Ann Thorac Surg 2008;85:1447-1448. doi:10.1016/j.athoracsur.2007.10.077
© 2008 The Society of Thoracic Surgeons
Case Reports
Chronic Expanding Hematoma in Sternum Resected 5 Years After Median Sternotomy
Susumu Kunisawa, MDa,*,
Shinji Kosaka, MDa,
Tadashi Matsukura, MDa,
Takashi Nakashima, MDa,
Takahiro Okabayashi, MDa,
Hiroyuki Miyagawa, MDb,
Yoichiro Miyake, MDb
a Division of Thoracic Surgery, Kochi Health Sciences Center, Kochi City, Kochi, Japan
b Division of Cardiovascular Surgery, Kochi Health Sciences Center, Kochi City, Kochi, Japan
Accepted for publication October 23, 2007.
* Address correspondence to Dr Kunisawa, Division of the Thoracic Surgery, Kochi Health Sciences Center, 2125-1, Ike, Kochi City, Kochi, 781-8555, Japan (Email: susumu_kunisawa{at}khsc.or.jp).
 |
Abstract
|
|---|
Chronic expanding hematomas occur at various locations in the body; however, their occurrence in the sternum has not been reported yet. We report a patient with chronic expanding hematoma in the sternum 5 years after undergoing a median sternotomy for cardiac surgery. Although preoperative biopsy specimens did not lead to a definitive diagnosis, we could not rule out the possibility of a malignant tumor because of the expanding and infiltrative behavior of the hematoma. We performed a sternectomy and reconstructed the chest wall using artificial materials.
|
Introduction
|
|---|
Chronic expanding hematomas (CEHs), initially identified by Reid and Kommareddi [1], occur at various locations in the body. Their occurrence has been reported in thoracic cavities [2–4]. However, CEHs in the sternum have not been reported yet. It is difficult to differentiate CEHs from malignant tumors because CEHs sometimes behave in an invasive manner similar to malignant tumors. Furthermore, malignant tumors occasionally contain a large amount of blood. We describe a patient with CEH in the sternum that was resected 5 years after he underwent a median sternotomy.
A 79-year-old man who had undergone a median sternotomy for cardiac surgery, aorta replacement for aortic arch aneurysm, 5 years ago was followed up. He took some medications for hypertension and hepatitis C, but did not take anticoagulants during the follow-up period. He felt something unusual in the precordial region, which was determined to be an erythematous mass surrounded by redness (Fig 1). Computed tomography (CT) of the chest showed a round mass shadow obliterating the sternum (Fig 2). The mass in the current CT was larger than that obtained in the CT 1 year ago, and had extended into the surrounding sternal bone. Although the sternal wires used during the previous cardiac surgery obstructed the view, chest magnetic resonance imaging showed that the mass was filled with fluid. To differentiate between a CEH and a malignant tumor, we performed a needle biopsy of the mass. Cytological examination revealed only the blood component with no evidence of malignant or inflammatory cells. Blood chemistry analysis showed mild anemia and a mild hepatic dysfunction. We could not reach a definite diagnosis and completely ruled out malignancy. Furthermore, there was a synthetic graft under the expanding mass. Therefore, we believed it was appropriate to surgically remove the mass.
View larger version (109K):
[in this window]
[in a new window]
|
Fig 1. The patient presented with an erythematous mass in the precordial region with circumscribed redness of the surrounding area.
|
|
The skin was incised at a sufficient distance from the mass. The sternal bone was cut from the manubrium at the sternal angle, and the second to sixth ribs were amputated bilaterally at the costochondral junctions. We reconstructed the chest wall with a Gore-Tex sheet (W. L. Gore & Assoc, Flagstaff, AZ) and Bard mesh (C.R. Bard Inc, Murray Hill, NJ), we placed two Kirschner wires (Mizuho Co Ltd, Tokyo, Japan) above the sheets, and we hardened them with cranioplastic cement (Johnson & Johnson K.K., Tokyo, Japan) to form a structure similar to the sternal bone (Fig 3). The operation lasted 247 minutes, and the total blood loss was 640 mL.
Macroscopic observation showed that the mass was hollow and filled with old blood. Pathologic examination revealed the presence of dense fibrous tissues integrated with bone beams surrounding the hematoma, hemosiderin deposits, lymphocyte infiltration, fibroblast proliferation, and foreign-body granulomas, including foreign-body giant cells. There was no evidence of malignancy.
Although the chest had to be drained for approximately 2 weeks postoperatively, the patient was discharged 48 days after surgery without evidence of a flail chest. At the 1-year follow-up, there was no sign of recurrence.
|
Comment
|
|---|
Although CEHs have been reported, the underlying mechanism for their formation is still unclear. One possibility is that cellular breakdown products of leukocytes, erythrocytes, hemoglobin, platelets, and fibrin inside the clot cause a fibroblastic reaction. Continued inflammation increases the permeability of the vascular wall resulting in the bleeding of the damaged capillaries beneath the fibrous capsule [5].
It is very difficult to differentiate CEHs from malignant tumors. The medical history of the patient is important, because most cases with CEH have a history of trauma or surgery. In our case, there had been a previous surgery in the sternal region; therefore, we should have thought about CEH as the first differential diagnosis. In suspected cases of CEH, an magnetic resonance imaging examination is preferred to a computed tomographic examination, because magnetic resonance imaging can clearly show the tumor and detailed inner fluid characteristics of the mass better than CT [6]. Preoperative pathologic and cytological diagnosis to distinguish CEHs from malignant tumors is difficult and must be done carefully, because blood can also accumulate in malignant tumors with hematoma. Pathology can be determined definitively only after surgical removal of the mass.
Complete removal of a CEH as a whole is recommended as drainage or removal of the inner substance without removal of the entire capsule may cause massive bleeding, and incomplete removal may lead to a recurrence [2]. Because CEHs have a potential tendency to invade the surrounding structures, ruptures of CEHs have been reported [2]. In our case, the patient had an artificial aorta beneath the CEH. Initially, we decided to perform a sternectomy because the possibility of a malignant tumor was not ruled out. However, even if the mass had been diagnosed as a benign CEH preoperatively, a complete resection would have been chosen because drainage alone can cause an infection to the graft, or the expanding hematoma could eventually rupture into the graft. The decision to perform a sternectomy in the case of a benign disease is difficult, because loss of the chest wall can cause a flail chest. We reconstructed the chest using artificial materials and prevented the occurrence of a flail chest. At the 1-year follow-up after the operation, the reconstructed chest wall was stable, and the patient was doing well.
|
References
|
|---|
- Reid JD, Kommareddi S. Chronic expanding hematoma JAMA 1980;244:2441-2442.[Abstract/Free Full Text]
- Okubo K, Okamoto T, Isobe J, Ueno Y. Rupture of a chronic expanding hematoma of the thorax into lung parenchyma J Thorac Cardiovasc Surg 2004;127:1838-1840.[Free Full Text]
- Uramoto H, Nakanishi R, Eihuku R, et al. Chronic expanding hematoma in the chest J Cardiovasc Surg 2000;41:143-146.[Medline]
- Okada D, Koizumi K, Kawamoto M, et al. A case of chronic expanding hematoma presenting as a huge mass in the pleural cavity J Nippon Med Sch 2002;69:282-285.[Medline]
- Labadie EL, Glover D. Physiopathogenesis of subdural hematomas J Neurosurg 1976;45:382-392.[Medline]
- Imaizumi S, Morita T, Ogose A, et al. Soft tissue sarcoma mimicking chronic hematoma: value of magnetic resonance imaging in differential diagnosis J Orthop Sci 2002;7:33-37.[Medline]
Top
Abstract
Introduction
