Ann Thorac Surg 1999;67:238-240
© 1999 The Society of Thoracic Surgeons
Case Reports
Papillary endothelial hyperplasia presenting as a chest wall neoplasm
Ignacio G. Duarte, MDa,
H. Jewel Chang, MDb,
Jan C. Kennedy, MDb,
Joseph I. Miller, Jr, MDa
a Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
b Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
Accepted for publication June 17, 1998.
Address reprint requests to Dr Miller, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, 25 Prescott St, Atlanta, GA 30308
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Abstract
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Soft tissue hematomas generally resolve but may persist and develop into slow-growing, organized masses. These chronic expanding hematomas are characterized by a pseudocapsule and a predominantly necrotic central cavity, with foci of newly formed capillaries. These have been called chronic expanding hematomas or Masson’s papillary endothelial hyperplasia. These lesions can mimic vascular neoplasms and must be considered in the evaluation of expanding soft tissue vascular malformations.
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Introduction
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Chronic expanding hematoma (extravascular papillary endothelial hyperplasia) is a rare nonneoplastic reactive process characterized by endothelial cell proliferation and fibrous encapsulation after the formation of a traumatic soft tissue cyst [1–3]. This entity has also been termed old ancient hematoma and Masson’s pseudoangiosarcoma. The diagnosis of this uncommon entity is often difficult because it is easily mistaken for relatively more frequent malignant vascular malformations, particularly angiosarcoma. We describe a patient who underwent left chest wall resection for a presumptive diagnosis of recurrent hemangioendothelioma, with subsequent histopathologic evidence of a chronic expanding hematoma.
At the age of 13, a 49-year-old man had previously undergone resection of a left chest wall tumor that was diagnosed as a rare combined hemangioendothelioma–hemangiopericytoma. He had remained in good health until 1993, at which time he noticed a slow-growing, asymptomatic mass at the site of the previous operation, initially presumed to be a lipoma by his primary physician. Two months before hospital admission, while exercising, he experienced a sharp pain at the site of the mass radiating between the axilla and anterior chest and was referred for further evaluation.
Physical examination revealed a firm, smooth, rounded mass in the left anterior chest wall, without palpable adenopathy. The initial chest radiograph revealed an ill-defined soft tissue density overlying the left midthorax, approximately 10 cm in greatest diameter. Computed tomography of the chest demonstrated a large, pleural-based mass in the left midanterior chest wall, extending into the overlying soft tissue and into the lung posteriorly (Fig 1). It appeared to involve at least four ribs of the anterior chest wall. Inhomogeneous enhancement with nodular areas of increased density on delayed images was visible after the administration of intravenous contrast medium, although there was no evidence of demonstrable blood flow on ultrasound evaluation. Preoperative fine-needle and core-needle aspiration were clinically significant for blood, fibrin, and vascular channels, consistent with a vascular lesion (hemangioma, hemangiopericytoma).
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Fig 1. Computed tomographic scan demonstrating an 8 x 9 cm pleural-based left chest wall mass with peripheral calcification extending into the upper lobe of the left lung. No evidence of mediastinal or axillary adenopathy is present. (L = left; R = right.)
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A presumptive diagnosis of a recurrent vascular tumor was made, and the patient underwent a radical en bloc left chest wall resection, including ribs 2 to 5. The mass was found to be adherent to the underlying lung and could not be separated; consequently a left upper lobectomy was also performed. The thoracic wall was reconstructed with double-folded Prolene mesh, (Ethicon, Summerville, NJ) covered with a serratus anterior muscle flap. He tolerated the procedure well, had an uncomplicated postoperative course, and was discharged on postoperative day 12.
Gross evaluation of the resected specimen revealed an expanding fusiform mass, 9 x 8.5 x 4 cm, present between the second and third ribs. Cut sections demonstrated a fibrous capsule surrounding focally hemorrhagic, tan friable material (Fig 2). Microscopic examination demonstrated a pseudocapsule consisting of hyalinized, hypocellular, fibrous tissue with interspersed foreign body giant cells. The cavity was composed predominantly of necrotic debris, fibrin, and red blood cells. Cellular areas demonstrated endothelial cell proliferation, along with fibrin thrombi forming papillary fronds and vascular channels consistent with organizing thrombus with recanalization (Fig 3). The endothelium did not demonstrate any nuclear pleiomorphism, and mitotic activity was absent.
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Fig 2. Gross lesion with a fibrous pseudocapsule and focally hemorrhagic, friable material in the central cavity.
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Fig 3. Photomicrograph of the organized cystic mass, with areas of endothelial cell proliferation forming vascular channels consistent with organizing thrombus with recanalization (hematoxylin and eosin, x10 before 52% reduction.)
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Although most hematomas resolve spontaneously, a few persist and can undergo organization into slow-growing lesions, mimicking vascular neoplasms. The terms "chronic expanding hematoma" and "extravascular papillary endothelial hyperplasia" have been used to describe this uncommon benign process [4, 5]. Histologically, it resembles the development of calcific myonecrosis after compartment syndrome injury to an extremity [6, 7]. Indeed, the term "ancient hematoma" has recently been suggested to unify these pathologically related, benign soft tissue vascular lesions without reported malignant degeneration [8]. Its true significance, however, lies in its similarity to more commonly occurring malignant processes (angiosarcoma). As in the present case, these rare lesions are typically not determined until the patient has undergone an en bloc surgical resection for a presumed vascular malignancy.
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References
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Abstract
Introduction
