Endocrine Abstracts

Introduction: Although usually considered as benign tumors, cavernous hemangiomas are venous malformations due to endothelial dysmorphogenesis and not true neoplasias. They are usually asymptomatic but occasionally can cause compressive symptoms or serious internal bleeding. They may arise in almost any vascularised organ, but their presentation in an adrenal gland is highly infrequent, and can masquerade as pheochromocytoma, adrenal carcinoma or metastatic malignant lesion.

Methods: We performed a retrospective revision of the patient’s clinical record and of the literature. The patient gave informed consent.

Results (clinical case): A 72 year-old male, with obesity, type 2 diabetes and non-alcoholic fatty liver disease was referred to our Endocrinology clinic after the finding of a large right adrenal mass in an abdominal ultrasonography performed in the context of epigastralgia, dyspepsia and hepatomegaly. His office blood pressure was normal and he had no history of hyperkalemia or hypertensive episodes. There were no signs or symptoms suggesting Cushing’s syndrome, no weight loss, skin lesions suggesting melanoma or other obvious signs of metastatic malignant disease. A CT abdominal scan and adrenal function tests were ordered. Plasma metanephrines (31/54 pg/ml), aldosterone, renin and aldosterone/renin ratio were normal, plasma cortisol after overnight suppression with dexamethasone 1 mg was also normal. The CT described a grossly spherical mass of 7.5 cm diameter occupying the right adrenal; the lesion was solid, hyperdense and heterogeneous, with multiple nodular and tubular foci. The presumptive diagnosis was adrenal carcinoma, distant metastasis, pheochromocytoma or hemangioma. The left adrenal gland showed a 1.6 cm hyperdense mass, not characterizable as adenoma. There were no other findings suggesting abdominal neoplasm or metastases. With functioning pheochromocytoma ruled out, the patient underwent laparotomy and right adrenalectomy which was uneventful; during the procedure a FNAC was obtained from the left adrenal. The pathology report was: Adrenal gland of 10.5 cm containing a 7.5 cm cavernous hemangioma, partially thrombotic, in the context of cortical adrenal hyperplasia or adenoma, negative for malignancy. The FNAC from the left adrenal was negative for malignancy also. The patient remains asymptomatic and 6 months after the surgery the adrenal function remains normal. For the follow-up of the left adrenal gland, an abdominal MRI scan has been ordered.

Conclusions: Adrenal hemangiomas are infrequent, but they should be included in the differential diagnosis of adrenal masses. They can masquerade as malignant lesions. Surgical treatment is often indicated in order to ascertain the diagnosis and to avoid complications.