FRI260 Adrenal Hemangioma, Mimicker Or Malignant?

Abstract

Abstract Disclosure: C. Pham: None. C.E. Chiu: None. B. Barnett: None. Background: Adrenal hemangioma is a rare condition that can mimic other adrenal pathologies. Clinical Case: A 49 year old male with history of heart failure presented with cardiogenic shock requiring inotropes and heart transplant evaluation. On CT patient was noted to have a 2.2 cm left adrenal nodule containing calcifications. Initial tests had indeterminate 1 mg overnight DST, normal plasma free metanephrines and elevated plasma free normetanephrines 2.06 nmol/L (0-0.89 nmol/L). PRA was 22.82 ng/mL/hr (0.25-5.82 ng/ml/hr) with aldosterone 10.8 ng/dL (<16 ng/dL) on spironolactone. 24 hour urine tests showed normal free cortisol 9.8 mcg/24hr (4-50 mcg/24hr) and elevated total metanephrines at 1245 mcg/24hr (182-739 mcg/24hr), metanephrines at 303 mcg/24hr (58-283 mcg/24hr), and normetanephrines at 942 mcg/24hr (88-649 mcg/24hr). Adrenal CT demonstrated HU of 59 units on noncontrast phase, with -86.7% absolute washout and -17.6% relative washout. I-123 MIBG Scan was obtained with no radiotracer uptake noted. Patient underwent laparoscopic adrenalectomy for definitive diagnosis and was found to have adrenal hemangioma with CD31 and ERG with hemosiderin laden macrophages on pathology. Adrenal hemangioma is rare and can mimic other adrenal pathology. Most patients present with abdominal symptoms such as flank pain or are found to have an adrenal incidentaloma on imaging. CT findings are associated with heterogenous internal structure, peripheral patchy enhancement, or calcifications, which are also seen in malignancy and pheochromocytoma. In all cases, HU if recorded are noted to be >10 on the unenhanced phase and <60% absolute washout. In one case series of 52 adrenal hemangiomas, only 3 patients had positive biochemical tests and on average were 11 cm in size. Formal diagnosis is made pathologically. Treatment for adrenal hemangioma is typically resection for symptomatic relief, with some patients with small lesions electing to observe. In all surgical cases reviewed in a case series adrenalectomy was pursued as opposed to needle biopsy due to large size of lesion and concern for possible malignancy. In this specific case, biochemical testing was falsely positive given the patient’s presentation of cardiogenic shock and inotropes causing elevated catecholamine levels and given imaging findings could not fully rule out pheochromocytoma. Given the small size of lesion, the patient in a non-transplant setting likely could have pursued close observation as opposed to resection. Conclusion: Adrenal hemangioma can have imaging characteristics that can mimic several other adrenal pathological conditions, such as malignancy or pheochromocytoma. Treatment through surgical management is likely not necessary in patients with hemangioma, though would be important in ruling out other adrenal pathology. Presentation: Friday, June 16, 2023