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J Thorac Cardiovasc Surg 2003;126:1202-1203
© 2003 The American Association for Thoracic Surgery

Brief communication

Successful treatment of huge chronic expanding hematoma after thoracoplasty

Iwao Takanami, MDa,*

a Department of Surgery, Teikyo School of Medicine, Tokyo, Japan

Received for publication March 11, 2003; accepted for publication April 24, 2003.

* Address for reprints: Iwao Takanami, MD, Department of Surgery, Teikyo School of Medicine, 2-11 Kaga 2-Chome, Itabashi-Ku, Tokyo, 173 Japan
takanami{at}med.teikyo-u.ac.jp

Chronic expanding hematoma in the chest is known to be a specific type of chronic empyema. Four cases of chronic expanding hematomas after thoracoplasty have been reported in Japan.1-3 As far as I have been able to determine, no such cases have been reported in other countries. Incomplete treatment for tuberculosis, such as thoracoplasty, is considered to be one of the origins of this disease. Here I describe the successful treatment of a patient with chronic expanding hematoma after a thoracoplasty.

Clinical summary

A 79-year-old man was admitted with a chest wall swelling. Fifty-two years earlier, at the age of 27 years, the patient underwent thoracoplasty for the treatment of tuberculosis. A year earlier a tumor had been detected in the right axilla, which had gradually protruded. For the purpose of more detailed examination, he was transferred to my hospital. Physical examination revealed a large tumor, 30 x 10 x 10 cm in size, from the right axillar region to the anterior chest region, with skeletal deformity and operative scars due to the thoracoplasty. Chest roentgenogram showed a well-defined complete opacification in the right upper thorax and right upper skeletal deformities due to the thoracoplasty. Magnetic resonance imaging revealed a heterogenous mass growing from the adjacent of remained ribs to the anterior chest (Figure 1). On needle biopsy, there was only a fibrous connective tissue with fibrin infiltrated with a few small lymphocytes and neutrophils. With the permeable values of hemodynamics and respiratory functions, his general condition also indicated that he could tolerate the operation.



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  		Figure 1. Axial image of magnetic resonance imaging.

 
Tumor extirpation was performed under a clinical diagnosis of chronic empyema. The fibrous hard adhesion was evident but new vascularizations were not so severe; the total blood loss was 530 mL. The tumor was encapsulated in part by connective tissue and measured 25 x 10 x 10 cm and weighed 650 g (Figure 2). Microscopic observation showed that the resected mass was a brownish fragile tissue covered with partial fibrous capsule containing ossiform materials and was diagnosed as organizing hyalinized old hematoma without any microscopic evidence of a neoplasm. The postoperative course was uneventful, and the patient has since been well for more than 6 months.



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  		Figure 2. Macroscopic findings of the tumor.

 
Discussion

Chronic expanding hematomas occur on various locations.4 In most cases, the hematoma continues growing slowly as a space-occupying mass for long periods after surgical treatment or injury. There are some reports of a huge mass presenting as chronic expanding hematoma in intrathoracic cavity or extrathoracic cavity after thoracic surgery, thoracoplasty, or tuberculous pleuritis.1-4 Chronic expanding hematoma remains a rare disease but should be considered in the differential diagnosis in cases of an expanding mass when there is a history of tuberculous pleuritis and thoracoplasty. Chronic expanding hematoma should be differentiated from soft tissue neoplasms, as both may present as a painless, slowly expanding mass; on radiologic findings, several kinds of soft tissue sarcoma commonly reveal hemorrhagic or cystic changes. This disease in the chest is recognized as a specific type of chronic empyema, so-called organizing empyema. This lesion is usually a nonpurulent lesion with no bacteria, including mycobacteria.

Four cases of chronic hematomas after thoracoplasty have been reported in Japan. One possible mechanism of chronic hematoma is that microscopic hematomas forming after the initial hemorrhage do not resolve naturally and slowly grow due to repeated organization and hemorrhage from new fragile microvessels beneath the fibrous capsule. Labadie and Glover5 proposed that the breakdown products derived from erythrocytes, hemoglobin, leukocytes, and other solid blood elements induce mild inflammation, and such continued inflammation causes increased permeability of the vascular wall and bleeding from dilated microvessels beneath the fibrous capsule. Incomplete treatment for tuberculosis, such as artificial pneumothorax and thoracoplasty, is also considered to be one of the causes of this disease.

The extrathoracic mass in this case arose adjacent to the remaining ribs after thoracoplasty. Incomplete removal sometimes leads to recurrence. Complete removal of chronic expanding hematoma is not easy because of abundant new vascularizations beneath the capsule and the presence of a fibrous hard adhesion to the chest wall. Massive bleeding during separation of adhesion is reported to be occasionally dangerous to patients, but intraoperative blood loss in this case was 530 g, which was a smaller bleeding volume than expected, and the chronic hematoma was completely removed. Microscopic observation in this case was encapsulated hematoma with calcification, and there was no sign of bacterial or tuberculous infections.

In a case of gradual growth of a mass at the site of the previous thoracoplasty, the existence of a chronic expanding hematoma should be considered.

References

  1. Uramoto H, Nakanishi R, Eifuku R, et al. Chronic expanding hematoma in the chest. J Cardiovasc Surg. 2000;41:143–146[Medline]
  2. Hanagiri T, Muranaka H, Hashimoto M, et al. Chronic expanding hematoma in the chest. Ann Thorac Surg. 1997;64:559–561[Abstract/Free Full Text]
  3. Takeo S, Hora N, Ohtsu Y, Motohiro A, Ichinose Y, Ohta M. Giant extrathoracic hematoma after thoracoplasty—a case report. Jpn J Surg. 1991;21:360–363[Medline]
  4. Reid JD, Kommareddi S, Lankerani M, Park MD. Chronic expanding hematomas. A clinicopathologic entity. JAMA. 1980;244:2441–2442[Abstract/Free Full Text]
  5. Labadie EL, Glover D. Physiopathologenesis of subdural hematoma: Part 1, Histological and biochemical comparison of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg. 1967;45:382–392




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