A 20.1kg adrenal cavernous haemangioma presenting as a giant retroperitoneal mass: diagnostic difficulties and operative strategy

Background Adrenal haemangiomas are rare, usually benign vascular growths that tend to be small, found by chance, and easily forgotten. But in rare cases, they can behave more like malignant retroperitoneal masses disrupting normal anatomy and making both diagnosis and surgery a real challenge. Tumours weighing more than 20 kg. (That’s almost unheard of) Case presentation A 67 years old woman presented with six months of progressive abdominal distension on a four years background of intermittent left loin pain. Her medical history include hypertension, type 2 diabetes, atrial fibrillation and heart failure. CT showed a massive retroperitoneal mass 22.3×20.9×24.0 cm extending from diaphragm to pelvis. It was pressing on the bowels, both kidneys, and even the great vessels. It looked like it might be coming from the adrenal gland. After optimisation for anaemia (Hb 9 g/dL) and hypothyroidism (levothyroxine 100 µg), and per‑protocol anticoagulation management, she underwent midline laparotomy. The tumour, densely adherent to aorta, inferior vena cava and ureter, was removed en‑bloc using meticulous dissection and LigaSure. Concomitant umbilical hernia was repaired with a 30×30 cm pre‑peritoneal polypropylene underlay mesh (5 cm overlap). The tumour weighed 20.1 kg. Histology showed adrenal cavernous haemangioma with intact margins. Recovery was uncomplicated. She is well at > 2 months follow‑up. Conclusions This case really highlights how tricky it can be to diagnose and manage these giant adrenal vascular tumours. Despite their size and appearance on imaging, which can mimic malignancy, they are often benign. The key to a good outcome lies in solid pre-operative optimisation and slow, careful dissection around the major vessels. When done right, full excision is curative.