Adrenal adenoma with organizing hematoma: diagnostic dilemma at MRI

Adrenal Hemangioma: A Common Tumor at Uncommon Site

Adrenal hemangiomas are rare vascular tumors. These are benign, mostly nonfunctioning and asymptomatic. Cavernous adrenal hemangiomas are more common in the elderly, with female preponderance. A computed tomography (CT) scan can diagnose their benign nature. Most cases are managed surgically, and laparoscopy is the most common approach followed nowadays.

A young female presented with nausea, pain, and a vague mass palpable in the right abdomen. With CT findings favoring benign lesion or nonfunctioning adenoma but symptomatic, the patient had to undergo diagnostic laparoscopy and adrenalectomy. Adrenal hemangiomas are rare lesions. Moreover, involving a young female further makes their diagnosis difficult. Hence, they must be kept as one of the differential diagnosis in evaluation of adrenal mass in young females.

Adrenal Cavernous Hemangioma: A Rarely Perceived Pathology-Case Illustration and Review of Literature

Cavernous hemangiomas are endothelial tumors that rarely affect the adrenal glands. Most of these tumors remain silent and are incidentally found on abdominal imaging. Hardly ever, these tumors are endocrinologically functional. They may present as vague abdominal pain. Surgical resection remains the mainstay for large masses. In this paper, we are presenting a case of adrenal cavernous hemangioma in a 83-year-old male patient who initially presented for workup of vague abdominal and bilateral flank pain. A computed tomography scan of the abdomen showed an 8 cm right adrenal adenoma which was metabolically nonfunctional. The mass was completely resected through an open subcostal incision, with no encountered postoperative complications. A highlight of all published cases of adrenal hemangiomas since 1955 is also presented and reviewed.

Papillary renal cell carcinoma with massive hematoma mimicking hemangioma

It is extremely rare that papillary renal cell carcinoma has a massive hemorrhage. We report a case of papillary renal cell carcinoma with a massive hemorrhage which showed hemangioma-like imaging findings such as a globular discontinuous enhancement on the corticomedullary phase with a gradual centripetal fill-in pattern on the excretory phase on computed tomography and heterogeneously hyperintensity on T2-weighted magnetic resonance imaging. We also discuss a plausible mechanism explaining such imaging findings, with reference to pathological findings.

Diagnostic dilemmas in enlarged and diffusely hemorrhagic adrenal glands

We have noted an increasing number of cases of enlarged adrenal glands where the underlying diagnosis was masked by a diffusely hemorrhagic process. We identified from our database 59 cases (32 consults, 27 routine) of adrenal glands with diffuse (>25%) hemorrhage received between 2000 and 2014. Fifty-three adrenalectomies and 6 biopsies were identified. The diagnoses after central review were 41 adrenocortical adenomas, 1 nodular adrenocortical hyperplasia with associated myelolipoma, 1 benign adrenocortical cyst, and 10 nonneoplastic adrenal glands with hemorrhage. A definitive diagnosis for the 6 biopsies was precluded by the sample size. The adrenocortical adenomas (size, 1-13 cm; 25%-95% hemorrhage) showed clear cell change in the neoplastic area (10%-80% of the tumor), 19 showed focal calcification (1 with ossification), 11 showed areas of papillary endothelial hyperplasia, 10 showed scattered lymphoplasmacytic inflammation, 6 showed benign cortical tissue extending beyond the adrenal capsule into soft tissue, 1 showed necrosis in the form of ghost cells, 2 showed lipomatous change, and 6 were associated with incidental benign lesions (1 cortical cyst, 1 schwannoma, and 4 myelolipomas). Twenty-four of the adrenocortical adenomas were consults where the referring pathologist had trouble classifying the lesion. Of the 10 nonneoplastic adrenals (4.5-22 cm; 40%-80% hemorrhage), 2 were consults. In summary, pathologists have difficulties recognizing adrenocortical adenomas in the setting of a massively enlarged and hemorrhagic adrenal gland. Although there is a correlation between adrenocortical malignancy and size, hemorrhage into nonmalignant adrenal glands can result in markedly enlarged adrenals.

Computed tomography, magnetic resonance imaging and 11C-metomidate positron emission tomography for evaluation of adrenal incidentalomas

BACKGROUND

Given the higher sensitivity of modern computed tomography (CT) scanners, adrenal incidentalomas are being discovered increasingly often. This implies a growing quantitative diagnostic and clinical problem. CT and/or magnetic resonance imaging (MRI) and usually thorough hormonal testing are routinely used to determine the origin of these lesions. Recently, positron emission tomography (PET) using the tracer (11)C-metomidate (MTO) has been established as an alternative diagnostic method with high sensitivity for identifying adrenocortical lesions. The aim of this study was to evaluate the clinical use and value of MTO-PET compared to CT and MRI in the characterisation and work-up of adrenal incidentalomas.

METHODS

Initially, we retrospectively evaluated 20 adrenal incidentalomas in patients who had undergone CT, MRI and MTO-PET and from whom we had either histopathological diagnosis or clinical follow-up data. After this analysis we conducted a prospective study in order to compare the imaging modalities. In the latter study, 24 incidentalomas were imaged by CT, MRI and MTO-PET and the results were correlated to those from histopathology (n=8) and clinical diagnosis after follow-up (n=16).

RESULTS

In the retrospective analysis, MRI and especially MTO-PET, correlated well to histopathology and clinical diagnosis after follow-up, whereas specificity with CT was low. This was possibly due to the presence of several haematomas/fibrosis which were misdiagnosed as adrenocortical adenomas. In the prospective cohort, sensitivity and specificity with CT were 0.71 and 1.0, respectively, and further characterisation by MRI increased these values to 0.86 and 1.0, whereas maximum sensitivity and specificity were reached when MTO-PET was added.

CONCLUSION

The diagnosis of an adrenocortical adenoma may be established by CT in most patients and by MRI in an additional number. For the few remaining patients needing further characterisation, MTO-PET is advantageous as an additional imaging modality.