DOI: 10.1148/radiol.2293012159
(Radiology 2003;229:726-729.)
Case 65: Hemangioma of the Chest Wall1
Justin Q. Ly, MD and
Timothy G. Sanders, MD
1 From the Department of Radiology and Nuclear Medicine, Wilford Hall USAF Medical Center, 759th MDTS/MTRD, 2200 Bergquist Dr, Suite 1, Lackland AFB, TX 78236-5300. Received January 14, 2002; revision requested March 6; revision received April 3; accepted May 23. Address correspondence to J.Q.L. (e-mail: jly15544@hotmail.com).
Index terms: Diagnosis Please • Angioma, soft tissues 474.3141 • Thorax, CT, 474.1211 • Thorax, MR, 474.121411
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HISTORY
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A 79-year-old man had a slowly enlarging mass in the left lateral portion of his chest wall. He first noticed the mass 5 years earlier, but he ignored it until he experienced a dull ache localized in the area of the mass. Physical examination revealed a soft-tissue prominence that was firm but lacked discrete margins, associated bruits, or visible discoloration. The patient denied a history of malignancy but reported a history of an enlarged prostate. Conventional radiography, computed tomography (CT), and magnetic resonance (MR) imaging of the chest were performed.
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IMAGING FINDINGS
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Conventional radiographic images of the chest demonstrated a subtle soft-tissue mass (Fig 1) involving the left lateral chest wall. The underlying osseous structures had a normal appearance, and no calcifications were depicted. Contiguous 5-mm transverse contrast material–enhanced CT scans obtained at the level of the thoracic inlet to the level of the upper abdomen demonstrated a mass with an extensive fatty component and interspersed tubular elements of soft-tissue attenuation at the left chest wall (Fig 2). A small calcification can be seen within the soft-tissue mass; however, the underlying osseous structures, including the left posterolateral thoracic ribs, have a normal appearance.
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Figure 2. Transverse contrast material-enhanced CT scan of the chest. In the region deep to the left serratus muscles and superficial to the intercostal muscles, a mass (straight arrow) that is largely fat attenuating and that contains multiple discrete nodular areas of soft-tissue attenuation and a small round calcification (curved arrow) that represents a small phlebolith can be seen. Notice the lack of enhancement of the mass, which is related to the timing of the bolus.
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Transverse and coronal T1-weighted MR imaging of the left lateral chest wall was performed with and without intravenous contrast material and was followed by transverse and coronal T2-weighted MR imaging, which was performed with frequency-selective fat saturation. T1-weighted images demonstrated a heterogeneous mass that contained numerous nodular structures of intermediate signal intensity and interspersed areas of high signal intensity that produced a lacy appearance (Fig 3). T2-weighted images (with fat saturation) revealed areas of low signal intensity that corresponded to the areas of high signal intensity on T1-weighted images. T2-weighted images also revealed nodular structures containing high signal intensity; these corresponded to the areas of low signal intensity seen on T1-weighted images (Fig 4).
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Figure 3. Transverse T1-weighted spin-echo MR image (repetition time msec/echo time msec, 466/17) of the chest. Image reveals a heterogeneous mass (arrow) in the left chest wall composed of numerous nodular masses of intermediate signal intensity interspersed with areas of high signal intensity, which follows fat signal intensity on images obtained with all sequences.
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Figure 4. Transverse T2-weighted fast spin-echo MR image (3,300/65) of the chest. Image obtained with frequency-selective fat saturation shows a predominantly hyperintense lobulated mass (arrow) with interspersed areas of low signal intensity that represent fibrofatty septa.
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After intravenous administration of contrast material, the nodular elements were enhanced (Fig 5). The osseous structures demonstrated normal morphology and signal intensity characteristics with all imaging sequences. The coronal MR images showed the craniocaudal extent of the chest wall lesion (Fig 6).
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Figure 5. Transverse T1-weighted gadolinium-enhanced spin-echo MR image (416/14) obtained with frequency-selective fat saturation demonstrates a soft-tissue mass (arrow) with numerous areas of serpentine enhancement.
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DISCUSSION
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Differential considerations for a mass involving the chest wall include hemangioma, infection, plasmacytoma or primary bone tumor, and soft-tissue masses such as lipoma, liposarcoma, neurogenic or desmoid tumor, and elastofibroma dorsi. Infection is unlikely in this patient given the indolent course over a 5-year period. The lack of osseous destruction argues against plasmacytoma or primary bone tumor. The heterogeneous nodular appearance of this tumor is unusual for a lipoma, and the presence of a calcifiation (phlebolith) is uncharacteristic of a liposarcoma. Neurogenic tumors are usually paraspinal in location. Although they usually contain areas of calcification, desmoid tumors do not specifically contain phleboliths and, moreover, do not generally demonstrate hyperintensity on T2-weighted MR images (1). The very caudal extent of this lesion, the presence of a phlebolith, and the lack of bilateral lesions argue against the benign asymptomatic entity known as elastofibroma dorsi (2). Thus, in view of the history and imaging findings, the most likely diagnosis is hemangioma.
Soft-tissue hemangiomas are benign vascular neoplasms that are thought by most physicians to be congenital in origin, although some authors have theorized that they represent a proliferation of vascular elements resultant from prior trauma (3). Soft-tissue hemangiomas are one of the most common benign soft-tissue tumors (4), and they are usually detected by the 3rd decade of life. Soft-tissue hemangiomas can originate in a number of locations. Cutaneous hemangiomas are identified at physical examination and rarely require imaging to establish a diagnosis. On the other hand, deep soft-tissue hemangiomas often require imaging to establish a definitive diagnosis, and they can arise nearly anywhere, including subcutaneous, intermuscular, intramuscular, or synovial tissues. Histologically, soft-tissue hemangiomas appear as a proliferation of normal vascular elements with interspersed fatty overgrowth and can be categorized as one of five histologic subtypes: capillary, cavernous, venous, arteriovenous, or mixed (5).
The soft-tissue hemangioma in this patient was an intramuscular hemangioma of the left lateral chest wall. Soft-tissue hemangiomas that originate within skeletal muscle (intramuscular hemangiomas) are relatively uncommon and account for only 0.7% of all reported hemangiomas (6). Even less common are hemangiomas that occur in the chest wall. Of the reported chest wall hemangiomas, most originate within soft tissues (7–11), although two case reports describe chest wall hemangiomas that arose from the ribs (12,13). Clinical manifestations typically include a palpable mass, subtle soft-tissue bulging, pain, or a combination of these signs and symptoms. Constitutional symptoms are usually absent.
The imaging of soft-tissue hemangiomas typically begins with conventional radiography. In some instances, an ill-defined soft-tissue mass is depicted, as was the case in this patient. Phleboliths are the only conventional radiographic finding helpful in diagnosing soft-tissue hemangioma, and these should be carefully searched for in every patient. Regional osseous abnormalities, including periostitis, trabecular coarsening, and cortical thickening, thinning, and erosion, can be seen on conventional radiographs (14), and an awareness of these associated osseous abnormalities can be useful when making the diagnosis. Ultrasonography is useful for demonstrating the presence and extent of a mass suspected on the basis of physical or radiographic findings (15). CT plays a role in the evaluation of the effect of deep soft-tissue hemangiomas on adjacent osseous structures. CT can also demonstrate the characteristic fatty appearance of the tumor and occasionally reveal a phlebolith (a focal calcification, as was seen in our patient), which is specific to soft-tissue hemangiomas (16).
Soft-tissue hemangiomas have a characteristic MR appearance, and when classic MR findings are present, a definitive diagnosis can be established without the use of more invasive diagnostic techniques, such as open or percutaneous biopsy. Typically, T1-weighted MR images demonstrate a soft-tissue mass of intermediate signal intensity with interspersed areas of high signal intensity that can appear lacy and correspond to areas of fatty proliferation. This results in an overall heterogeneous appearance. T2-weighted images typically demonstrate a predominantly hyperintense mass with interspersed areas of low to intermediate signal intensity that are representative of hemosiderin deposition, fibrous septa, and/or smooth muscle (16). Small, round areas of low signal intensity depicted with any sequence may represent phleboliths or areas of signal void secondary to high-velocity blood flow within the vascular channels. Contrast material enhances numerous vascular channels throughout the vascular lesion.
The standard treatment of deep soft-tissue hemangiomas is complete excision with clean margins. Chest wall reconstruction should be considered if more than two ribs are resected (17). Although tumors can recur locally in up to 18% of patients after surgical resection (18), to our knowledge there are no reported instances of malignant degeneration or metastasis. In general, embolization is much more difficult with hemangiomas than with arterial venous malformations because of the smaller feeding arteries in hemangiomas (19). Thus, angiography is rarely used for therapy, but it is frequently used for surgical planning and both to improve hemostasis during the actual surgery and to demonstrate feeding and draining vessels (20). This patient underwent complete excision of the hemangioma in the left chest wall, and he remains healthy and without evidence of local recurrence 3 years later.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Air Force or Defense.
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REFERENCES
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Congratulations to the 52 individuals who submitted the most likely diagnosis (hemangioma of the chest wall) for Diagnosis Please, Case 65. The names and locations of the individuals, as submitted, are as follows:
- Dr Jorge Ahualli, Tucuman, Argentina
- Kimberly K. Amrami, MD, Rochester, Minn
- Arangasamy Anbarasu, MD, FRCR, Coventry, England, United Kingdom
- Philip A. Araoz, MD, Rochester, Minn
- Ken Baliga, Rockford, Ill
- Peter C. Buetow, Bellingham, Wash
- Theresa M. Corrigan, Louisville, Ky
- Sebastián Costantino, MD, Mar del Plata, Argentina
- Wagner Diniz de Paula, MD, Brasilia, Brazil
- Mustafa Kemal Demir, MD, Ataköy, Istanbul, Turkey
- María Jesús Díaz Candamio, A Coruña, Spain
- Esther Dominguez-Franjo, Madrid, Spain
- H. Doumanian, MD, Merrillville, Ind
- Akira Fujikawa, Tokyo, Japan
- Ann S. Fulcher, MD, Richmond, Va
- Yolanda García Hidalgo Tortosa, Tarragona, Spain
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Jorge M. Garin, Malaga, Spain
- Mark Goldshein, MD, Andover, Mass
- Athanasios D. Gouliamos, MD, Athens, Greece
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Patrick Kiely, FRCR, FFR(RCSI), Limerick, Ireland
- Eric Kinder, MD, Seattle, Wash
- James A. Kirkham, MD, Minneapolis, Minn
- Arlene Klink, MD, Irvine, Calif
- J. C. LeClerc, Saint Dizier, France
- Donald R. Lewis, Jr, MD, Huntington, WV
- Antonio J. Madureira, MD, Porto, Portugal
- John A. Mattingly, MD, Belleville, Ill
- Luis Mendez-Uriburu, MD, Tucuman, Argentina
- Peter Miltner, MD, Heidelberg, Germany
- Manabu Minami, MD, Tokyo, Japan
- Tammam Nehme, Wenatchee, Wash
- Laura Oleaga, Bilbao, Spain
- David M. Panicek, MD, New York, NY
- Young Jin Park, MD, Changwon City, Gyeng-nam, South Korea
- Narendrakumar Patel MD, Newburgh, NY
- Mario Pliego, MD, Bloomington, Minn
- Dr S. P. Prabhu, Bristol, England, United Kingdom
- T. N. Anuradha Rao, Toronto, Ontario, Canada
- James Ravenel, MD, Charleston, SC
- Dr N. Saravanan, Chandigarh, India
- Pierre J. Sauvage, MD, Mâcon, France
- Mustafa Secil, MD, Izmir, Turkey
- Matt Shapiro, MD, Staunton, Va
- Dr Marius Stellmann, Stade, Germany
- Meriç Tüzün, Ankara, Turkey
- Elida Vazquez, MD, Barcelona, Spain
- Dr Sanjay R. Vydianath, MRCP, Birmingham, England, United Kingdom
- Jeff West, MD, Jacksonville, Fla
- Scott White, Rockford, Ill
- Jeffrey H. Zapolsky, MD, Oshkosh, Wis
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Intramuscular hemangioma of the chest wall: an unusual tumor.
J. Thorac. Cardiovasc. Surg.,
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134(5):
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IMAGING FINDINGS
