Coexisting adrenal hemangioma and aldosterone-producing micronodule presented as adrenal incidentaloma

Adrenal hemangiomas are rare benign vascular tumors, an uncommon cause of adrenal incidentalomas. We report a patient with coexisting adrenal hemangioma and aldosterone-producing micronodules within the same adrenal gland. A 67-year-old man was referred for an incidental left adrenal mass. Noncontrast computed tomography revealed a 1.6 × 1.4 cm lesion with an unenhanced attenuation value of 40 Hounsfield units. Initial hormonal evaluation was unremarkable except for an elevated aldosterone-to-renin ratio (ARR) of 115.6. On follow-up evaluation, the ARR decreased to 52.8, with a relatively low aldosterone concentration of 9.5 ng/dL (264 pmol/L; reference range, 2.52-39.2 ng/dL [69-1087 pmol/L]), yielding equivocal findings for primary aldosteronism. Serial imaging revealed growth to 3.4 × 2.8 cm over 3 years. Magnetic resonance imaging revealed a T2-hyperintense lesion with peripheral nodular enhancement and delayed centripetal filling, suggestive of adrenal hemangioma. Owing to continued growth, laparoscopic adrenalectomy was performed. Histopathological examination confirmed cavernous hemangioma. Given the marked postoperative reduction in ARR to 9.7, additional pathological review identified an adjacent CYP11B2-positive aldosterone-producing micronodule. This report illustrates that adrenal incidentalomas may have dual pathologies. An integrated assessment of imaging, biochemical findings, clinical course, and histopathology, together with close clinicopathological collaboration, is essential for accurate diagnosis and management.