Cavernous Hemangioma: A Rare Adrenal Tumor Associated With Hyperaldosteronism

Adrenal cavernous hemangiomas are rare benign venous malformations characterized by vascular dysmorphogenesis. A 53-year-old male patient was referred for a surgical consultation with a 5 cm heterogeneous, lipid-poor, incidental left adrenal mass. It was detected on a computed tomography (CT) scan performed for left upper quadrant pain. His past medical history was significant for poorly-controlled hypertension on a multi-drug regimen, anxiety, headaches, insomnia, and palpitations. Laboratory testing performed by his primary care physician revealed elevated plasma catecholamines, which were concerning for pheochromocytoma. A repeat workup by endocrinology and endocrine surgery showed biochemical evidence of primary hyperaldosteronism with an aldosterone/plasma renin ratio of 36.8 and normal plasma catecholamines and metanephrines. Due to the biochemical workup, size, and radiological features of the mass, a decision to proceed with a left adrenalectomy was made. The patient was started on phenoxybenzamine two weeks before surgery due to a high index of clinical suspicion for a pheochromocytoma, despite the equivocal biochemical workup. Surgical pathology revealed a cavernous hemangioma with pseudonodular thickening of the adrenal cortex without evidence of malignancy, adrenal adenoma, or pheochromocytoma. On follow-up, the patient was on fewer antihypertensive medications with normal blood pressure and a normalized aldosterone/plasma renin ratio. A diagnosis of cavernous hemangioma should be considered for adrenal masses of uncertain biology and biochemical activity.