Giant Cavernous Haemangioma of the Anterior Mediastinum

Cavernous hemangiomas of the anterior mediastinum is rare. We present a case of a 56-year-old male patient with a giant cavernous hemangioma of the anterior mediastinum, 18 cm in diameters, approached by left posterolateral thoracotomy. To the best of our knowledge, such a unique case has not been previously presented in the literature.


Introduction
Cavernous haemangioma is very rare benign tumour, presenting only in the 0.5% of all mediastinal masses [1]. It is generally located in the anterior mediastinum, and 75% of the cases are diagnosed before the age of 35. We present a case of a large sized cavernous haemangioma of the anterior mediastinum with radiological and operative findings.

Case Report
A 56-year-old male patient presented with back pain for the last three weeks. He had no medical history of a remarkable pathology and was not under any regular medication. Chest auscultation revealed lowered breath sounds on the left side. Chest x-ray and computed tomographic scan showed a left paracardiac mass of 18 cm in diameter ( Figure  1). The mass was thought to arise from the anterior mediastinum. It included a few millimetric calcifications. It was also displacing the heart towards the right hemithorax.
A left posterolateral thoracotomy was performed through the fifth intercostal space. The pulmonary adhesions with the mass were divided and a giant encapsulated tumour originating from the anterior mediastinum was excised with sharp and blunt dissection. The blood supply of the mass was originating from the proximal part of the left internal mammarian artery and ligated. The tumour was 18 cm in diameter ( Figure 2). Pathological examination revealed a mass weighing of 1075 gr. Histological examination revealed a well circumscribed vascular proliferative lesion including large thickwalled vessels with prominent muscular wall and cavernous spaces. The final diagnosis was cavernous haemangioma. The patient was discharged home six days after surgery after an uneventful postoperative period.

Discussion
Cavernous haemangioma of the anterior mediastinum is very rare with an incidence of less than 0.5% of all mediastinal masses [1]. Yamazaki et al. [2] reported that there were only 51 cases of mediastinal haemangioma reported in Japan in the last 50 years. To the best of our knowledge, this size of a mediastinal haemangioma has not been previously published in the literature. The most common symptoms are chest pain and dyspnoea and are generally caused by the pressure of the mass to the surrounding organs [1,3,4]. The only symptom in our case was the back pain for the last three weeks. Most tumours are encapsulated like in our case and 75% of the cases are diagnosed before the age of 35 [1]. Our patient was 56-years-old which might explain the large size of the tumour. Chest x-ray, thorax computed tomography (CT) scan and magnetic resonance imaging can be used for the diagnosis. Phlebolite is a specific finding which can be seen in chest x-ray and more commonly in CT scan which was not present in our case [5,6]. Calcification is another finding of the CT scan, which was also detected in our patient. Haemangiomas are classified as capillary, cavernous or venous types, according to the size of their vascular spaces. Cavernous and capillary haemangiomas are the most common types, but venous haemangiomas are extremely rare [4]. Our case was diagnosed as cavernous haemangioma after the final histopathological examination. Cavernous haemangiomas do not spontaneously regress, unlike the capillary type. Surgical interventions are often needed for cavernous haemangiomas as they could cause pressure on vital structures including the great vessels, major airways and lung. They can also cause thrombocytopenia, microangiopathic haemolytic anaemia and coagulopathy [4].
Open approaches are necessary for large sized tumour like in our case, where VATS can be used for the excision of smaller tumours [4].
In conclusion, cavernous haemangiomas are rare but must be evaluated in the differential diagnosis of the anterior mediastinal masses. Thoracotomy can be used to approach large sized tumours.
Informed Consent: Written informed consent was obtained from patient/patients who participated in this study.