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Weekly Chest CasesArchive of Old Cases

Case No : 646 Date 2010-03-14

  • Courtesy of Hyo Jin Kim, MD, Chin A Yi / Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • Age/Sex 22 / F
  • Chief ComplaintIncidental findings on chest radiograph
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Sclerosing hemangioma
Radiologic Findings
Chest radiographs shows 5.4 cm, well defined mass in right middle lung zone. Non뻙ontrast CT scans demostrate about 57 mm well defined, noncalcified mass, which straddling the right major fissure. On enhanced CT, the mass showed heterogenous strong enhancement (96HU). PET-CT scans show mild heterogenous increased FDG uptake (SUV=3.7) in pulmonary mass in right lung.
Brief Review
Lebow and Hybbell first described sclerosing hemangioma in 1956. It is a rare benign tumor, characterized microscopically by four major histologic components: solid, papillary, sclerotic, and hemngiomatous in varying proportions. There have been many investigations of the histogenesis of the tumor, but it is still uncertain whether its origin is endothelial or epithelial. However, recent immunohistochemical and ultrastructural data support the concept that sclerosing hemangioma is an epithelial neoplasm derived from type II pneumocytes and bronchiolar epithelial cells. Four pathologic patterns are recognized: solid, hemorrhagic, papillary, and sclerotic. There is a female-to-male predominance of approximately 4 to 5:1, a gender difference that may be related to the presence of estrogen receptors in some tumors. Most lesions are discovered in patients between 30 and 50 years of age. Most cases were asymptomatic, but some presented with hemoptysis, cough, chest pain, dyspnea, and pleurisy. The lesions range from 0.8 to 8.2 cm in diameter, but most are less than 3.5 cm in diameter. They are usually well-defined, circumscribed, hemorrhagic nodules. The tumor is often subpleural, and a thin fibrous pseudocapsule separates it from the adjacent compressed lung parenchyma. On CT, sclerosing hemangioma appeared as well defined juxtapleural masses in all cases. The tumors enhanced by visual criteria in all but one patient with the smallest mass. The CT density of the enhancing mass ranged from 96 to 157 HU. Some patients had calcifications and a few had well defined areas of low attenuation, corresponding with angiomatous, solid and sclerotic, and cystic areas, retrospectively. MRI findings were also reported: They had mixed areas of high and low signal intensity on both T1- and T2- weighted images and were totally enhanced on postcontrast enhanced T1-weighted images. The T1 high signal intensity areas corresponded to those including abundant clear cells, and the T2-weighted low signal intensity areas corresponded to the fibrotic or hemorrhagic areas in the tumors.
The experience using FDG-PET scan in sclerosing hemangioma is limited. There are only two published reports of FDG-PET scan findings in sclerosing hemangioma. In the patient reported by Hara et al., only slightly elevated uptake with an SUV of 1.8 was noted.8 In the patient reported by de Koning et al., the uptake was only slightly greater than background (SUV of 1.6).9 In contrast, two patients reported by HSU et al., the masses demonstrated SUV of 2.72 and 3.93, respectively, which were well above the cut-off value (SUV of 2.5) suggestive of malignancy. The high FDG uptake may be attributed to the larger tumour size and potentially low-grade malignant nature of sclerosing hemangioma, a conclusion also supported by the elevated level of tumor marker, CA-153, in the second patient.
References
1. Im JG, Kim WH, Han MC, Han YM, Chung JW, Ahn JM, Do YS. Sclerosing hemangiomas of the lung and interlobar fissures: CT findings. J Comput Assist Tomogr 1994; 18 : 34-38
2. Sugio K, Yokoyama H, Kaneko S, Ishida T, Sugimachi K. Sclerosing hemangioma of the lung: radiographic and pathological study. Ann Thorac Surg 1992; 53: 295-30
3. Fujiyoshi F, Ichinari N, Fukukura Y, et al. Sclerosing hemangioma of the lung: MR findings and correlation with pathologic features. Journal of Comput Assist Tomogr 1998; 22(6):1006-1008.
4. PK HSU, HF CHENG, YC YEH, YC WU, WH HSU, pulmonary sclerosing haemangioma mimicking lung cancer on PET scan. Resp 2009; 14: 903-912
Keywords
Lung, Benign tumor,

No. of Applicants : 101

▶ Correct Answer : 27/101,  26.7%
  • - Inha University Hospital , Korea (South) Ju Won Lee
  • - Osaka University , Japan Osamu Honda
  • - NTUH , Taiwan Kuei-pin Chung
  • - SoonChunHyang univ. hospital , Korea (South) Kim Jae Hyun
  • - SMC , Korea (South) Jihoon Cha
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - freelancer , Korea (South) DAE HYOUN CHO
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - CHU Nancy , France, Metropolitan Guillaume LUX
  • - Yonsei university Shinchon Severance hospital , Korea (South) Na-young Shin
  • - Armed Forces Chun-Cheon Hospital , Korea (South) Chae Lim
  • - IRSA , France jean-luc BIGOT
  • - IRSA rochefort , France Viviane Pages
  • - SacrCoeur , Canada Andrea Ojanguren
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Kwang Myung Sungae Hospital , Korea (South) Jiyong Rhee
  • - Yonsei University, College of Medicine , Korea (South) Chansik An
  • - , Korea (South) GA RAM KIM
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
▶ Correct Answer as Differential Diagnosis : 19/101,  18.8%
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - University of British Columbia , Canada Amr Ajlan
  • - radiologist, aditya imaging centre , India vivek patel
  • - care hospital , India Chary D
  • - Osaka University , Japan Hiromitsu Sumikawa
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) YOOKYUNG KIM
  • - MBAL-POPOVO EOOD , Bulgaria VLADISLAV RUSINOV
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) Sang Min Lee
  • - Konkuk university hospital , Korea (South) Jeong Geun Yi
  • - Hopital du SacrCoeur , Canada Abraham Bohadana
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - NASA SCANS , India RAKESH BHATIA
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
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