AJR 2004; 182:411-414
© American Roentgen Ray Society
Sonography, CT, and MRI of Giant Cavernous Hemangioma of the Kidney: Correlation with Pathologic Findings
Remy W. F. Geenen1,
Michael A. den Bakker2,
Chris H. Bangma3,
Shahid M. Hussain1 and
Gabriel P. Krestin1
1 Department of Radiology, Erasmus Medical Center, PO Box 2040, Rotterdam, 3000
CA, The Netherlands.
2 Department of Pathology, Erasmus Medical Center, Rotterdam, 3000 CA, The
Netherlands.
3 Department of Urology, Erasmus Medical Center, Rotterdam, 3000 CA, The
Netherlands.
Received January 24, 2003;
accepted after revision July 21, 2003.
Address correspondence to R. W. F. Geenen
(r.geenen{at}erasmusmc.nl).
Introduction
Hemangiomas are benign vascular tumors that probably arise from embryonic
rests of unipotent angioblastic cells
[1]. A distinction is made
between capillary and cavernous forms. The kidney is the most commonly
affected organ of the urinary tract; 198 cases of renal hemangiomas had been
reported as of the early 1990s. Renal hemangiomas usually occur as a single
entity, showing no predilection for either sex. The most common sites of
occurrence are the pyramids of the kidneys and the renal pelvis. Renal
hemangiomas usually measure 1–2 cm, but their size can range from
microscopic to larger than 10 cm. The symptoms produced can range from none to
gross hematuria and colic due to the passage of blood clots
[1]. Renal hemangiomas are
benign and extremely rare; in one series in which 17,941 patients were
studied, only one renal cavernous hemangioma was found
[2]. Little is known about
imaging this condition. We report the sonographic, CT, and MRI features of a
pathologically proven renal cavernous hemangioma.
Case Report
A 22-year-old woman presented in a community hospital with recurring
cystitis that sometimes was accompanied by fever. The patient reported that
for more than 5 years, she had experienced a dull ache in the left flank.
Routine hematology and chemistry blood tests showed no abnormalities. The
initial finding for urinary sediment was 10–20 leukocytes on a
high-power magnification. Results from a urine culture and cytology analysis
showed no abnormalities. Sonography depicted an enlarged left kidney with no
distinct tumor in it. CT scan confirmed the enlarged left kidney. In the
central part of the kidney, a mass with low density was seen. The possibility
of xanthogranulomatous pyelonephritis was considered.
Because sterile pyuria was found, we performed a serology test for
schistosomiasis and the Mantoux test for tuberculosis. Findings for both
examinations were negative. Cystoscopic findings were normal, and retrograde
urography of the left kidney showed a normal pelvis and calices. Renography
revealed decreased function in the lower pole of the left kidney (46%) and
normal function in the right kidney (54%). A sonographically guided renal
biopsy obtained normal renal tissue. The patient was referred for further
diagnosis and therapy. Results of routine chemistry and hematology tests were
also normal. The urinary sediment now showed microscopic hematuria and no
pyuria. A urine culture obtained at this time showed no pathogenic
microorganisms. Sonography was repeated with a 3.5-MHz transducer (Sonoline
Elegra, Siemens, Erlangen, Germany) and showed an enlarged (13.1-cm) left
kidney; the prominent hilum displayed internal hypoechogenic areas. Power
Doppler sonography revealed a normal vascular pattern
(Fig. 1A). The results of the
blood tests and sonography led us to consider renal cell carcinoma as a
possible differential diagnosis, although the patient was young and the
sonographic appearance was not pathognomonic.
In an attempt to characterize the tumor as benign or malignant, we
performed MRI with a 1.5-T scanner (Gyroscan ACS-NT, Philips Medical Systems,
Best, The Netherlands). It revealed an enlarged left kidney with abnormal
signal intensity centered in the medulla, with fingerlike extensions spreading
into the renal cortex. (Fig.
1B). Compared with the normal tissue in the right kidney, the mass
in the left kidney had low signal intensity on T1-weighted images and high
signal intensity on T2-weighted images. The renal pelvis was normal
(Fig. 1C), which ruled out a
transitional cell carcinoma, and on T2-weighted images, several low intensity
ring- or tubelike areas resembling flow voids were seen in the mass
(Fig. 1B). The left renal vein
was enlarged. During the arterial phase of dynamic contrast-enhanced MRI, the
left kidney displayed a normally enhancing thinned cortex. Contrast material
was seen filling the mass during the venous phase (Figs.
1D and
1E). We performed MDCT
angiography (Volume Zoom, Siemens) to visualize the feeding and draining
vessels of this highly vascular lesion in more detail and observed thinning of
the renal cortex; thick, enhancing vascular channels
(Fig. 1F); and the dilated left
renal vein (Fig. 1G).
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Fig. 1B. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Coronal T2-weighted image reveals high signal intensity
centered in medulla of kidney with fingerlike extensions over cortex. Some
flow voids (arrow) are visible.
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Fig. 1C. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Axial T2-weighted image obtained with fat suppression
shows high-signal-intensity lesion and normal renal pelvis
(arrow).
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Fig. 1D. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Contrast-enhanced axial T1-weighted image obtained
during arterial phase shows thinned, normally enhancing cortex with
low-signal-intensity lesion.
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Fig. 1E. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Contrast-enhanced axial T1-weighted image obtained
during venous phase shows contrast filling lesion and dilated left renal vein
(arrow).
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Fig. 1F. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Coronal multiplanar reconstruction of CT angiogram
shows thinning of cortex and contrast filling of vascular channel
(arrow) in lower pole of left kidney.
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The presence of the flow voids, early enhancement of vascular channels, and
filling of the mass with contrast material during the venous phase caused us
to suspect a renal cavernous hemangioma. It was impossible to rule out
malignancy, so a nephrectomy was performed and the kidney was submitted for
pathologic examination. Cystic structures and microcystic conglomerates were
seen protruding from the cortical surface
(Fig. 1H) covered by the renal
capsule and focally involving the hilum. Histologic findings were normal renal
tissue consisting of normal glomeruli and tubules intermingled with vascular
structures of widely varying diameters and with considerable variation in
vessel wall thickness. The vascular structures were lined by flattened
endothelial cells. Cellular atypia or mitosis was not observed, although the
normal renal architecture was distorted by the lesion. A cavernous hemangioma
was diagnosed. The biopsy specimen obtained earlier must have been acquired in
the normal renal tissue.
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Fig. 1H. —22-year-old woman with dull ache in left flank and
microscopic hematuria. Photograph of gross pathologic specimen from sliced
kidney shows renal cortex and medulla with multicystic lesion composed of
abnormal blood vessels, many containing blood and fibrin.
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Discussion
In the literature, the radiologic features of renal cavernous hemangiomas
are not well described, and reports of large studies are lacking. Descriptions
of renal cavernous hemangiomas on angiography have included a normal
appearance [3], a hypovascular
mass producing varying degrees of caliceal deformity
[4], and a hypervascular mass
with rapid arteriovenous shunting
[5]. Three case reports all
described the sonographic appearance of renal cavernous hemangioma as a
hyperechoic lesion [2,
6,
7], in contrast to the
hypoechoic lesion we found. No color or power Doppler sonography was used in
the previously cited case reports. Although we found no description of the
features of the renal cavernous hemangioma on CT angiography, we found its CT
appearance described as a mass that is isodense relative to the renal cortex
during the excretory phase [2],
a homogeneously enhancing mass with peripheral hypoenhancement during the
portal phase [6], and a solid
lesion of 32 H before and 58 H after contrast injection
[7].
In our patient, CT angiography revealed enhancement of thick vascular
channels and a dilated left renal vein. It seems likely that any of the three
angiographic patterns of renal cavernous hemangiomas described in the
literature
[3–5]
could also appear on CT angiography of this lesion. To our knowledge, no case
report in the English-language literature describes the MRI appearance of a
renal cavernous hemangioma. The abnormal signal intensity—hypointense on
T1-weighted images and hyperintense on T2-weighted images—was centered
in the medulla with fingerlike extensions over the renal cortex. On
T2-weighted images, flow voids were seen. The normal arterial enhancement of a
thinned cortex and the filling-in of the mass with contrast material during
the venous phase were additional features.
Renal cavernous hemangiomas typically are pathologically proven, fibrous,
thick-walled vascular structures that are comparable to the lesion described
in this report. Blood flow is often slow in the channels of this lesion, which
results in normal findings on power Doppler sonography, flow voids, and venous
phase filling of the mass after contrast administration. In most patients,
treatment consists of nephrectomy, either to rule out a renal cell carcinoma
or to stop severe hematuria.
In summary, sonography showed the mass in our patient as a hypoechogenic
renal mass with normal power Doppler signals. MRI showed the lesion, best seen
on T2-weighted sequences, as a hyperintense mass with some flow voids. After
contrast administration, the mass became filled with contrast material. On CT
angiography, enhancement of thick vascular channels and a dilated renal vein
were depicted. This combination of findings suggests a renal cavernous
hemangioma, although a preoperative diagnosis remains difficult because there
are no pathognomonic imaging findings.
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Introduction
Case Report
