Introduction
Vascular tumors affecting the chest wall are very rare. The literature suggests sporadic case reports of chest wall hemangiomas. Hemangioma is defined as a neoplastic entity, which arises from blood vessels. Histologically it can be categorized as one of five histologic subtypes: capillary, cavernous, venous, arteriovenous or mixed [1]. Case reports describe hemangiomas of the chest wall arising from intercostal muscles (intramuscular, intercostal) or from the medullary canal of the rib (bone hemangioma). Intercostal hemangiomas account for approximately 0.01% of all benign hemangiomas [2]. We describe a patient with an intercostal venous hemangioma presenting as a chest wall tumor, for which resection of the chest wall was successfully accomplished.
Case report
A 36-year-old male was admitted to the Clinic of Thoracic Surgery for a slowly progressing chest mass and six-month pain of the thoracic spine and left chest. There was no medical history of trauma of the chest wall and no oncological disease. During clinical examination a slowly growing soft resistance located dorso-laterally in the range of the seventh to ninth rib on the left chest was found. Chest roentgenogram showed a left lateral soft-tissue mass of the chest wall. Chest magnetic resonance (MR) imaging showed a well-bordered tumor of the left chest wall, with a size of 9.5 x 9 x 3 cm with calcifications, overgrowing to the seventh and eighth intercostal space (Fig. 1). According to the result of MR, hemangioma was suspected. The patient underwent surgery. A complete resection of the tumor with the left seventh, eighth and ninth ribs and their intercostal muscles was successfully accomplished (Fig. 2B). Blood loss was up to 500 ml. Reconstruction of the chest wall was achieved using polypropylene mesh (Fig. 2A). Microscopically, structures of benign vascular lesions corresponding to intramuscular venous hemangioma with numerous phleboliths were found in adipose tissue and striped muscle in the resected chest wall. The surgical margins were negative for tumor structures. The patient was discharged on the seventh postoperative day, and presently, ten months after the operation, he is doing well, without any evidence of local recurrence.
Discussion
Intramuscular hemangiomas occur most often in people under 30 years of age and show no sex predilection. Generally they are considered to be congenital, but factors such as chest trauma or repetitive bruises may play a role in development of intramuscular hemangioma [2, 3]. Patients with intercostal hemangioma clinically may present with palpable mass of the thoracic wall, soft-tissue bulging, pain or a combination of these signs and symptoms. Intercostal hemangioma should be included in the differential diagnosis of primary soft tissue chest wall tumors, such as fibromas, lipomas, giant cell tumors, neurogenic tumors, desmoids, soft tissue sarcomas, connective tissue tumors and metastatic tumors. Conventional radiography hemangiomas may be seen as an ill-defined soft-tissue mass. Phleboliths are specific to hemangiomas and helpful in diagnosing soft-tissue hemangioma [4]. Regional ribs may show periostitis, trabecular coarsening and cortical changes such as thickening, thinning or erosion [5].
Computed tomography (CT) of the chest localizes and characterizes chest wall hemangioma, its effect on adjacent structures and it can also reveal phleboliths. A preliminary diagnosis may be established by MR examination, when classic MR findings are present: tumor mass of low or intermediate signal intensity in T1-weighted images and a high signal intensity in T2-weighted images (vascularity is manifested as a high signal intensity) [4]. Invasive diagnostic techniques, such as open or percutaneous (CT-guided or echo-guided) needle biopsy are also available, but needle biopsy of hemangioma may cause bleeding. In the case of big hemangiomas, a preoperative embolization of hemangiomas with the aim to minimize the risk of intraoperative complications like excessive bleeding, is necessary before surgery. Intercostal hemangiomas are managed by complete surgical chest wall resection with clean surgical margins. The next decision about skeletal reconstruction depends on the size and location of the defect. Large chest wall defects (> 5 cm) require skeletal reconstruction. Posterior defects that lie above the fourth rib and are covered by the scapula do not need to be reconstructed. The choice of synthetic prosthetic material depends on the location of the defect, its size and surgeon’s preference and experience.
In conclusion, this case represents a very rare intercostal hemangioma of the chest wall. Presumptive diagnosis was based on MR, resection was performed for definitive diagnosis and treatment.
Disclosure
Authors report no conflict of interest.
References
1. Murphey MD, Fairbairn KJ, Parman LM, Baxter KG, Parsa MB, Smith WS. Musculoskeletal angiomatous lesions: radiologic-pathologic correlation. Radi-ographics 1995; 15: 893-917.
2. Scott JE. Haemangioma in skeletal muscle. Br J Surg 1957; 44: 496-501.
3. Shimizu K, Yamashita Y, Hihara J, Seto Y, Toge T. Cavernous hemangioma of the rib. Ann Thorac Surg 2002; 74: 932-934.
4. Ly JQ, Sanders TG. Case 65: hemangioma of the chest wall. Radiology 2003; 229: 726-729.
5. Sung MS, Kang HS, Lee HG. Regional bone changes in deep soft tissue hemangiomas: radiographic and MR features. Skeletal Radiol 1998; 27: 205-210.
