (TR/TE: 9230/81.5 msec) confirmeda heterogeneously high signal intensity mass separatedfrom and superior to the left kidney.

gadolinium (Gd) must be vascular and certainlyrepresent venous sinuses. Enhancement with Gd is thefinding most characteristic of a hemangioma [4].

According to the radiological features of thislesion, the differential diagnosis includings: pheochro-mocytoma, and adrenocortical carcinoma. Pheochrom-cytoma are catecholamine-producing tumors that arisefrom chromaffin cells with well enhacement. Thetypical imaging characteristics of a pheochromocy-toma are a round, well-circumscribed and homoge-neous soft-tissue mass. At MR imaging, pheochromo-cytomas are generally hypointense compared with

normal liver on T1-weighted images [7]. On T2-weighted images, they are typically very hyperintenseto fat [7]. When intravenous contrast material is given,a pheochromocytoma will enhance inhomogeneously[8].

On CT, adrenocortical carcinoma appears as alarge mass, often with central necrosis. As a result, thetumor enhances heterogeneously, with the greatestenhancement often at the periphery [9-11]. Ruling outcarcinoma in a nonfunctioning adrenal mass preopera-tively remains difficult [4].

In conclusion, when we encounter an adrenalmass having the following radiologic features, adrenalhemangiomas should be included in the differentialdiagnosis. These are phleboliths of adrenal tumors onplain abdominal radiograms or CT scan, a heteroge-nously echogenic mass at ultrasound, a low-attenuatedtumor with enhancement from its peripheral portion inenhanced CT scan, and a mass hypointense in T1-weighted images and hyperintense in T2-weightedimages with enhancement from peripheral area aftercontrast medium administration. Above all of them,the most important radiological features suggestive ofadrenal hemangioma are phleboliths and enhancementfrom peripheral area after contrast medium administra-tion on CT, and MR images.

REFERENCES

1. Salup R, Finegold R, Borochovitz D, Boehnke M,Posner M. Cavernous hemangioma of the adrenal gland.J Urol 1992; 147: 110-112

2. Weiss JM, Schulte JW. Adrenal hemangioma: a casereport. J Urol 1966; 95: 604-606

3. Rothberg M, Bastidas J, Mattey WE, Bernas E. Adrenalhemangiomas: angiographic appearance of a rare tumor.Radiology 1978; 126: 341-344

4. Honig SC, Klavans MS, Hyde C, Siroky MB. Adrenalhemangioma: an unusual adrenal mass delineated withmagnetic resonance imaging. J Urol 1991; 146: 400-402

5. McNulty JG, Lea Thomas M, Tighe JR. Angiographicdiagnosis of benign adrenal adenoma. AJR Am JRoentgenol 1968; 104: 386-388

6. Hamrick-Turner JE, Abbitt PL, Allen BC, Fowler JE Jr,Cranston PE, Harrison RB. Adrenal hemangioma: MRfindings with pathologic correlation. J Comput AssistTomogr 1993; 17: 503-505

7. Quint LE, Glazer GM, Francis IR, Shapiro B,Chenevert TL. Pheochromocytoma and paraganglioma:comparison of MR imaging with CT and I-131 MIBGscintigraphy. Radiology 1987; 165: 89-93

8. Dähnert W. Pheochromocytoma. In: John JR, Snyder A,ed. Radiology review manual. 5th edition. PhiladelphiaBaltimore New York London Buenos Aires Hong KongSydney Tokyo: Lippincott Williams & Wilkins 2003:935-936

9. Caoili EM, Korobkin M, Francis IR et al. Adrenalmasses: characterization with combined unenhanced

CT and MR Imaging manifestation of Adrenal Hemangioma 373

Figure 4. The microscopic picture (H &E stain 200x)shows variable cystic spaces filled with bloody fluid andred cells. Numerous small papillary structures are coveredby containing hyaline cores.

Figure 3. Axial T1-weighted gadolinium-enhanced fastspoiled gradient echo (FSPGR) MR image (100/1.5)obtained with frequency-selective fat saturationdemonstrates a soft-t issue mass (arrowhead) withenhancement from its peripheral portion.

and delayed enhanced CT. Radiology 2002; 222: 629-633

10. Dunnick NR, Korobkin M. Imaging of adrenal inciden-talomas: current status. AJR Am J Roentgenol 2002;179: 559-568

11. Fishman EK, Deutch BM, Hartman DS, Goldman SM,Zerhouni EA, Siegelman SS. Primary adrenocorticalcarcinoma: CT evaluation with clinical correlation. AJRAm J Roentgenol 1987; 148: 531-535

CT and MR Imaging manifestation of Adrenal Hemangioma374

CT and MR Imaging manifestation of Adrenal Hemangioma 375