SUN-480 - Benign by Name, Not by Nature: Adrenal Hemangioma with Perioperative Adrenal Insufficiency

Background

Adrenal hemangiomas are rare benign vascular tumors representing about 1.33% of adrenalectomy specimens, often discovered incidentally during imaging. They are typically non-functional, with most patients remaining asymptomatic at diagnosis. Reported complications include spontaneous rupture with hemorrhagic shock and, in rare cases, mild autonomous cortisol secretion (MACS) with subsequent postoperative adrenal insufficiency. We present a rare case of an incidentally identified adrenal hemangioma complicated by perioperative adrenal insufficiency.

Case presentation

A 79-year-old woman, recently treated with high-dose corticosteroids for polymyalgia rheumatica, presented for chronic constipation evaluation. Abdominal CT incidentally revealed a left sided 11.8 x 9.1 cm heterogenous adrenal mass with internal coarse calcifications.

She reported no symptoms of functional adrenal pathology. Although interpretation of cortisol and ACTH was limited by exogenous steroids, laboratory evaluation including plasma metanephrines indicated a non-functioning adrenal mass. Given radiographic concern for malignancy and absence of metastatic disease, surgical resection was pursued.

She underwent left adrenalectomy. Intraoperatively, she developed significant hypotension responding promptly to intravenous hydrocortisone, raising concern for perioperative adrenal insufficiency. Postoperatively, she remained hypotensive, requiring ICU admission, vasopressors and stress dose hydrocortisone. Vasopressor support was discontinued, and hydrocortisone was tapered to oral dose prior to discharge. Final pathology revealed benign adrenal hemangioma.

Conclusion

This case highlights the diagnostic challenges of adrenal hemangiomas, whose imaging features often overlap with pheochromocytoma and adrenal carcinoma. The perioperative adrenal insufficiency is a clinically significant finding. Although typically hormonally inactive, rare cases demonstrate MACS with postoperative adrenal insufficiency requiring up to 12 months of recovery. Postoperative adrenal insufficiency occurs in 46–54% of patients undergoing adrenalectomy for presumed non-functioning masses, particularly in elderly patients with diabetes, hypertension, obesity, and larger tumors.

This underscores the need to anticipate adrenal insufficiency in elderly patients undergoing adrenalectomy, likely due to contralateral adrenal suppression from subtle cortisol autonomy. Perioperative glucocorticoid coverage and postoperative monitoring should be considered, especially in patients with MACS or recent glucocorticoid exposure affecting cortisol testing.

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