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Weekly Chest CasesArchive of Old Cases

Case No : 1009 Date 2017-02-27

  • Courtesy of Boda Nam, MD., Tae Jung Kim, MD. / Samsung Medical Center
  • Age/Sex 48 / F
  • Chief ComplaintAbnormal finding on chest CT scan for metastasis work-up due to malignant melanoma (pelvis).
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Diagnosis With Brief Discussion

Diagnosis
Mediastinal hemangioma
Radiologic Findings
Fig 1. Chest PA shows a subtle nodular opacity in the left apex.
Fig 2-5. Mediastinal window setting of the chest CT scan shows a 19mm sized nodular lesion in the left apical paravertebral area, which closely abuts the costovertebral junction of left 2nd rib. The nodule shows heterogeneous attenuation without calcification on precontrast scan. After contrast administration, the nodule shows marked and heterogeneous enhancement (average 194 HU).
Fig 6. FDG-PET/CT scan shows no definite hypermetabolism in the nodule.
Brief Review
Hemangioma is a rare, benign vascular tumor that counts for less than 0.5% of all mediastinal masses. The cause of hemangioma is unclear. It has been speculated that they represent either true neoplasm or developmental vascular anomalies. At histologic examination, these tumors consist of large interconnecting vascular spaces lined by flattened cuboidal epithelium along with a varying amount of interspersed stromal elements, such as fat, myxoid, and fibrinous tissues. They are categorized as capillary, cavernous, or venous hemangiomas on the basis of the size of the vascular spaces. Most mediastinal hemangiomas are found in the anterior mediastinum; however, a few arise in the posterior mediastinum.
The preoperative diagnosis may be difficult because the tumors usually manifest as nonspecific mediastinal masses on image finding. Phleboliths, a potentially diagnostic finding, are seen in only 10% of conventional radiographs. Calcification is more readily identifiable on CT scans. Punctate calcification is seen more commonly and needs to be differentiated from the calcification seen in patients with teratoma or cartilaginous tumor. However, our case also did not contain any calcifications suggesting phleboliths.
Hemangiomas commonly appear as heterogeneous lesions on unenhanced CT scans. Their appearance depends on the stromal content and degree of thrombosed vascular channels. Contrast enhancement is most often heterogeneous and central. Gradually increasing and persistent enhancement has been seen on dynamic contrast-enhanced CT scans. Large draining veins have also been seen on delayed images. In our case, the hemangioma showed heterogeneous and avid enhancement but gradually increasing or persistent enhancement could not be confirmed because dynamic contrast scans were not taken.In mediastinal hemangiomas, FDG uptake is known to be as low and similar to hemangiomas of extremities. FDG-PET may provide information to differentiate hemangiomas from malignant neoplasms except for small or dominantly necrotizing lesions that PET cannot provide accurate data due to limitation inspatial resolution.
References
1. Prachi P., Hean M., Frederic R. Case130: Mediastinal Hemangioma. Radiology 2008; 246:634-637
2. H. Page, Melissa L., Cesar A. Mediastinal Hemangioma: Radiographic and CT Features in 14 Patients. Radiology 1994; 193:399-402
3. Sakurai K., Hara M., Ozawa Y et al., Thoracic hemangiomas: imaging via CT, MR, and PET along with pathologic correlation. J Thorac Imaging 2008;23(2):114-120
Keywords
Mediastinum, Posterior mediastinum,

No. of Applicants : 120

▶ Correct Answer : 24/120,  20.0%
  • - Otsu Municipal Hospital , Japan NORIATSU ICHIBA
  • - Yokohama-asahi-chuo-general hospital , Japan KYOKO NAGAI
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Pusan national university hospital , Korea (South) MIRI JEONG
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Pusan national university hospital , Korea (South) SeungHyun Lee
  • - Yonsei University, Wonju Severance Christian Hospital , Korea (South) JUYEON LEE
  • - , Korea (South) JIN KEONG YANG
  • - , Korea (South) JH LEE
  • - Chung buk national university hospital , Korea (South) hong gwon Byun
  • - Bahcesehir University School of Medicine, Radiology Department , Turkey Mustafa Kemal Demir
  • - Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Samsung Medical Center , Korea (South) MIN YEONG KIM
  • - Samsung medical center , Korea (South) Ran Kim
  • - Medicheck health care , Korea (South) Chae hun Lim
  • - Other , Korea (South) MINKYU KWAK
  • - Kyeongpook National University Hospital , Korea (South) SUNGJUN MOON
  • - Aerospace medical group, Air Force Education and Training Command , Korea (South) Donghwan Kim
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Samsung Medical Center , Korea (South) Jeonghyun Lee
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Pusan National University Yangsan Hospital , Korea (South) JUNMEE YOU
  • - Korea University Guro Hospital , Korea (South) HWANSEOK YONG
  • - Korea University Ansan Hospital , Korea (South) CHERRY KIM
▶ Correct Answer as Differential Diagnosis : 34/120,  28.3%
  • - Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - Kizawa Memorial Hospital , Japan Tomohiro Ando
  • - Apollo hospital , India SAMSON K
  • - Korea University Guro Hospital , Korea (South) Bit Na Park
  • - Korea University Guro Hospital , Korea (South) PARK SOYEON
  • - Chungbuk National University Hospital , Korea (South) SOOJUNG LEE
  • - Other , Korea (South) SEONG SU KANG
  • - KAMC , Saudi Arabia NESREEN HASSAN ABOUROKBAH
  • - Chonnam National University Hospital , Korea (South) GUNSU KIM
  • - The Jikei university , Japan TAKU GOMI
  • - Ajou University Hospital , Korea (South) Taeyang Ha
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - pusan national university hospital , Korea (South) kim jeongmyeong
  • - Chungbuk national university , Korea (South) Yong Hun Kim
  • - Samsung Medical Center , Korea (South) KYOWON GU
  • - Chungbuk National University Hospital , Korea (South) LEE JUNG HWAN
  • - CLINIQUE STE CLOTILDE , Reunion patrick serge MASCAREL
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Other , Korea (South) HAYEON LEE
  • - Chungbuk national university hospital , Korea (South) Miran Yeon Yeon
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - GHICL , France MANUEL TOLEDANO
  • - , Korea (South) RANG LEE
  • - VENKATESHWAR HOSPITAL NEW DELHI , India RAKESH BHATIA
  • - Korea university medical center, guro hospital , Korea (South) Lee kyu chong
  • - , Korea (South) JINWOO HAN
  • - pusan national university hospital , Korea (South) jiwon lee
  • - , Korea (South) HYEONMI RYU
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Korea University Guro Hospital , Korea (South) Yoonmi Choi
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Current Editor : Sang Young Oh, M.D., Ph.D Email : sangyoung.oh@gmail.com

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