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Weekly Chest CasesArchive of Old Cases

Case No : 1248 Date 2021-09-22

  • Courtesy of Yeonu Choi, Tae Jung Kim / Samsung Medical Center
  • Age/Sex 59 / F
  • Chief ComplaintAbnormal imaging finding History of atrial fibrillation
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7

Diagnosis With Brief Discussion

Diagnosis
Mediastinal hemangioma + hematoma
Radiologic Findings
Fig. 1. Chest posteroanterior radiograph showing an approximately 63-mm mass in left anterior mediastinum. Left atrial enlargement is also seen.
Fig. 2. Pre-contrast computed tomography (CT) scan demonstrating a well-defined low-attenuated left anterior mediastinal mass with multiple peripheral punctates or curvilinear calcifications.
Fig. 3. Early arterial-phase CT scan, taken 2 months prior, showing poor enhancement of the mass.
Figs. 4 and 5. Enhanced CT scans showing progressive peripheral enhancement with a contrast extravasation-like enhancement pattern in the mass (average Hounsfield units: 130). The central portion of the mass shows poor enhancement.
Fig. 6. Surgical specimen showing a mass with extensive hemorrhage, hematoma, necrosis, and calcifications, consistent with arteriovenous hemangioma.
Brief Review
Hemangioma is a rare, benign vascular tumor that accounts for < 0.5% of all mediastinal masses. It has been speculated that hemangiomas represent either true neoplasms or developmental vascular anomalies. Histologically, these tumors consist of large interconnecting vascular spaces lined by flattened cuboidal epithelium along with varying amounts of interspersed stromal elements, such as fat, myxoid, and fibrinous tissues. They are categorized as capillary, cavernous, or venous hemangiomas based on the size of the vascular spaces. Most mediastinal hemangiomas are found in the anterior mediastinum; however, a few arise in the posterior mediastinum.
Mediastinal hemangiomas usually manifest as nonspecific soft-tissue masses. Phleboliths, multiple enhanced vessels, and peripheral puddling of contrast enhancement may be potential diagnostic features. Phleboliths, a potentially diagnostic finding, are seen in only 10% of conventional radiographs. Punctate calcification is more common and needs to be differentiated from the calcification seen in patients with teratoma or cartilaginous tumors.
Hemangiomas commonly appear as heterogeneous lesions on unenhanced computed tomography (CT). Their appearance depends on the stromal content and the degree of thrombosed vascular channels. The pattern of contrast enhancement varies, including central, mixed central and peripheral, peripheral, and nonspecific increased attenuation. Gradually increasing and persistent enhancement has been seen on dynamic contrast-enhanced CT. Large draining veins have also been observed in delayed images.
In our case, the hemangioma showed peripheral punctate calcifications, consistent with phleboliths. Early arterial-phase CT showed poor enhancement of the mass; however, follow-up enhanced CT showed a prominent peripheral enhancement pattern with an unusual contrast extravasation pattern. The differential diagnoses included vessel aneurysm; however, there was no direct communication between the mass and the adjacent vessel.
References
1. Agarwal PP, Seely JM, Matzinger FR. Case 130: mediastinal hemangioma. Radiology. 2008;246(2):634-7.
2. Cheung YC, Ng SH, Wan YL, Tan CF, Wong HF, Ng KK. Dynamic CT features of mediastinal hemangioma: more information for evaluation. Clin Imaging. 2000;24(5):276-8.
3. McAdams HP, Rosado-de-Christenson ML, Moran CA. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology. 1994;193(2):399-402.
4. Sakurai K, Hara M, Ozawa Y, Nakagawa M, Shibamoto Y. Thoracic hemangiomas: imaging via CT, MR, and PET along with pathologic correlation. J Thorac Imaging. 2008;23(2):114-20.
Please refer to
Case 1215 Case 1034 Case 1009
Keywords

No. of Applicants : 90

▶ Correct Answer : 30/90,  33.3%
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Other , Korea (South) HYEJIN YANG
  • - , Korea (South) HYEYOUNG CHOI
  • - Other , Korea (South) MINGI SHIN
  • - National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - , Japan CHIAKI SATO
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Other , Korea (South) SEONGSU KANG
  • - Scans world , India PHILSON JOSEPH MUKKADA
  • - , Korea (South) JIN YOUNG LEE
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Chonbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Osaka University , Japan AKINORI HATA
  • - , Korea (South) HYEWON CHOI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Gifu University Hospital , Japan Yo Kaneko
  • - McGill , Canada MUTAZ ADNAN KHAIRO
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Other , Korea (South) MINSU KIM
  • - Chonbuk National University Hospital , Korea (South) MINJEE KIM
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , Japan KAZUMA TERAUCHI
  • - Private sector , Greece VASILIOS TZILAS
  • - , Japan YUKI HAYASHI
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - Hanyang University Hospital , Korea (South) SEUNG JIN YOO
▶ Correct Answer as Differential Diagnosis : 12/90,  13.3%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - , Japan HIROAKI ARAKAWA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Other , Korea (South) SEUNGHYUN LIM
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
▶ Semi-Correct Answer : 1/90,  1.1%
  • - Columbia asia hospital Hebbal ,Bengaluru , India PRAVIN KUMAR M
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