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JAMA Surg. Published online June 26, 2013. doi:10.1001/jamasurg.2013.310b
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ANSWER: EXOPHYTIC SOLITARY GIANT CAVERNOUS HEMANGIOMA OF STOMACH

Exploratory laparotomy was performed. A giant purple-red mass grew out of the serosal layer of the posterior wall of the stomach (Figure 2) and adhered to the mesentery of the transverse colon, duodenum, and retroperitoneal great vessels. After completely separating the lesion from adjacent structures, the mass shrunk significantly. The mass was removed by subtotal gastrectomy and the patient received a 1200-mL whole-blood transfusion during surgery. No similar lesion was found in other abdominal organs. The excised mass weighed 1.8 kg and measured 25 × 14 × 5 cm. On cut section, the mass had numerous cavernous sinuses with thin walls but gastric mucosa was not involved. Gross specimen and histopathological examination confirmed cavernous hemangioma. The postoperative course was uneventful and the patient was well with no recurrence at the 6-month follow-up evaluation.

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Figure 2. Intraoperative photograph showing a giant purple-red mass originating from the posterior wall of the stomach.

Cavernous hemangiomas are benign congenital tumors of endothelial cells containing mature blood vessels. About 80% are located on the face and neck, with the next most common location being the liver. Gastrointestinal hemangiomas may occur anywhere in the gastrointestinal tract, especially in the small intestine. Occasionally, these tumors may originate from the mesentery or omentum.1,2 Gastric hemangiomas consist of less than 2% of benign gastric neoplasm, and giant exophytic hemangioma of stomach is rarely encountered in adults.3 The clinical manifestations of gastrointestinal hemangioma range from incidental finding to a large symptomatic mass with gastrointestinal bleeding. Decreased hemoglobin, signs of gastrointestinal bleeding, and a positive stool test for occult blood are helpful for diagnosing gastrointestinal hemangioma but are not as valuable in the diagnosis of exophytic hemangioma of the gastrointestinal tract, as described in our case. The diagnosis of such a lesion can be challenging. Computed tomography with bolus intravenous contrast is extremely useful in evaluating abdominal vascular anomalies and helps to distinguish vascular vs lymphatic malformations. However, it cannot show enhancement in certain conditions such as torsion of the tumor pedicle, thrombosis formation in the vessel of the tumor, or necrosis. Differential diagnosis of gastric hemangioma should include gastrointestinal stromal tumor and neurilemmoma, as they may mimic exophytic solitary gastric hemangioma like the case we described rather than manifesting as an intragastric mass. Surgical excision is the treatment of choice for an isolated giant hemangioma of stomach.4 If the tumor is pedunculated and limited to mucosa, simple endoscopic excision could be feasible.

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Correspondence: Dianbo Cao, MD, PhD, Department of Radiology, The First Hospital of Jilin University, XinMinZhu St 71, Changchun, Jilin Province, 130021 China (happybo126@126.com).

Accepted for Publication: March 26, 2012.

Published Online: June 26, 2013. 10.1001/jamasurg.2013.310a 10.1001/jamasurg.2013.310b

Author Contributions:Study concept and design: Cao. Acquisition of data: Tai. Analysis and interpretation of data: All authors. Drafting of the manuscript: Tai and Cao. Critical revision of the manuscript for important intellectual content: Sun and Cao. Administrative, technical, and material support: Cao.

Conflict of Interest Disclosures: None reported.

Chin KF, Khair G, Babu PS, Morgan DR. Cavernous hemangioma arising from the gastro-splenic ligament: a case report.  World J Gastroenterol. 2009;15(30):3831-3833
PubMed   |  Link to Article
Okazaki H, Fujiwara Y, Sugimori S,  et al.  Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1044 consecutive patients.  J Gastroenterol. 2009;44(6):550-555
PubMed   |  Link to Article
Lin CH, Hsieh HF, Yu JC,  et al.  Spontaneous rupture of a large exogastric hemangioma complicated by hemoperitoneum and sepsis.  J Formos Med Assoc. 2006;105(12):1027-1030
PubMed   |  Link to Article
Menon P, Rao KL, Bhasin S,  et al.  Giant isolated cavernous hemangioma of the stomach.  J Pediatr Surg. 2007;42(4):747-749
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Intraoperative photograph showing a giant purple-red mass originating from the posterior wall of the stomach.

Tables

References

Chin KF, Khair G, Babu PS, Morgan DR. Cavernous hemangioma arising from the gastro-splenic ligament: a case report.  World J Gastroenterol. 2009;15(30):3831-3833
PubMed   |  Link to Article
Okazaki H, Fujiwara Y, Sugimori S,  et al.  Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1044 consecutive patients.  J Gastroenterol. 2009;44(6):550-555
PubMed   |  Link to Article
Lin CH, Hsieh HF, Yu JC,  et al.  Spontaneous rupture of a large exogastric hemangioma complicated by hemoperitoneum and sepsis.  J Formos Med Assoc. 2006;105(12):1027-1030
PubMed   |  Link to Article
Menon P, Rao KL, Bhasin S,  et al.  Giant isolated cavernous hemangioma of the stomach.  J Pediatr Surg. 2007;42(4):747-749
PubMed   |  Link to Article

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