Cavernous hemangiomas are rare tumors. They are benign lesions that histopathologically consist of vascular lacunae lined by a single layer of endothelial cells [6].
Most are non-functioning tumors; only few secreting adrenal hemangiomas have been described until now [7].
Adrenal hemangiomas are mostly unilateral lesions, which appear between the ages of 50 and 70 years, more frequently in women (2:1 female-to-male ratio) [3].
Adrenal hemangiomas are often asymptomatic until the size of the mass has grown significantly and they are discovered accidentally during imaging studies [8]. The tumor size has ranged from 2 to 25 cm in diameter, and the weight has ranged from a few grams to 5 kg [6]. Our mass falls within these characteristics.
According to Noh et al., the most common symptom was flank pain or distress (21.2%) [8]. Our patient had a right upper quadrant abdominal pain.
Among the imaging methods to characterize the adrenal masses, ultrasound appearance is non-specific, hypoechogenic or heterogeneously echogenic [9], while CT is the more useful. On CT, the adrenal hemangioma appears as a well-encapsulated, heterogeneous, hypodense lesion that shows peripheral patchy enhancements on contrast-enhanced CT [10], with spotty calcifications probably due to phleboliths in dilated vascular spaces [7]. These characteristics are non-specific, because they are also present in other adrenal tumors; therefore, the definitive diagnosis is postoperative, after histopathological evaluation [7, 8].
It is important to make a differential diagnosis with renal tumors, other adrenal tumors, and metastases of breast, renal, gastrointestinal, lung, and melanoma cancers [11]. On histopathological inspection, cavernous hemangiomas consist of blood-filled sinusoidal canals that, especially at the periphery of the lesion, determine the characteristic pattern of peripheral patchy contrast enhancement seen on CT imaging [11]. Most of these tumors may have areas of thrombosis, hemorrhage, necrosis, and contextual calcifications [6].
On other useful imaging modality is magnetic resonance. It may show homogeneous well-encapsulated masses hypointense on T1-weighted images with central hyperintense signal and with hyperintense signal on T2-weighted images, as a consequence of bleeding and calcification [1, 6]. Our patient did not perform this exam due to his clinical condition.
The indications for resection of this neoplasm are for masses larger than 3.5 cm, to relieve mass effect symptoms, to exclude malignant tumors, and to avoid complications such as retroperitoneal hemorrhage and rupture [12]. Our patient had a lesion of about 18 cm and was anemic, so he underwent urgent right adrenalectomy with an intraperitoneal laparoscopic approach.