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Ann Thorac Surg 1997;64:559-561
© 1997 The Society of Thoracic Surgeons

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Case Reports

Chronic Expanding Hematoma in the Chest

Departments of Chest Surgery, Respiratory Disease, Radiology, and Pathology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan

Accepted for publication March 31, 1997.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
We herein report the successful surgical treatment of 2 cases of chronic expanding hematoma in the chest. The first patient, who had undergone thoracoplasty 42 years earlier due to tuberculosis, became aware of a slowly growing mass protruding in the lateral thoracic wall. The second patient, who had tuberculous pleurisy 36 years earlier, was referred to our department because of a slowly expanding intrathoracic mass revealed by a roentgenogram. The tumors, which were encapsulated chronic hematomas, were both surgically resected. These cases are rare because of the development of a very large mass after undergoing treatment for tuberculosis more than 30 years previously.

	Introduction

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Chronic expanding hematoma in the chest is known as a specific type of chronic empyema or chronic pleurisy [1–3]. A slowly expanding mass sometimes develops in patients with a history of thoracoplasty or tuberculous pleurisy. A surgical resection is the first line of treatment, because it is difficult to distinguish it from other malignant diseases, concomitant with chronic empyema, such as malignant lymphoma and squamous cell carcinoma [4, 5], and because the mass may cause mediastinum deviation and extrathoracic protrusion in the late stage. We herein describe 2 rare cases of chronic expanding hematoma that developed into very large masses over a long period of time.

	Case Reports

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Patient 1
A 71-year-old man was admitted to our hospital presenting with a chest wall tumor. He had also been suffering from hemosputa for 2 years. Forty-two years earlier, at the age of 29 years, the patient had undergone thoracoplasty for the treatment of tuberculosis; 6 years earlier a tumor was detected in the right axilla, which had gradually protruded; and 2 years previously the patient had experienced the expectoration of bloody sputum. Magnetic resonance imaging revealed a heterogeneous mass growing from the right axilla to the right hilus of the lung (Fig 1). On needle biopsy, pure blood was aspirated from a subcapsular lesion, and a biopsy specimen at a more profound level of the lesion revealed necrotic tissue. Tumor extirpation was performed under a clinical diagnosis of chronic empyema with a hemorrhagic lesion. The bleeding volume during the operation was 1,510 mL, because the area surrounding the fibrous capsule was rich in small blood vessels. The tumor measured 23 x 14 x 13 cm and weighed 2,800 g. Histologic examination showed fresh hematoma caused by a rich source of blood from dilated capillaries beneath the fibrous capsule and organized tissue in the central lesion (Fig 2). The postoperative course was uneventful, and the patient has since been well for more than 6 months.

View larger version (135K): [in this window] [in a new window]   Fig 1. . Axial image of contrast-enhanced magnetic resonance imaging. A well-demarcated tumor with inhomogenous internal signals is seen protruding in the right axillary lesion. The tumor also grew from the interlobar space into the right lung hilum.

View larger version (160K): [in this window] [in a new window]   Fig 2. . Histologic examination showed a fresh hematoma with dilated capillaries beneath a thick fibrous capsule. No neoplastic lesions were observed.

View larger version (120K): [in this window] [in a new window]   Fig 3. . Contrast-enhanced computed tomogram of the chest. A left intrathoracic mass markedly compressed the mediastinum and contralateral lung. The mass with spotty calcifications showed irregular enhancement in the subcapsular lesion.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

The mechanism for the expansion of such hematomas is still not well understood. Labadie and Glover [8] proposed that the breakdown products derived from erythrocytes, hemoglobin, leukocytes, and other solid blood elements induce mild inflammation, and such continued inflammation causes increased permeability of the vascular wall and bleeding from dilated microvessels beneath the fibrous capsule. Although hematomas usually resolve without causing any clinical problems, the threshold for the expansion and contributing factors are still not completely understood. In addition, such incomplete treatment for tuberculosis as artificial pneumothorax and thoracoplasty, which previously was performed frequently in Japan, is also considered to be one of the causes of this disease [1, 2]. In some cases, thoracic trauma has also been identified as a possible cause of the disease [3].

Surgical resection at an early stage is the preferred treatment to prevent mediastinal deviation and extrathoracic protrusion and also because it is difficult to make a differential diagnosis from malignancies such as malignant lymphoma or squamous cell carcinoma [4, 5]. The surgical procedure should be a complete resection even if the tumor is benign, because incomplete treatment, such as drainage and curettage of the contents, could result in massive bleeding from the hypervascular subcapsular lesion [1, 2].

The present cases showed two different growth patterns. In the first case a huge extrathoracic protruding mass developed at the site of the previous thoracoplasty, whereas in the second case an intrathoracic mass developed compressing the mediastinum and contralateral lung. Both tumors grew gradually over a long period of time. Chronic expanding hematoma remains a rare disease, but should be considered in the differential diagnosis in cases of an expanding mass in the thoracic cavity when there is a history of tuberculous pleurisy, thoracotomy, or thoracic trauma.

	Footnotes

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Address reprint requests to Dr Nagashima, Department of Chest Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu 802, Japan.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Harada K, Taniki T, Yoshizawa K, Inoue K, Nagano T. Cases of chronic pleurisy with persisting hemorrhagic lesion after old tuberculous pleuritis. J Jpn Assoc Thorac Surg 1983;31:2152–8.
2. Shinada J, Yoshimura H, Hirai S, Kagawa A, Ishihara A. Chronic hemorrhagic empyema developed in thirty three years after the right pneumonectomy. A case report. J Jpn Assoc Thorac Surg 1991;39:1204–7.
3. Kasamatsu Y, Onodera H, Toda S, et al. A case of chronic expanding hematoma after thoracic injury 49 years previously. Jpn J Chest Dis 1993;52:159–63.
4. Iuchi K, Ichimia A, Akashi A, et al. Non-Hodgkin's lymphoma of the pleural cavity developing from long-standing pyothorax. Cancer 1987;60:1771–5.[Medline]
5. Willen R, Bruce T, Dahlstrom G, Dubiel WT. Squamous epithelial cancer in metaplastic pleura following extrapleural pneumothorax for pulmonary tuberculosis. Virch Arch [A] 1976;370:225–31.
6. Ried JD, Kommareddi S, Lankerani M, Park MC. Chronic expanding hematomas. A clinicopathologic entity. JAMA 1980;244:2441–2.[Abstract/Free Full Text]
7. Lewis Jr VL, Johnson PE. Chronic expanding hematoma. Plast Reconstr Surg 1987;79:465–7.[Medline]
8. Labadie EL, Glover D. Physiopathogenesis of subdural hematomas. Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg 1976;45:382–92.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hanagiri, T. Articles by Nagashima, A. Search for Related Content PubMed PubMed Citation Articles by Hanagiri, T. Articles by Nagashima, A.