대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Cavernous hemangioma

Radiologic Findings

Fig 1. Multiple tiny nodular opacities in both lung field.
Fig 2-5. Chest CT with lung window setting shows multiple small discrete solid nodules in both lungs. Precontrast and contrast enhancement CT images show multiple small solid nodules and internal subtle enhancement in both lung.
Fig 6. PET-CT demonstrates no hypermetabolism in pulmonary nodules

Brief Review

Etiology and Distribution The etiology of cavernous hemangiomas remains incompletely understood; however, they are generally regarded as congenital vascular malformations, potentially linked to genetic loss-of-function mutations. Pulmonary cavernous hemangioma (PCH) can present as either solitary or multiple lesions. When multiple lesions occur, PCH is frequently associated with hereditary hemorrhagic telangiectasia (HHT). These lesions can arise throughout the lower respiratory tract—including the lung parenchyma, airways, and bronchioles—though they typically do not extend into the bronchial lumen.
Clinical Presentation Most PCH patients are asymptomatic, with lesions often discovered incidentally during routine physical examinations. However, as the condition progresses, patients may develop non-specific respiratory symptoms such as cough, sputum, hemoptysis, chest pain, acute dyspnea, or intrathoracic hemorrhage. The severity of these symptoms is closely related to the lesion's size, location, and number, as well as potential vascular degeneration within the hemangioma. Accordingly, the management of PCH varies depending on symptom severity and the extent of the lesions.
Radiological Findings and Diagnostic Challenges On conventional chest CT, PCH typically presents as isolated or multiple nodular lesions, sometimes containing punctate, small nodular, or needle-like calcifications. These calcifications result from calcium deposition on primary venous thrombi within the tumor’s blood vessels; however, the occurrence rate remains below 10%.
In terms of enhancement patterns, PCH often shows mild to moderate uniform enhancement during the arterial phase, which may slightly decrease in the venous phase. Notably, these lesions are frequently located in close anatomical proximity to adjacent bronchi and blood vessels. Unlike cavernous hemangiomas in other solid organs, such as the liver, PCH often lacks the characteristic "centripetal enhancement" (peripheral pooling) pattern on conventional CT. This absence of typical vascular filling makes a definitive preoperative diagnosis challenging.
The Role of Advanced Imaging (Spectral CT) To overcome these diagnostic hurdles, dual-layer spectral CT has proven highly useful, especially for lesions characterized by small volume, high density, or unclear enhancement patterns. In such cases, iodine density images derived from spectral-based imaging can clearly demonstrate the presence and distribution of iodine concentration within the lesion. This provides direct evidence of the blood supply, significantly improving the diagnostic accuracy for PCH before surgical intervention.

References

1. Bae KS et al. Diagnosis of multiple pulmonary cavernous hemangiomas via dual-layer spectral CT: A case report. Medicine 2020 99:p e22495
2. Li W et al Pulmonary cavernous hemangioma: a case report. BMC Pulm Med. 2025;16;25:25
3. Lee JH et al. Multiple Cavernous Hemangiomas of the Posterior Mediastinum, Lung, and Liver: A Case Report. J Chest Surg 2021;54: 547-550

Keywords