Adrenal hemangioma is a rare benign adrenal tumor originating from vascular endothelial cells. Approximately 80-100 cases have been reported in the literature, with the cavernous type being most common. It is more frequently detected in women aged 50-70 years and most are asymptomatic — discovered incidentally. The tumor frequently reaches large sizes (>10 cm) and demonstrates peripheral nodular enhancement and centripetal filling pattern similar to liver hemangioma. However, in large lesions, the imaging pattern may be atypical due to hemorrhage, thrombosis, fibrosis, and calcification. It does not secrete hormones and has no risk of malignant transformation. Surgical resection is curative for large or symptomatic lesions; spontaneous rupture is rare but can be life-threatening.
Age Range
40-80
Peak Age
60
Gender
Female predominant
Prevalence
Rare
Adrenal hemangioma arises from hamartomatous proliferation of vascular endothelial cells within the adrenal gland. Histologically, it consists of blood-filled cavernous spaces (sinusoids) — these spaces are lined by a single layer of endothelial cells and separated by fibrous septa. The slow blood flow within cavernous spaces forms the basis of the peripheral nodular enhancement pattern: contrast agent first enters peripheral sinusoids and slowly progresses to central sinusoids (centripetal filling). In the center of large hemangiomas, blood flow is very slow or stasis develops → central thrombosis → organized thrombus → fibrosis and calcification. This central fibrotic-calcified area manifests as central low density on CT and low T2 signal on MRI. Hemorrhage develops from rupture of cavernous space walls and creates T1 hyperintense foci. The presence of phleboliths (organized thrombus calcifications) is highly specific for hemangioma. The tumor's lack of hormone secretion is explained by its vascular origin without adrenal cortical/medullary cells.
The pattern starting with peripheral nodular enhancement at aortic density in arterial phase and showing progressive centripetal filling in delayed phase is pathognomonic for adrenal cavernous hemangioma. This enhancement pattern is identical to the classic pattern in hepatic cavernous hemangioma and reflects the slow sinusoidal blood flow of cavernous spaces.
On non-contrast CT, a large (generally >6 cm), well-defined, heterogeneous density adrenal mass is seen. Central areas show low density (thrombosis, fibrosis, or hemorrhage). Peripheral punctate calcifications (phleboliths) are highly specific for hemangioma and can be seen in up to 50% of cases. Phleboliths appear as round or oval, smooth-bordered, small (<5 mm) calcifications. Hemorrhagic foci may appear as hyperdense areas in large lesions.
Report Sentence
A large, heterogeneous density mass is seen in the adrenal lodge with peripheral punctate calcifications (phleboliths) consistent with hemangioma.
On contrast-enhanced CT, peripheral nodular enhancement is observed in the arterial phase — peripherally enhancing nodular areas at density close to the aorta. Central areas do not enhance. This pattern is identical to the classic peripheral nodular enhancement in hepatic cavernous hemangioma. The enhancing peripheral nodules represent patent cavernous spaces at the tumor periphery. Enhancement may be asymmetric in large lesions.
Report Sentence
The mass demonstrates peripheral nodular enhancement at aortic density in the arterial phase; pathognomonic finding consistent with cavernous hemangioma.
In the delayed phase (5-15 minutes), peripheral enhancement progresses centrally (centripetal filling). The tumor enhances progressively; however, the center of large lesions may not enhance at all due to thrombosis/fibrosis ('scar' area). Complete filling may be seen in small lesions while incomplete filling is more typical in large lesions. This centripetal filling pattern is based on the same mechanism as delayed filling in liver hemangioma.
Report Sentence
Progression of peripheral enhancement centrally (centripetal filling) is observed in the delayed phase; this pattern strongly supports the diagnosis of adrenal cavernous hemangioma.
On T2-weighted MRI, peripheral areas show markedly hyperintense signal ('light bulb' like) — reflecting the long T2 relaxation time of stagnant blood in cavernous spaces. Central areas show variable signal: thrombus shows low-intermediate T2 signal, fibrosis shows low T2 signal, hemorrhage shows stage-dependent signal. Calcified areas show signal loss on all sequences. This peripheral high, central low T2 signal pattern is characteristic of large adrenal hemangioma.
Report Sentence
The mass demonstrates peripheral markedly hyperintense with central low signal heterogeneous pattern on T2-weighted images; consistent with adrenal cavernous hemangioma.
On T1-weighted images, the mass shows heterogeneous signal. Patent cavernous spaces show low-intermediate T1 signal, while subacute hemorrhagic foci may be T1 hyperintense (methemoglobin). Chronic organized thrombus areas show intermediate T1 signal. The fibrotic central area shows low T1 signal. This T1 heterogeneity reflects the presence of blood products at different stages.
Report Sentence
The mass demonstrates heterogeneous signal on T1-weighted images with focal T1 hyperintense areas consistent with subacute hemorrhage.
On Tc-99m labeled red blood cell scintigraphy (RBC scan), delayed blood pool activity is observed in the adrenal mass. Peripheral activity in early phase with progressive central filling in delayed phase (1-2 hours). This finding proves the lesion contains vascular spaces and strongly supports hemangioma diagnosis. Specificity is high but sensitivity is low for small (<3 cm) lesions.
Report Sentence
Delayed blood pool activity is observed in the adrenal mass on Tc-99m labeled red blood cell scintigraphy; pathognomonic finding strongly supporting hemangioma diagnosis.
Criteria
Wide, blood-filled cavernous spaces. Most common type. Endothelial-lined sinusoids separated by fibrous septa.
Distinct Features
Classic peripheral nodular enhancement pattern. Can reach large sizes (>10 cm). Phleboliths more common in this type.
Criteria
Consists of small, narrow capillary vessels. Very rare. Lobular proliferative capillary network.
Distinct Features
More homogeneous and rapid enhancement (different from cavernous). Smaller size. Peripheral nodular pattern may not be prominent — may show homogeneous early enhancement.
Criteria
Deviates from classic pattern due to extensive thrombosis, hemorrhage, or fibrosis. Usually in very large (>10 cm) lesions.
Distinct Features
Peripheral nodular enhancement may be atypical or minimal. Central calcification prominent. T2 hyperintensity decreased or heterogeneous on MRI. Imaging diagnosis difficult in this subtype — biopsy or surgery may be needed if malignancy cannot be excluded.
Distinguishing Feature
Adrenocortical carcinoma is irregularly bordered, heterogeneous mass without peripheral nodular enhancement. Carcinoma shows aggressive growth (vascular invasion, metastasis). Hormonal syndromes may accompany. Phleboliths not seen in carcinoma.
Distinguishing Feature
Pheochromocytoma shows early intense enhancement (diffuse, not peripheral nodular). Very bright T2 but different enhancement pattern. Associated with catecholamine elevation. MIBG positive. No phleboliths.
Distinguishing Feature
Metastasis with known malignancy history. Enhancement heterogeneous and irregular — no peripheral nodular pattern. Phleboliths and centripetal filling not expected. Metastasis may be bilateral.
Distinguishing Feature
Adrenal cyst is thin-walled, water-density (<20 HU), non-enhancing. Hemangioma is solid vascular mass with enhancement. Cyst shows very high homogeneous T2 signal while hemangioma shows heterogeneous T2.
Urgency
routineManagement
conservativeBiopsy
Not NeededFollow-up
12-monthAdrenal hemangioma is a completely benign tumor. When classic imaging findings are present, diagnosis can be made by imaging without biopsy. Follow-up is sufficient for asymptomatic small lesions. Surgical resection should be considered for large (>10 cm) or symptomatic lesions due to small but present risk of spontaneous rupture. Surgery or biopsy may be needed for large lesions with atypical imaging when malignancy cannot be excluded. Bleeding risk should be assessed if biopsy is planned. No hormone secretion and no functional evaluation needed.
Adrenal hemangioma is difficult to diagnose preoperatively due to its rarity. Peripheral nodular enhancement and T2 hyperintensity may show hepatic hemangioma-like pattern. Surgery may be considered for large lesions due to risk of spontaneous hemorrhage.