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A 26-Year-Old Man With a Slowly Growing Heterogeneous Intrathoracic MassMan With Heterogeneous Intrathoracic Mass FREE TO VIEW

Julianne Nichols, DO; Natalie Berger, MD; Vanessa Yap, MD; Daniel Fusco, MD; Debapriya Datta, MD, FCCP
Author and Funding Information

From the Division of Internal Medicine (Drs Nichols and Berger), the Division of Pulmonary and Critical Care Medicine (Drs Yap and Datta), and the Department of Cardiothoracic Surgery (Dr Fusco), University of Connecticut Health Center, Farmington, CT.

Correspondence to: Debapriya Datta, MD, FCCP, Pulmonary and Critical Care Medicine, University of CT Health Center, 263 Farmington Ave, Farmington, CT 06030; e-mail: ddatta@uchc.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(1):e19-e23. doi:10.1378/chest.13-2471
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A 26-year-old man presented with complaints of left-sided chest pain and shortness of breath with moderate exertion, of 6 month duration. The patient had a history of asthma but reported that the exertional shortness of breath was not like his typical asthma symptoms and was not associated with wheezing. The left-sided chest pain was a dull and constant ache, without any aggravating or relieving factors. The patient denied fever, chills, night sweats, cough, or weight loss. Past medical history was significant for asthma since childhood, which was well controlled on budesonide inhaler. He had received a gunshot wound 1½ years earlier and had abdominal surgery at that time “to stop the bleeding,” but records of the procedure were not accessible.

Examination revealed a young man who appeared well and in no distress. Vital signs were as follows: temperature, 36.6°C; heart rate, 80/min, regular; BP, 120/76 mm Hg; respiratory rate, 15/min; and oxygen saturation, 98% on room air. There was no pallor, icterus, or cyanosis. No jugular venous distension, thyromegaly, or cervical lymphadenopathy was discerned. Lung examination revealed diminished breath sounds at the left base with decreased vocal resonance and increased dullness to percussion. Cardiac examination revealed normal heart sounds without any murmur. No organomegaly or localized tenderness was noted on abdominal examination. A midline surgical scar was noted on his abdominal wall. A rounded scar, 2 cm in diameter, was present about 5 cm lateral to the midline scar on the left, likely representing the entry gunshot wound; no exit wounds were visible. Neurologic examination was normal.

CBC count and basic metabolic panel were within normal limits. Chest radiographs showed opacity at the left base (Figs 1A, 1B). Chest CT scan with contrast revealed a large heterogeneous mass with a large central fluid component in the left lower hemithorax (Fig 2). The mass appeared to arise in the lung parenchyma, with extension to the pleural surface. Minimal enhancement was noted in a small area of the pleura adjoining the lesion. Contiguous margin of the diaphragm appeared indistinct, with absence of fat plane with the spleen, raising the possibility that the mass may represent a splenic pseudocyst (Fig 3). A technetium99-labeled sulfur colloid scan was performed (Fig 4), which revealed that the mass was not contiguous with the spleen, thereby ruling out a splenic pseudocyst.

Figure Jump LinkFigure 1. A, Chest radiograph posteroanterior view showing opacity at left lung base. B, Chest radiograph lateral view showing opacity at left lung base. PA = posteroanterior.Grahic Jump Location

Figure Jump LinkFigure 2. CT scan of the chest with contrast showing a large heterogeneous mass (8.5 × 6.7 cm) with a central fluid component in the left lower hemithorax. A, Lung window. B, Mediastinal window.Grahic Jump Location

Figure Jump LinkFigure 3. Coronal section of chest CT scan showing that the contiguous margin of the diaphragm between the spleen and the lung mass is indistinct, with absence of a fat plane between the diaphragm and the spleen.Grahic Jump Location

Figure Jump LinkFigure 4. Technetium99-labeled sulfur colloid scan showing uptake in the liver and spleen. No uptake is seen in the mass in the lower left hemithorax, abutting the diaphragm and spleen, indicating it is not in continuity with the spleen. A, Sagittal section. B, Coronal section.Grahic Jump Location

The patient did not wish to pursue any further diagnostic tests initially. He returned with worsening complaints of chest pain and shortness of breath a few months later. There were no complaints of associated fever, cough, night sweats, weight loss, or loss of appetite. A repeat chest CT scan showed an increase in the size of the mass-like lesion. A biopsy was attempted; the needle aspirate revealed brownish, purulent material. Because of concerns about this being a loculated empyema vs malignant tumor, surgical resection was planned. On thoracotomy, extensive adhesions were noted involving the left lower lobe of the lung and the chest wall. Extensive dissection and lysis of adhesions were performed. The left lower lobe of the lung appeared destroyed by the loculated collection, which contained dense necrotic material, which was sent for staining and culture for routine bacteria, acid-fast bacilli, and fungus. The left lower lobe was resected, and the residual collection in the lobe on sectioning appeared as a rubbery, fibrinous mass with a cavity. Histopathology revealed multifocal chronic inflammation with multifocal dense scar. No evidence of malignancy was seen. Microbiologic studies results were all negative.

What is the diagnosis?
Diagnosis: Chronic expanding thoracic hematoma with liquefaction

Chronic expanding thoracic hematoma (CETH) is an uncommon entity that presents as a progressively enlarging thoracic mass, which consists of a central mass of blood within a fibrous capsule. It is an encapsulated hematoma, which usually develops in the lung parenchyma but may also occur in the pleural cavity. It usually occurs in patients with history of thoracic trauma or thoracic surgery, such as thoracoplasty. In Japan and Korea, it has been reported in patients with a history of TB and thoracoplasty. Because of liquefaction of the hematoma occurring over time, it is also referred to as chronic hemorrhagic empyema. It can mimic neoplasm and needs to be differentiated from malignancies arising in the thorax.

The pathogenesis of CETH is poorly understood but is hypothesized to be an inflammatory process, occurring within the encapsulated hematoma, caused by the breakdown products of blood cells and fibrin. This damages the capillaries in the granulation tissue in the inner lining of the hematoma capsule, causing intermittent bleeding that makes it expand over time. The permeability of the vascular wall is increased by the degraded blood products, resulting in bleeding from dilated capillaries in the granulation tissue beneath the fibrous capsule. Although calcification in the walls of the hematoma is reported, some degree of elasticity appears to exist, which allows these hematomas to gradually enlarge over a period of time, with intermittent bleeding.

Common presenting symptom is shortness of breath, usually related to lung compression from the slowly growing hematoma. It can occupy the entire hemithorax, causing respiratory distress. Chest pain has also been reported. CETH can be life-threatening, leading to respiratory failure or hemoptysis. The duration of symptoms ranges from 1 to 30 years in reported cases.

On chest CT scan, CETH appears as a heterogeneous mass with variable wall thickness. These lesions are difficult to differentiate from sarcomas or other soft tissue malignancies, because many of them may contain hemorrhagic and cystic radiographic features. Loculated empyema can also be considered in the differential but can be clinically differentiated by the absence of signs of infection and chronicity of symptoms. Thoracic splenosis, although rare, is another differential. It typically occurs after thoracic trauma causing splenic injury and diaphragmatic rupture, which results in seeding of the thoracic cavity with splenic tissue. It usually appears as multiple, small, pleural-based nodules, although over time some may grow to a large size. They can be differentiated by positive uptake on a technetium99-labeled sulfur colloid scan. The best diagnostic tools are chest CT scan and MRI. T1- and T2-weighted magnetic resonance images are reported to show variably hyperintense areas in the mass that indicate the presence of fresh and old blood. Capillary bleeding in the periphery of the mass may be evident on gadolinium-enhanced MRI. Based on existing case reports, the role of PET scan in the diagnosis of CETH appears unclear. These hematomas may be PET scan avid. Hence, PET scans may not definitively differentiate CETH from malignancy and infection. The finding of old blood or necrotic material on needle biopsy and aspiration may be the first clue that the lesion represents a CETH. Often, diagnosis is made during thoracotomy and resection of the hematoma.

Surgical resection early in the clinical course is the treatment of choice. Surgery is warranted, as it is often difficult to differentiate CETH from malignancies. Total surgical resection of the hematoma, including the capsule, is recommended. Surgery should be a complete resection, as drainage and curettage of contents or removal of the inner substance without whole capsule excision has been reported to cause uncontrollable bleeding from residual hypervascular capsule or recurrence of the hematoma within several years. Lobectomy is occasionally required, depending on the extent of destruction of the lobe caused by the expanding hematoma. Transarterial embolization has been attempted unsuccessfully to treat hemoptysis in a patient with CETH. However, good outcomes following localized resection and pleural decortication have been reported.

Clinical Course

The patient’s postoperative course was complicated by pulmonary embolism, for which he was started on heparin infusion. He subsequently developed a hemothorax on the side of surgery and had thoracostomy and drainage performed. Heparin was discontinued, and an inferior vena caval filter was inserted. Following this, the patient made a satisfactory recovery, with resolution of his symptoms. Chest radiograph 2 months after surgery showed resolution of the left basal abnormality (Fig 5). On follow-up 6 months after surgery, the patient is doing well.

Figure Jump LinkFigure 5. Chest radiograph showing resolution of mass-like lesion in left hemithorax, 2 mo following surgery. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location

  • 1. CETH is an encapsulated hematoma consisting of a central mass of blood undergoing liquefaction within a fibrous capsule. It is an uncommon entity, which may develop in the lung parenchyma or pleural cavity of patients with a history of thoracic trauma or thoracic surgery or TB treated with thoracoplasty. CETH gradually enlarges over time because of intermittent bleeding occurring from damaged capillaries in the granulation tissue lining the capsule.

  • 2. CETH may be difficult to differentiate from thoracic malignancies such as soft tissue sarcomas, loculated empyema, and splenic pseudocyst, which may show similar radiographic features on CT imaging. Characteristic features on MRI, absence of uptake on technetium99-labeled sulfur colloid scan, tissue biopsy, and resection of lesion may be required to confirm the diagnosis.

  • 3. On chest CT scan, CETH appears as a circumscribed heterogeneous mass with variable wall thickness. MRI reveals a mass with variable hyperintense areas that indicate the presence of fresh and old blood.

  • 4. The finding of old blood or necrotic material on needle biopsy and aspiration may be the first clue that CETH is present. Often diagnosis is made during thoracotomy.

  • 5. Surgical resection of the encapsulated hematoma, with or without lobectomy, is preferred therapy, which has better outcomes when performed early in the clinical course.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Imanaka K, Sugimoto K, Aoki M, Okumura N, Onishi H, Hashimoto K. MRI finding of chronic hemorrhagic empyema: a case report. Radiat Med. 1996;14(4):201-203. [PubMed]
 
Hanagiri T, Muranaka H, Hashimoto M, et al. Chronic expanding hematoma in the chest. Ann Thorac Surg. 1997;64(2):559-561. [CrossRef] [PubMed]
 
Roper CL, Cooper JD. Chronic expanding hematoma of the thorax. J Thorac Cardiovasc Surg. 2001;122(5):1046-1048. [CrossRef] [PubMed]
 
Hwang GL, Moffatt SD, Mitchell JD, Leung AN. Chronic expanding hematoma of the thorax. AJR Am J Roentgenol. 2003;180(4):1182-1183. [CrossRef] [PubMed]
 
Athanassiadi K, Reiffen HP, Dickgreber N, et al. A different surgical approach for an intrathoracic expanding hematoma. J Thorac Cardiovasc Surg. 2007;133(3):832-834. [CrossRef] [PubMed]
 
Kwon YS, Koh WJ, Kim TS, Lee KS, Kim BT, Shim YM. Chronic expanding hematoma of the thorax. Yonsei Med J. 2007;48(2):337-340. [CrossRef] [PubMed]
 
Takahama M, Yamamoto R, Nakajima R, Izumi N, Tada H. Extrathoracic protrusion of a chronic expanding hematoma in the chest mimicking a soft tissue tumor. Gen Thorac Cardiovasc Surg. 2010;58(4):202-204. [CrossRef] [PubMed]
 
Hata Y, Sakamoto S, Shiraga N, et al. A case of chronic expanding hematoma resulting in fatal hemoptysis. J Thorac Dis. 2012;4(5):508-511. [PubMed]
 

Figures

Figure Jump LinkFigure 1. A, Chest radiograph posteroanterior view showing opacity at left lung base. B, Chest radiograph lateral view showing opacity at left lung base. PA = posteroanterior.Grahic Jump Location
Figure Jump LinkFigure 2. CT scan of the chest with contrast showing a large heterogeneous mass (8.5 × 6.7 cm) with a central fluid component in the left lower hemithorax. A, Lung window. B, Mediastinal window.Grahic Jump Location
Figure Jump LinkFigure 3. Coronal section of chest CT scan showing that the contiguous margin of the diaphragm between the spleen and the lung mass is indistinct, with absence of a fat plane between the diaphragm and the spleen.Grahic Jump Location
Figure Jump LinkFigure 4. Technetium99-labeled sulfur colloid scan showing uptake in the liver and spleen. No uptake is seen in the mass in the lower left hemithorax, abutting the diaphragm and spleen, indicating it is not in continuity with the spleen. A, Sagittal section. B, Coronal section.Grahic Jump Location
Figure Jump LinkFigure 5. Chest radiograph showing resolution of mass-like lesion in left hemithorax, 2 mo following surgery. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location

Tables

Suggested Readings

Imanaka K, Sugimoto K, Aoki M, Okumura N, Onishi H, Hashimoto K. MRI finding of chronic hemorrhagic empyema: a case report. Radiat Med. 1996;14(4):201-203. [PubMed]
 
Hanagiri T, Muranaka H, Hashimoto M, et al. Chronic expanding hematoma in the chest. Ann Thorac Surg. 1997;64(2):559-561. [CrossRef] [PubMed]
 
Roper CL, Cooper JD. Chronic expanding hematoma of the thorax. J Thorac Cardiovasc Surg. 2001;122(5):1046-1048. [CrossRef] [PubMed]
 
Hwang GL, Moffatt SD, Mitchell JD, Leung AN. Chronic expanding hematoma of the thorax. AJR Am J Roentgenol. 2003;180(4):1182-1183. [CrossRef] [PubMed]
 
Athanassiadi K, Reiffen HP, Dickgreber N, et al. A different surgical approach for an intrathoracic expanding hematoma. J Thorac Cardiovasc Surg. 2007;133(3):832-834. [CrossRef] [PubMed]
 
Kwon YS, Koh WJ, Kim TS, Lee KS, Kim BT, Shim YM. Chronic expanding hematoma of the thorax. Yonsei Med J. 2007;48(2):337-340. [CrossRef] [PubMed]
 
Takahama M, Yamamoto R, Nakajima R, Izumi N, Tada H. Extrathoracic protrusion of a chronic expanding hematoma in the chest mimicking a soft tissue tumor. Gen Thorac Cardiovasc Surg. 2010;58(4):202-204. [CrossRef] [PubMed]
 
Hata Y, Sakamoto S, Shiraga N, et al. A case of chronic expanding hematoma resulting in fatal hemoptysis. J Thorac Dis. 2012;4(5):508-511. [PubMed]
 
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