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Chronic Expanding Hematoma of the Thorax

Stanford University Medical Center Stanford University Medical School Stanford, CA 94305-5105

A 67-year-old Asian woman presented with a 5-month history of an expanding left chest wall mass. (Most reported cases of expanding hematoma of the thorax have been reported in the Asian population.) The patient denied associated symptoms. The patient had undergone a left pneumonectomy 40 years previously for bronchiectasis.

At physical examination, a 5 x 4 cm nontender mass was noted in the mid axillary line along a well-healed thoracotomy incision. Chest radiography showed an opacified left hemithorax with tracheal deviation to the left but otherwise midline mediastinal structures (Fig. 3A). CT showed a large heterogeneous mass with central low attenuation and a thick wall containing flecks of calcification filling most of the left hemithorax and extending into the subcutaneous tissues (Fig. 3B).

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —67-year-old woman with chronic expanding hematoma of thorax. Chest radiograph shows opacification of left hemithorax with mild tracheal deviation to left and midline mediastinal structures.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —67-year-old woman with chronic expanding hematoma of thorax. CT scan shows heterogeneous mass (arrows) in left hemithorax extending into extrathoracic soft tissue.

The differential diagnosis of this mass included chronic tuberculous empyema and softtissue sarcoma. At the surgical biopsy, incision of the chest wall mass revealed reddish brown fluid in continuity with the pleural space. The biopsy incision was extended, and approximately 700 mL of material with a solid fibrinous consistency was curetted and removed. Samples sent for histopathologic and microbiologic analysis revealed aggregates of fibrin and extensive necrotic debris, with no evidence of neoplasia or infection.

Chronic expanding hematoma of the thorax is a rare entity [1]. Affected patients typically have a history of medical or surgical therapy for tuberculosis. The presenting symptom is usually dyspnea related to lung compression or a slowly growing chest wall mass, both of which develop 30 years or more after treatment for tuberculosis.

The pathogenesis of chronic expanding hematomas is poorly understood. Labadie and Glover [2] theorized that this self-perpetuating expanding process is due to the irritant effects of blood and its breakdown products, which cause repeated episodes of bleeding from capillaries in the granulation tissue.

Radiographically, chronic expanding hematoma of the thorax appears as an intrathoracic mass. The CT findings consist of a heterogeneous mass with a wall of variable thickness that often contains peripheral areas of calcification [3]. On MR imaging, chronic expanding hematoma of the thorax has been reported to have a low-signal-intensity peripheral capsule and central contents of varying signal intensities ranging from high to low [4].

References

1. Uramoto H, Nakanishi R, Eifuku R, et al. Chronic expanding hematoma in the chest. J Cardiovasc On the AJR Viewbox Surg (Torino) 2000;41:143 –146
2. Labadie EL, Glover D. Physiopathogenesis of subdural hematomas. 1. Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg 1976;45:382 –392[Medline]
3. Hanagiri T, Muranaka H, Hashimoto M, et al. Chronic expanding hematoma in the chest. Ann Thorac Surg 1997;64:559 –561[Abstract/Free Full Text]
4. Akata S, Ohkubo Y, Jinho P, et al. MR features of a case of chronic expanding hematoma. Clin Imaging 2000;24:44 –46[Medline]

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