Chest imaging
Case TypeClinical Cases
Authors
Li Guan, Yalong Liu, Dingxue Du, Wei Jia
Patient70 years, male
A 70-year-old male incidentally found a large mass of the anterior mediastinum without dyspnea and chest pain.
Contrast-enhanced CT scan showed a lobulated, solid mass under the left anterior mediastinal pleura, measuring 6.5x5.3cm, with round smooth calcifications scattered randomly.
Arterial phase images were collected 30 seconds after beginning of contrast injection, most of the tumor showed slight enhancement (CT value increased by less than 10HU), while patchy obvious enhancement (CT value increased by 40HU) was detected in the venous phase (50 seconds after the beginning of contrast injection). The left cephalobrachial vein was obviously displaced. No hilar or mediastinal lymphadenopathy was detected.
After excluding surgical contraindications, surgical resection was performed. the postoperative pathological results confirmed that it was venous hemangioma and there was no special discomfort after the operation.
No evidence of recurrence at 15 months after surgery was detected.
Mediastinal hemangiomas, which account for approximately 0.5% or less of all mediastinal tumors, are almost benign tumors made up of abundant vascular [1, 2]. Histologically, hemangioma is characterized by increased endothelial cell turnover and proliferation of normal vascular components and have various amounts of interposed stromal elements (e.g., fat, myxoid, and fibrous tissue) [2, 3]. Usually appearing after birth, growing rapidly, and then involuting over time [2]. There is a wide range of ages at the time of diagnosis (26 days–76 years), and the peak incidence is in the first decade of life [2]. There is no sex predilection [1]. The tumors are categorized according to the size of their vascular spaces as capillary, cavernous, or venous hemangiomas. Venous hemangiomas (VH) are extremely rare and they only account for 1% of all mediastinal hemangiomas [2].
One-third to one-half of the patients had no symptoms at presentation; the rest of the patients had non-specific symptoms such as cough, chest pain, and dyspnea caused by larger mass compression or, less likely, invasion of adjacent structures [2].
The mass is located behind the sternum, and the chest radiograph can not show clearly and locate the tumor accurately. Contrast-enhanced CT scans can show the exact location and adjacent structures of the tumor, which is of key importance to operation planning. Hemangiomas are usually round or lobulated, with smooth margins. Calcified small round phleboliths are of great significance in indicating the vascular nature of the mass, although phleboliths can be detected in only 10% of cases [2]. In our case, we could observe this finding. According to Seline et al., central “puddling” of contrast material also indicates the diagnosis of mediastinal hemangioma [2, 3], which has also been confirmed in our case. We noticed an obvious enhancement area caused by contrast media siltation inside the mass in venous phase, which could increase confidence in the diagnosis of hemangioma. Because the symptoms and imaging findings are usually non-specific, the accurate diagnosis of mediastinal hemangioma before an operation is difficult. Surgery is an important way of diagnosis and treatment. Because the tumor may recur after incomplete resection, complete resection of the tumor is recommended [1].
Almost all mediastinal hemangiomas are benign, but occasionally, large masses can cause compression or invasion to adjacent structures, requiring multiple operations [4]. Till now, there has no metastasis or recurrence case been reported. Because of abundant vascular of the mass, it is of great significance to indicate the diagnosis of hemangioma before surgery for reducing intraoperative blood loss.
[1] Yilmaz A, Kavas M, Ersev A, Ekinci GH, Haciomeroglu O, Atinkaya C, Akkaya E (2014) Venous hemangioma of the anterior mediastinum. ClinRespir J. doi: 10.1111/crj.12241
[2] Yoshino N, Okada D, Ujiie H, Akiyama H, Nishimura Y, Koizumi K, Shimizu K (2012) Ann Thorac Cardiovasc Surg 18(3):247-50. doi: 10.5761/acts.cr.11.01706
[3] Hirai K, Takeuchi S, Bessho R, Ozaki Y, Koizumi K, Shimizu K (2010) J Nippon Med Sch 77(2):115-8. doi: 10.1272/jnms.77.115
[4] Goizueta AA, Libbey P, Moulton A, et al. BMJ Case Rep published Online First: [please include Day Month Year]. doi: 10.1136/bcr-2016-218759
URL: | https://www.eurorad.org/case/18121 |
DOI: | 10.35100/eurorad/case.18121 |
ISSN: | 1563-4086 |
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