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Renal hemangioma is an uncommon benign tumor which usually causes pain-lessor painful
gross hematuria. Its preoperative diagnosis is extremely difficult oreven impossible.
We experienced three cases of renal hemangioma, located mainly at the pelvo-calyceal junction
or in the inner medulla. US demonstrated variable echogenecity,and CT revealed a lack of
significant enhancement. Where there is gross hema-turiain a young adult, especially when the
renal mass located in the pelvoca-lyceal junction or inner medulla shows little enhancement on
CT, renal heman-gioma should form part of the differential diagnosis.


Hemangioma is a rare tumor found in the urinary tract. Though it may oc-cur in any part of
the tract, the kidney is most frequently affected, fol-lowed by the urinary bladder, ureters, and
urethra (1 -4). It is one of the benign causes of hematuria in young adults. Diagnosis is often
difficult and preopera-tive diagnosis is rare (5 -7). An understanding of the radiological findings
of this rareentity may, however, facilitate its preoperative diagnosis, which may require limited
renal resection (8, 9). We report the radiologic findings of three cases of renal heman-gioma,
including those of US and CT scans.
CASE REPORT S
Case 1
A 31-year-old man presented with colicky abdominal pain and gross hematuria. He complained of
frequency, dysuria, and a residual urine sensation after voiding. Excretory urography (IVU) showed
smooth extrinsic indentation in the lower pole ca-lyx. Ultrasonography revealed a well-defined
echogenic mass containing multiple ane-choic areas in the inferior pole of the right kidney (Fig.
1). Selective renal angiography showed avascularity of the mass and displacement of the interlobar
and segmental ar-teries. Radical nephrectomy was performed. The mass was spongy-like and
consisted of multiple blood-filled spaces; microscopic examination showed it was located in the
inner medulla. The pathologic findings were consistent with cavernous hemangioma (Table 1).
Case 2
A 43-year-old man presented with gross hematuria and pain in the left flank. US demonstrated a
1.5-cm-sized mass in the pelvis of the left kidney, which was isoechoic to renal cortex (Fig. 2A).
There was also an echogenic blood clot in the urinary blad-der. Enhanced CT scan showed a
lobulated, low attenuated mass adjacent to the renal pelvis (Fig. 2B). The renal mass, the density
of which was 35.2 and 44.4 Hounsfield units on unenhaned- and en-hanced CT scans, respectively,
did not show significant en-hancement. Because of the possibility of malignancy, a left
nephrectomy was performed. On patholgic examination revealed multiple vascular channels of
variable size be-neath the pelvic mucosa. The pathologic diagnosis was cav-ernous hemangioma.
Case 3
A 43-year-old man presented with left lower abdominal pain which had lasted for one month. He
had a history of renal tuberculosis and a left ureteral stone. Physical exami-nation was
unremarkable. US showed a mass, about 2 cm in size and slightly hyperechoic to renal cortex, in
the low-er pole of the left kidney. It had poor margin. Unehanced CT scan showed a lobulated
mass with higher attenuation than the renal parenchyma; after the intravenous administration of
contrast material, the mass did not show signifi-cant enhancement (Fig. 3A). Renal cell carcinoma
was di-agnosed, and the patient was referred for left nephrecto-my. Pathologic analysis of the
specimen showed a hemor-rhagic lesion in the corticome-dullary junction of the lower pole (Fig.
3B). Microscopical-ly, the hemorrhagic area was seen to composed of capillary-sized vessels, and
there was no evidence of malignancy.


D I S C U S S I O N
Although renal hemangioma can be found in any part of the kidney, the most frequent location is
the tip of the papilla. The submucosal region, the papilla, and the medul-la account for 90% of
anatomic locations, and the renal parenchyma and capsule the rest (2, 5 -7).
Renal hemangiomas are usually solitary and unilateral, without significant side or sex predilection,
but in 12% of the cases are multiple. Hemangiomas of the urinary tract are generally considered
to be an isolated disease, but may be associated with tuberous sclerosis, Sturge-Weber syn-drome,
and Klippel-Trenaunay-Weber syndrome. The size of a renal hemangioma ranges from 1 -2 cm in
diameter to as large as the kidney itself (1 -5, 7, 9).
Clinical symptoms including colicky painful or painless intermittent hematuria frequently appear in
the third or fourth decade (1 -5). In our cases, painful hematuria was encountered in two patients
and flank and abdominal pain in all three.
Because there are no specific clinical or radiological find-ings for the tumors, renal hemangiomas
are often missed. It is impossible to detect them on IVU unless they are large enough to produce
calyceal deformity or a filling defect.
Their angiographic appearance varies and may be as hy-pervascular, hypovascular, or normal.
The US findings of renal hemangiomas are similar to those of liver hemangiomas, which on
ultrasound is often echogenic (2). A hypoechoic rim, intratumoral cysts, and the absence of
acoustic shadowing are important findings that may help distingish renal cell carcinoma from
an-giomyolipoma (10, 11). In our cases, the mass was hypere-choic in two patients, and isoechoic
to renal parenchyma in the other. In one of two patients with hyperechoic heman-gioma, the mass
contained anechoic areas in the center, corresponding to blood-filled spaces (Fig. 1). There was no
visible hypoechoic rim or posterior shadowing. In contrast to angiomyolipoma, the echogenecity of
which is in most cases equal to that of renal sinus (11), the echogenecity of hyperechoic
hemangiomas was less than that of renal sinus.
As most renal hemangiomas are located in the renal pelvis or at the medullary junction, the
possibility of a renal pel-vic tumor such as transitional cell carcinoma should be considered (12).
The US findings are nonspeficic, and may mimick more common tumors of the kidney, including
re-nal cell carcinoma and transitional cell carcinoma.
There are few descriptions of the CT findings of renal he-mangioma.
The tumor may enhance on injection of intra-venous contrast material, but are not usually
encapsulated (2). In two of our cases, however, the lesion was not signif-icantly enhanced. The
reason for this is not clear, but it might be due to intratumoral hemorrhaging of the mass.
Therapeutic measures for renal cavernous hemangioma range from no therapy to total nephrectomy
(2, 5, 8).
Management includes observation, nephrectomy, hem-inephrectomy, papillectomy and embolization.
In a healthy patient with mild to moderate hematuria who is clinically and radiographically well,
observation is not contraindicat-ed.
Renal hemangioma is seldom diagnosed preoperative-ly, and it is therefore impossible to
recommend specific treatment (4). Generally, surgery is considered when the tumor causes
symptoms such as life-threatening hemor-rhage, or when it is difficult to distinguish the lesion
from a disease such as carcinoma which requires nephrectomy.
Hemi- or total nephrectomy is the procedure of choice (1, 4, 7), and radiation therapy and
transarterial embolization are sometimes employed (1, 4, 6, 11).
In conclusion, the definitive preoperative diagnosis of re-nal hemangiomas is very difficult, and in
order to establish this, operative proof is required. Renal hemangioma shou-ld, however, be
included in the differential diagnosis, espe-cially when CT scanning reveals little enhancement of a
the renal mass located at the pelvocalyceal junction or in the inner medulla.





Fig. 1. Renal hemangioma in a 31-years-old man.
Longitudinal US shows a well-defined round echogenic mass le-sion
(arrows) containing multiple anechoic areas in the lower
pole of the right kidney.

Fig. 2. Renal hemangima in a 31-years-old man.
A . US shows a 1.5 cm-sized mass (arrow) in the pelvis of the left kidney, which is isoechoic to renal
parenchyma.
B. Enhanced CT scan shows a non-enhancing, low attenuated mass with lobulated margin (arrows)
adjacent to the pelvis.



Fig. 3. Renal hemangioma in a 31-years-old man.
A. Enhanced CT scan shows a non-enhancing mass with lobulated margin in the lower pole of the left
kidney. Unenhanced CT scan
shows a high-attenuated mass suggesting hemorrhage (not shown).
B. Gross pathologic specimen shows a hemorrhagic lesion (arrows) at the corticomedullary junction of the
lower pole.



Table 1. Summary of US, CT, and Pathologic Findings of Three Renal Hemangiomas
US CT
Size (cm) Location S u b t y p e
E c h o g e n i c i t y* Hypoechoic Rim Enhancement M a r g i n
Case 1 Echogenic mass ---1.8 medulla cavernous
with anechoic center
Case 2 Isoechoic -little lobulated 1.5 submucosa cavernous
of renal pelvis
Case 3 Slightly hyperechoic -little lobulated 2 . 0 c o r t i c o m e d u l l a r y c a p i l l a r y
j u n c t i o n
N o t e .─* US echogenecity was compared with surrounding normal renal parenchyma.