Adrenal haemangioma presenting as spontaneous haemorrhage

On ultrasound examination (US-Siemens Elegra, Erlangen, Germany), an inhomogeneous mass lesion was seen in the right adrenal region. It was about 7 cm in diameter. Abdominal computed tomography (CT-Siemens Somatom Plus 4, Erlangen, Germany) was subsequently performed. A mass lesion of the right adrenal gland was found (Figure 1a). The mass lesion had well-delineated contours, high density (65-70 HU) and no calcification. In the perirenal region, there was stranding representing the involvement of the perirenal fatty tissues in the retroperitonium. After intravenous contrast medium injection, no marked enhancement in the mass was detected because of its high density (Figure 1b).

On the basis of the clinical findings, the mass lesion was diagnosed as a haemorrhage in the right adrenal gland. The patient underwent surgery and the haemorrhagic adrenal gland was removed successfully. A small amount of haemorrhage was also present in the perirenal fatty tissues. Histologically, there were endothelium-lined blood-filled areas and necrosis, with adrenal tissue found under the tumour capsule (Figure 2). So, the diagnosis was haemorrhage in the cavernous haemangioma of the right adrenal gland. The previous history of the patient was normal. The post-operative course was uneventful. 12 days later, the patient was released from hospital.

With the advent of modern and sophisticated diagnostic techniques in US, CT and magnetic resonance imaging (MRI), adrenal haemangiomas, previously identified post mortem, are can now be diagnosed radiologically. However, most are diagnosed during workup for unrelated symptoms.

The US finding in adrenal haemangioma is a hyperechogenic inhomogeneous mass, usually including calcification (1,2). Extensive calcification makes it impossible to demonstrate either the solid or the cystic parts of the lesion. Non-contrast CT demonstrates a well-delineated complex mass, which has a predominantly solid component (1,3). Fatty areas and calcifications are seen. Lesions with hypodense centres and thick irregular peripheries with higher density are depicted. Peripheral enhancement on post-contrast CT of the lesion has been reported by Derchi et al. (1). They suggest that this could be of diagnostic importance in the differentiation of adrenal haemangiomas from other adrenal lesions. Rieber and Brambs (3) describe progressive enhancement from the periphery of the tumour to the centre, similar to the contrast enhancement of liver haemangiomas.

On MRI, T1-weighted images demonstrate an inhomogeneous lesion of mixed medium signal intensity comparable to that of the liver, suggesting the solid nature of the lesion. T2-weighted images demonstrate accurately the complex nature of the lesion with areas of necrosis, blood-filled vascular spaces and haemorrhage. The detection of calcification - seen as low intensity regions - is inadequate on both T1 and T2 sequences. Marotti et al. (4) claim that MRI has no diagnostic value. Conversely, Hayasaka et al. (5) reported that MRI showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, and dynamic MRI using contrast medium showed late and delayed enhancement, allowing definitive diagnosis. Rieber and Brambs (3) proposed that CT and MRI findings of adrenal haemangiomas were in some cases similar to those of liver haemangiomas.

Since there are no symptoms of adrenal haemangiomas, they are usually diagnosed clinically after reaching more than 10 cm in diameter. Tumour resection must be considered if the tumour changes in appearance or size (3). Adrenal haemangiomas are rare but there is a risk of retroperitoneal haemorrhage. In this case, there was haemorrhage in the adrenal gland and also in the perirenal fatty tissues. The only symptom seen was arterial hypertension. A literature search found only four cases of haemorrhage in the cavernous haemangioma of the adrenal gland.

Differential diagnosis includes adrenal carcinoma, phaeochromocytoma, and neuroblastoma. When adrenal calcified lesions are detected, metastases and tuberculosis should also be considered as possible differential diagnoses (4). If the lesion shows characteristic peripheral enhancement on either CT or MRI, the diagnosis is easily made. Both CT and MRI have achieved high accuracy in the investigation of patients suspected of having adrenal pathology. Spiral CT has allowed the examination to be tailored to demonstrating the adrenal with very high spatial resolution and it remains the most widely-used initial technique. These new techniques are frequently used for evaluating incidentally discovered adrenal masses and differentiating between adrenal adenomas and metastases.