Ann Thorac Surg 2009;87:1961. doi:10.1016/j.athoracsur.2008.09.035
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Chronic Expanding Mediastinal Hematoma
Tomoyuki Nakano, MD,
Shunsuke Endo, MD*,
Mitsuhiro Nokubi, MD,
Hiroyoshi Tsubochi, MD
Department of General Thoracic Surgery, Jichi Medical University and Saitama Medical Center, Tochigi, Japan
* Address correspondence to Dr Endo, Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical University, 1-3311, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan (Email: tcvshun{at}jichi.ac.jp).
A 70-year-old man, who had sustained a blunt chest injury 20 years earlier, presented for an examination for a 10-cm asymptomatic, slowly enlarging spherical tumor in the right-side mediastinum on chest roentgenogram taken at 2007 (Fig 1). The diameter had been 6 cm on chest roentgenogram taken in 2002 (Fig 2).
Physical findings were normal, as were the results of blood examinations, including coagulation study and tumor markers. Computed tomography with contrast medium showed a huge 12- x 12- x 10-cm well-circumscribed mass with a slightly enhanced capsule containing low-density contents (Fig 3). This was suggestive of a benign soft-tissue tumor with hematoma characteristics. The tumor compressed the superior vena cava anteriorly and the right upper lobe caudally. Bronchoscopy showed stenosis of the upper bronchus compressed by the tumor. A dissecting aneurysm in the descending aorta was stable.
Operative findings through an open thoracotomy showed that the tumor was located behind the superior vena cava in the mediastinum, with no invasion to the mediastinal organs. Tumor resection was completed. Right upper lobectomy was performed, because it was still collapsed after tumor removal. Operation time was 165 minutes, and blood loss was 600 mL.
Macroscopic findings and pathologic study showed no evidence of neoplasm or infection. A chronic expanding hematoma was diagnosed. Fresh thrombi and neovascularization were revealed around the inner wall of the capsule (Fig 4). The hematoma was thought to have been caused by the previous blunt chest injury. As determined from the clinical history and pathologic examination, continued inflammation after cellular breakdown products of leukocytes, erythrocytes, hemoglobin, platelets, and fibrin inside the clot possibly caused neovascularization beneath the fibrous capsule, resulting in the progressive expansion of the hematoma by the bleeding of the damaged capillaries.
