Ann Thorac Surg 2008;86:1974-1976. doi:10.1016/j.athoracsur.2008.04.109
© 2008 The Society of Thoracic Surgeons
Case Reports
Hemangioma of the Sternum
Serdar Onat, MDa,*,
Refik Ulku, MDa,
Alper Avci, MDa,
Bulent Mizrak, MDb,
Cemal Ozcelik, MDa
a Department of Thoracic Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
b Department of Pathology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
Accepted for publication April 28, 2008.
* Address correspondence to Dr Onat, Dicle University Faculty of Medicine, Department of Thoracic Surgery, Diyarbakir, 21280, Turkey (Email: onatserdar21{at}hotmail.com).
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Abstract
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Primary tumors of the sternum are rare and most of them are malignant. Benign lesions are typically chondromas, bone cysts, or hemangiomas. Among these tumors, hemangiomas are extremely rare. We report a rare case of hemangioma of the sternum. The patient was successfully treated with complete resection of the tumor and sternum stability was obtained by polypropylene mesh and methylmethacrylate.
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Introduction
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Primary tumors of the sternum are rare and most of them are malignant. Benign lesions are typically chondromas, bone cysts, or hemangiomas. Hemangiomas of the sternum create defects in the cortex and show expansile growth, requiring a careful differential diagnosis between these benign tumors and various malignant tumors. Hemangiomas of the sternum are rare, with only sporadic case reports in the literature.
A 32-year-old woman presented with anterior chest pain and an enlarging mass on the upper part of her sternum. Local examination revealed the expanding of the manubrium. Laboratory studies were all within normal limits. Lateral chest roentgenogram revealed a mass in the upper part of the sternum. A contrast-enhanced computed tomographic scan of the thorax was carried out and confirmed the markedly expanding mass and interruption of the cortex of the sternum (Fig 1). Focal destruction of the cortex was seen. No invasison of the tumor into the thoracic cavity was found. The technetium 99m methlyenediphosphonate scintigraphy showed osteoblastic activity in the upper part of the sternum. An aspiration biopsy of the lesion was performed. At the time of the aspiration biopsy, the needle easily punctured the thin anterior cortex and apparently fell into the lesion. The needle was filled by blood. Subsequent cytologic examination revealed only blood elements. No malignant cells were seen. Preoperatively, sternal resection and grafting had been planned. The lesion was explored through a longitudinal skin incision. All parts of the manubrium had been expanded. Cartilages of both sides of the first, second, third, and fourth ribs were removed. The sternum was seperated from the bilateral clavicles. The sternum was transected transversely through the fourth intercostal space. The resected sternum was then separated from the mediastinum and 11 x 5 x 5 cm mass was removed (Fig 2). Chest wall stability was obtained by polypropylene mesh and methlymethacrylate prosthetic material sutured to the edges of the sternal defect with nonabsorbable sutures. The hospital course was uneventful, and the patient was discharged on postoperative day 8. The specimen was macroscopically examined by the pathologist. After dissection of the sternum, a cytic lesion, filled with bood was seen. The dimension of cystic lesion was 8 x 5 x 3 cm. Histologic examination of the mass revealed a cavernous hemangioma (Fig 3).
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Fig 1. Thorax computed tomographic scan of markedly expanding mass and interruption of the cortex of the sternum.
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Comment
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Primary tumors of the sternum are rare and most of them are malignant [1, 2]. Benign lesions are typically chondromas, bone cysts, or hemangiomas [3]. Benign sternal tumors are uncommon. Among these tumors, the hemangiomas are extremely rare. Hemangiomas of the sternum are even more rare, with only sporadic case reports in the literature [4, 5]. This is the third case that has been published before now. Hemangiomas of the sternum show expansile growth, requiring a careful, differential diagnosis between these benign tumors and various malignant tumors. Benign sternal tumors are extremely rare, and all sternal tumors should be considered malignant until proven otherwise [5]. As imaging is not decisive in most cases, overly radical surgery is often performed because of an incorrect preoperative diagnosis of malignant bone tumor. This case illustrates the diagnosis and treatment of this unusual tumor. Most hemangiomas that arise from bones occur in the skull and vertebral column, and they account for approximately 1% of all bone tumors [6]. To choose the most suitable surgical procedure, we first performed percutanous biopsy. No complication, such as massive bleeding or subcutanous hematoma, occurred in relation to the biopsy. Open biopsy should be avoided because of risk for extensive bleeding [4]. Chest wall stability after a wide sternectomy can be obtained with different prosthetic materials and muscle or musculocutaneous flaps [7]. The methylmethacrylate is usually spread between two layers of polypropylene mesh [8]. Because there is no sharp distinction between benign hemangiomas and low-grade, malignant hemangioendotheliomas, and because of the relatively high recurrance rate of hemangiomas, the tumor should be resected with adjacent sternal tissue [4].
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References
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- Bernard JP, Rusch W. Chest wall tumorsIn: Shields WT, Locicero J, Ponn RB, Rusch W, editors. General thoracic surgery. 6th ed.. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2005. pp. 719-720.
- Medalion B, Bar I, Neuman R, Shargal Y, Merin G. Sternal hemangioma: a rare tumor J Thorac Cardiovasc Surg 1996;112:1402-1403.[Medline]
- Boker SM, Cullen GM, Swank M, Just JF. Case report 593: hemangioma of sternum Skeletal Radiol 1990;19:77-78.[Medline]
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Abstract
Introduction
