대한흉부영상의학회 Weekly Chest Cases

Case No : 469 Date 2006-10-23

Courtesy of Hwan Seok Yong, MD, Ok Hee Woo, MD, Eun-Young Kang / Korea University Guro Hospital, Korea
Age/Sex 23 / M
Chief ComplaintLung mass on routine check-up

Figure 1
Figure 2
Figure 3
Figure 4

Diagnosis With Brief Discussion

Diagnosis: Posterior Mediastinal Cavernous Hemangioma
Radiologic Findings: A 23-year-old man was admitted to our hospital for evaluation of a lung mass. On the CXR taken during the earlier check-up, no specific mass lesions were detected. However, 3 years later, a plain CXR displayed a right lower-paratracheal mass. The patient was an asymptomatic healthy smoker. He had a smoking history of five pack-years. Plain CXR demonstrated a smooth-marginated 2.5 cm × 2 cm lesion in the right lower-paratracheal area. Chest CT showed a 2.5 cm × 2.2 cm, well-defined and homogeneously enhancing mass, in the patient's right upper posterior mediastinum. No evidence of bony erosion of thoracic vertebrae was observed. The tumor was resected completely with no major bleeding.

Histologically, the tumor was characterized by well-circumscribed round hemorrhagic soft tissue, measuring 4 cm × 3 cm × 1.5 cm. Microscopically, the mass consisted of large, dilated, blood-filled vessels; all of which were lined by flattened endothelial tissue. These histological findings are consistent with the diagnosis of cavernous hemangioma.
Brief Review: Mediastinal hemangiomas are rare intrathoracic lesions that are well circumscribed, cystic, hemorrhagic tumors which occur in a range of diameters from 2 to 20 cm. They account for less than 0.5% of all mediastinal masses.

Mediastinal hemangiomas tend to appear as sharply marginated, circular, or lobular masses on CXR or chest CT images. Chest CT has proven useful with regard to the evaluation of the extent of such lesions and allowing the effects of non-operative therapy to be assessed, or to plan operative interventions. Hemangiomas should be considered in the differential diagnosis of well-marginated mediastinal masses that have heterogeneous attenuation on CT scans, show central enhancement after administration of contrast material or contain punctate calcification. Posterior mediastinal hemangiomas sometimes mimic neuroblastomas, which is the most common posterior mediastinal mass in children.

Mediastinal hemangiomas can be histologically classified into either capillary or cavernous types. Capillary hemangiomas are characterized by a lobular and solid growth pattern and feature dilated small vessels and a marked proliferation of endothelial cells, whereas cavernous hemangiomas tend to manifest as large dilated vascular spaces, with regions exhibiting interstitial inflammatory changes, fibrosis and smooth muscle proliferation. Although the two types of tumors resemble one another with regard to their clinical behavior, they exhibit distinct histo-morphological growth patterns. Cavernous-type tumors do not spontaneously regress, unlike the capillary type. As such, surgical procedures are often necessary for cavernous-type tumors. However, a cautious approach is clearly warranted in children and young adults suffering from mediastinal hemangiomas, as some lesions have been known to occasionally spontaneously regress. Surgical excision constitutes the current treatment of choice. Whenever possible, such hemangiomas should be excised completely. Angiography, then, is quite important with regard to the identification and embolization of major feeding vessels prior to surgery. The angiographic embolization of feeding vessels proved quite effective in minimizing operative blood loss in cases in which total resection is possible. In cases in which radical resection proves difficult, radiation therapy has been employed as a selective treatment modality.
References
Keywords: Mediastinum, Benign tumor,

No. of Applicants : 50

▶ Correct Answer : 4/50, 8.0%

- Pgimer, Chandigarh, India Ram Prakash Galwa
- Inha University Hospital, Incheon , Korea Sang Uk Park
- China Medical University Hospital,Taiwan Jun-Jun Yeh
- Sam Anyang Hospital, Korea Jae Seung Seo

▶ Correct Answer as Differential Diagnosis : 14/50, 28.0%

- Inje University Ilsan Paik Hospital, Korea Bae Geun Oh
- EKH, Berlin, Germany Michael Weber
- Ibra Hospital, Oman Shaker A.fadeel Omera
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- Homs National Hospital, Syria Rami Abou Zalaf
- St. VincentHospital, Korea Chae-hun Lim
- Radiologie Guiton, La Rocelle, France Jean-Luc Bigot
- Zulekha Hospital, Dubai Saurabh Khandelwal
- Zulekha Hospital, Dubai Julie Arora
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Annecy Hospital, France Gilles Genin
- Consultant Radiologist, Nassau, Bahamas Trupti Dabholkar
- Apollo Hospital, Bangalore, India R.G.Gopinath
- Pgimer, Chandigarh, India Ashish Gupta

▶ Semi-Correct Answer : 8/50, 16.0%

- EKH, Berlin, Germany Michael Weber
- National Taiwan University Hospital, Taiwan Yu-Feng Wei
- Annemasse, Polyclinique de Savoie, France Gay-Dpassier Philippe
- Hospital Sotiria, Athens, Greece Tzilas Vasilios
- Homs National Hospital, Syria Rami Abou Zalaf
- Ruby Hall Clinic, Pune, India Nikhil Unune
- Doctors Hospital, Nassau, Bahamas N.B.S.Mani
- SSG Hospital & Medical Collge, Vadodara, Gujarat, India Mahavir Swami

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 469 Date 2006-10-23

Discussion

No. of Applicants : 50