Ann Thorac Surg 2006;81:1903-1904
© 2006 The Society of Thoracic Surgeons
Case report
Meningioma of the Mediastinum Causing Spontaneous Hemothorax
Domenico Palimento, MD
a
,
Marcello Picchio, MD
b
,
*
a Department of Surgery, Civil Hospital "S. Paolo," Naples
b Department of Surgery, Civil Hospital "A. Fiorini," Terracina, Italy
Accepted for publication July 13, 2005.
* Address correspondence to Dr Picchio, via Stefano Boccapaduli, nr. 51, Rome, 00151 Italy (Email: marcellopicchio{at}libero.it).
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Abstract
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Ectopic meningiomas are extremely rare. Mediastinal tumors may rarely cause spontaneous hemothorax. We report a case of angioblastic meningioma of the posterior mediastinum causing spontaneous hemothorax.
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Introduction
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Spontaneous hemothorax, a collection of blood in the pleural cavity not related to trauma, is a rare disease manifestation. Hemothorax due to mediastinal tumors is extremely rare. We report a case of angioblastic meningioma of the posterior mediastinum, presenting as spontaneous hemothorax.
A 45-year-old woman was admitted with left thoracic pain, dyspnea, and easy fatigability for 24 hours. At admission, general conditions were satisfactory, blood pressure was 120/80 mm Hg, and the pulse rate was 75/min and regular. Physical examination of the thorax showed a decrease in tactile fremitus, dullness to percussion, and diminution of breath sounds all over the left hemithorax. Laboratory tests showed a red cell count of 3,770,000/mm3, hemoglobin of 12.0 gr/dL, and hematocrit of 31.7%, and an arterial blood gas analysis revealed a pH of 7.34 with PaO
2 of 82 mm Hg and PaCO
2 of 32 mm Hg. Chest roentgenogram showed the presence of a posterior paravertebral mass in the left hemithorax; the mass had smooth margins and it was 10 cm wide. Basal pleural effusion was also present.
Two hours after admission, the patient had hypotension (blood pressure, 50/60 mm Hg) with bradycardia (heart beat, 44/min) develop, and her hemoglobin was 6.5 gr/100 mL and her hematocrit was 19%. In spite of appropriate volume replacement with crystalloid solutions and packed red cells, restoration of hemodynamic stability was not achieved (blood pressure, 80/60 mm Hg). A computed tomographic scan of the thorax demonstrated the presence of an 11 cm wide left paravertebral mass. After contrast agent injection the mass showed hemorrhagic areas. A massive pleural effusion was also present with rightward shift of the mediastinum and hilum and collapse of the left lung (Fig 1).
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Fig 1. Computed tomographic scan of the chest showing the left hemothorax with collapsed lung and after contrast enhancement an 11 cm wide left paravertebral mass.
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Paracentesis of the left hemithorax returned blood. The patient underwent emergency left posterolateral thoracotomy. When the pleural cavity was opened, 2 L of blood were drained. The paravertebral mass as seen on computed tomographic scan was 12 cm wide, elastic, and off white in color. The mass was completely excised. The thoracic wound was closed with drainage of the left pleural cavity.
Histologic examination of the mass showed the presence of monomorphic spindle cells with a low mitotic index (5 x 10 high power view), an abundant vascular network, and focal hemorrhagic and necrotic areas (Fig 2). Immunohistochemical examination showed focal positivity to CD34, CD68, and vimentin. The morphologic and immunohistochemical patterns were compatible with the diagnosis of angioblastic meningioma.
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Fig 2. Photomicrograph of the resected mass shows a monomorphic proliferation of spindle-shaped cells that are connected with abundant vascular spaces. (Hematoxylin and eosin; original magnification x10.)
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The postoperative course was uneventful and the patient was discharged 7 days after operation. One month after operation the patient had magnetic resonance imaging of the head and spine, which excluded possible central nervous system lesions.
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Comment
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Meningiomas are common and usually benign, slow-growing tumors of the central nervous system. Ectopic meningiomas are uncommon and arise through metastatic spread of malignant meningiomas. Primary ectopic meningiomas are extremely rare extracranial and extraspinal tumors and have been reported sporadically in the head and neck region as well as in the lung, finger, skin, eyelid, retroperitoneum, thigh muscle, and foot [1]. The histogenesis of ectopic menigiomas is still unclear. They are believed to arise from ectopic arachnoid tissue or from mesenchymal cells or Schwann cells that have been differentiated into meningothelial cells [2, 3]. Only two previous mediastinal primary ectopic meningiomas have been described in the literature [4, 5]. Spontaneous hemorrhage associated with meningioma is uncommon and the reported incidence is 1.3% [6]. Helle and Conley [7] reported a higher risk of hemorrhage in angioblastic and malignant meningioma. On searching the PubMed data bank (ie, www.ncbi.nlm.nih.gov/PubMed) for mediastinal tumor and spontaneous hemothorax, we found only six reported cases of mediastinal tumors that have caused spontaneous hemothorax. We report the first case of ectopic meningioma of the mediastinum causing spontaneous hemothorax.
Spontaneous hemothorax may be treated conservatively with chest tube drainage in hemodynamically stable patients, but prompt thoracotomy is recommended in emergency patients [8].
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References
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Abstract
Introduction
