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Haemangioma of Anterior Mediastinum: A Case Report

H.K.Dutta¹, P.Biswanath², S.Gohain³, C. Bibhas³

¹Department of Pediatric Surgery

²Department of Pediatrics

³Departments of Pediatrics & General Surgery

Assam Medical College & Hospital

Dibrugarh, Assam, India

 

Correspondence:

Dr. H.K.Dutta, MS, M.Ch.

Assistant Professor of Pediatric Surgery, Assam Medical College & Hospital

Dibrugarh, Assam, India

PIN: 786002., E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Cavernous haemangiomas of anterior mediastinum are rare. We present a twelve year old boy who came with pain and swelling of left side of chest. Radiological investigations confirmed its origin from anterior mediastinum. Surgical resection and histopathological examination confirmed the diagnosis.

Key words: cavernous haemangioma, anterior mediastinum

  

Introduction

Anterior mediastinal masses deserve prompt diagnosis to rule out malignant conditions. Till year 2000 only 125 cases have been reported [1]. We report a rare case of cavernous haemangioma of the anterior mediastinum. No case among children has been reported in India.

Case report

A twelve year old boy presented in our Outpatient Pediatric Department with complains of pain and swelling over upper part of the left side of chest for one and a half year. Initially pain was occasional and aggravated by movement of the left arm. But later pain became continuous and severe with restriction of movements of left arm which had brought him to the hospital. Pain was associated with a swelling over upper part of the left side of chest which was initially small but increased gradually in size. There was no history of trauma, fever, cough or any similar swelling over other parts of the body There was also no history of dyspnea, palpitation, tingling or numbness or loss of power of left arm. He was operated 3 years back for an inguinal hernia.

On examination child was afebrile and vitals were stable. There was no pallor, icterus, clubbing, lymphadenopathy or edema. There was swelling over anterior and lateral aspect of chest from second intercostal space measuring 4cm X 5cm. It was oval shaped with smooth surface and ill defined margin. It was tender, dull on percussion and non pulsatile. Trachea and apex beat were deviated towards right side. Auscultation revealed diminished heart and breath sounds over left chest.

Investigation of blood and urine for routine examination were normal. A plain roentgenogram of the chest was obtained which revealed an oval paraspinal soft tissue density mass with well defined margins in mid-thoracic region (Fig.1). Lateral chest roentgenogram confirmed the anterior mediastinal location of the mass. USG guided aspiration cytology from the mediastinal mass could not give any definitive diagnosis. Serum b-HCG and a-fetoprotein levels were normal which excluded germ cell tumor of the mediastinum. Serial axial CT of the thorax revealed a 12.6 X 9.6cm2 heterogenous well circumscribed mass arising from left side of the anterior mediastinum and filling the whole of the left hemithorax (Fig. 2).

A left sided thoracotomy was performed which showed a well encapsulated soft tissue mass between the pericardium and hilum of the left lung, to which it was densely adherent (Fig. 3). The mass was excised (Fig. 4). Cut section showed spongy structure filled with blood (Fig. 5). Histology confirmed the mass to be a benign cavernous haemangioma (Fig. 6). The post operative course of the patient was uneventful. Last follow up at one and a half year, the patient was asymptomatic with a normal chest X-ray.

haemangioma 1

Figure1. X-Ray Chest showing 

haemangioma 2

Figure 2. CT scan showing the mass. Left mediastinal mass

haemangioma 3 haemangioma 4 haemangioma 5
Figure 3. Mass adherent to pericardium Figure 4. Resected mass  Figure 5. Spongy structure on cut section 

haemangioma 6

Figure 6. Cystic spaces filled with blood and separated by thin fibrous septae

Discussion

Haemangiomas are rare mediastinal tumor accounting for 0.5% of mediastinal masses [2 Half to one third of the cases are incidentally detected on routine chest radiograph. The age of presentation has a wide range from 2 months to 76 years but 75% cases occur in young adults before 35 years of age [3]. Anatomically, about two third of these tumors arise mostly in the anterior mediastinum and occasionally in the posterior mediastinum[1]. They are of three types – Capillary, Cavernous and Venous. Microscopically they are formed by dilated vessels lined by endothelial cells with fibrous septa. Symptoms from these tumors arise from compression of adjacent structures [2]. But some patients may present with symptoms suggestive of advanced malignancy like hoarseness, recurrent pleural effusion and superior vena caval obstruction [2,3,4]. Plain radiograph of chest is usually diagnostic, especially when calcified phleboliths are seen [5]. Contrast CT shows a heterogenous mass with central or less commonly peripheral enhancement [6,7]. These vascular tumors have been treated in children with alpha – 2a interferon, which can reduce the volume of the bulky tumor and increases the safety in patients with vital structures encasement. Differential diagnosis of calcified madiastinal masses are calcified thymic cyst, recurrent tracheal leiomyoma, mediastinal teratoma and calcified lymph nodes usually due to fungal diseases.

Conclusion

Most anterior mediastinal masses are malignant. The presence of phleboliths, heterogenecity and mild to moderate enhancement are features which favor haemangiomas over the more common tumors like Teratomas, Lymphomas and Germ Cell Tumors. Excisional biopsy through a limited incision should be performed as it allows complete removal of the tumor, resolution of associated compression symptoms and establishes the diagnosis with certainity.

 

 

REFERENCES

1. Taori KB, Mitra KR, Mohite AR et al. A case report and review of literature : Posterior mediastinal haemangioma. Indian J Radiol Imaging, 2002;12;83-85.

2. Cohen AJ: Mediastinal haemangiomas. Annals of thoracic surgery 1987; 43(6):656-659.

3. Davis JM; Benign Blood Vascular Tumors of the Mediastinum: Radiology 1978:126; 581-587.

4. Mc. Adams PH: Mediastinal Haemangioma; Radiographic and CT features in 14 patients. Radiology 1994: 193; 399 – 402.

5. Luis M et al, Surprising Surgical Successes. CHEST. Nov 2005.