A Huge Adrenal Incidentaloma With Suspicious Features and a Complete Cure!

Introduction: Adrenal hemangioma is an extremely rare benign vascular tumor occurring in adrenal glands (~0.01%). Its clinical presentation is usually vague and is frequently discovered as an incidentaloma. These tumors are mostly encountered at 40–70 years of age and are twice as common in women. We report a case of a nonfunctioning large adrenal incidentaloma with suspicious features on imaging. This in fact was an adrenal hemangioma diagnosed postoperatively with histopathology. Case Description: Our patient was 76 year old Hispanic male, active smoker, with medical history significant for well controlled Type 2 diabetes, hyperlipidemia and hypertension. He was seen for evaluation and management of an adrenal incidentaloma discovered on iv contrast enhanced CT performed to investigate recurrent hematuria. Imaging of the abdomen and pelvis revealed a posterior bladder mass measuring up to 2.6 cm and 20.1 cm x 17.1 cm x 20.5 cm left adrenal mass with few punctuate calcifications displacing the left kidney and spleen- findings concerning for adrenal cortical carcinoma. The right adrenal gland unremarkable. Given the size of mass and suspicious features hormonal workup was initiated in preparation for surgery. Workup was unremarkable for Pheochromocytoma {24 hour urine metanephrine 124 (nl: 0–300), normetanephrine 440 (nl: 0–400)}, Cushing syndrome {(negative 1 mg overnight dexamethasone suppression test), ACTH 22 (nl: 7—63)} and hyperaldosteronism (Aldosterone 5, renin 0.7). Patient underwent an uncomplicated total radical left adrenalectomy, he had no evidence of invasive disease. Pathology showed a large entirely encapsulated heterogenous adrenal mass weighing 2300 grams with largely solid (80%) and cystic components. There was hemorrhage and extensive infarcts- findings consistent with a Hemangioma. He recovered well. No evidence of adrenal insufficiency was noted on subsequent follow-ups. He had a normal surveillance CT scan at 6 months. Discussion: Adrenal hemangiomas are difficult to differentiate clinically and radiographically from adrenal cortical cancer. They must be evaluated to exclude hormonal hypersecretion and malignancy. Previous case reports hypothesized that adrenal hemangiomas may have functional hypersecretion due to mass effect on the adrenal parenchyma. There was no evidence of this in our patient. These tumors increase in size overtime. Surgical resection is often necessary to rule out any malignant potential and alleviate symptoms secondary to mass effect. Adrenal hemangiomas though rare and must be considered in the differential diagnosis.