대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Venous malformation of chest wall

Radiologic Findings

Fig 1. Chest radiograph demonstrates a well-defined, oval shaped mass with smooth margin in the left mid-lung field. No associated rib destruction or pleural effusion is identified.
Fig 2-6. Chest CT shows a well-defined soft-tissue mass in the left posterior chest wall, located in the extrapleural space and forming an obtuse angle with the adjacent lung. The lesion demonstrates poor enhancement, likely related to suboptimal bolus timing given the typical gradual and delayed enhancement pattern of cavernous hemangioma. Tortuous vascular structures with internal punctate calcifications, consistent with phleboliths, are noted

Brief Review

The patient was pathologically diagnosed with a cavernous hemangioma after surgical resection. Vascular malformations of the chest wall are uncommon and may arise in the cutaneous, subcutaneous, intermuscular, or intramuscular compartments. Among these entities, venous malformations are the most frequently encountered and have historically been referred to as cavernous hemangiomas.
Venous malformations are composed of dilated vascular channels and may demonstrate characteristic imaging features depending on the modality used. Although MR imaging— which was not performed in this case—often reveals serpiginous vascular channels with flow-related signal alterations, CT can provide important diagnostic clues. In particular, venous malformations may contain additional tissue components, most notably phleboliths, which represent dystrophic calcification of chronic thrombi. The identification of phleboliths on CT is a highly suggestive finding for a hemangioma, as these calcifications are observed in a 30% of venous malformations, consistent with the imaging findings in our case.
Chest wall hemangiomas are generally regarded as benign “do not touch” lesions, as their characteristic imaging appearance often allows confident diagnosis without the need for biopsy or surgical intervention, especially in asymptomatic patients. In the present case, however, the patient reported a one-year history of intermittent blood-tinged sputum. Although a direct causal relationship between the symptom and the chest wall lesion was considered unlikely, surgical resection was performed at the patient’s request to obtain a definitive diagnosis.
Typical imaging features of hemangiomas include areas of macroscopic fat and internal components such as phleboliths, fibrous septa, or dilated vascular spaces. Following contrast administration, hemangiomas usually exhibit slow, progressive enhancement, with gradual filling of the lesion during delayed phases. The relatively poor enhancement observed in our case is presumed to be related to the timing of contrast acquisition, which may not have adequately captured the delayed enhancement pattern characteristic of venous malformations.

References

1. Mansour J, Raptis D, Bhalla S, Heeger AP, Abbott GF, Parkar N, Hammer MM, Kiernan J, Raptis C. Diagnostic and imaging approaches to chest wall lesions. Radiographics 2022;42(2):359–378.
2. Kim WK, Park JS, Paik SH, Cha JG, Shin HK, Koh ES. Dynamic CT features of a hemangioma originating from the parietal pleura: a case report. J Korean Soc Radiol 2012;66(6):535–538.

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