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J Thorac Cardiovasc Surg 2004;127:1838-1840
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Department of General Thoracic Surgery, Gifu National Hospital, Gifu, Japan
Received for publication November 4, 2003; accepted for publication December 15, 2003.
* Address for reprints: Kenichi Okubo, MD, General Thoracic Surgery, Gifu National Hospital, Japan, 5-1-1 Hinohigashi, Gifu 500-8718, Japan
okubo{at}gifu.hosp.go.jp
Chronic expanding hematoma of the thorax is a rare entity and usually identified with mediastinal compression or chest wall protrusion in patients with a history of thoracotomy, tuberculous pleurisy, or thoracic trauma. We present a patient with chronic expanding hematoma of the thorax who had a massive hemoptysis caused by rupture into lung parenchyma.
Clinical summary
A 59-year-old woman with a history of thoracoplasty, which included resection of the 9th to 11th ribs for tuberculous empyema 24 years earlier, presented with a massive hemoptysis and dyspnea. She had had a chest wall protrusion pointed out for 4 months. She was brought to our hospital by ambulance, and chest roentgenography showed bilateral lung opacity. The chest roentgenogram 2 months before showed a right intrathoracic mass–like shadow with pleural calcification (Figure 1). Because of the repetitive hemoptysis and the progression of cyanosis, emergency tracheal intubation was done to secure the airway. The bleeding was suspected from the right middle or lower lobe, and the right bronchus intermedius was blocked with a balloon within an endotracheal tube (Univent; Fuji System Corp, Tokyo, Japan). Computed tomography showed a heterogenous mass in the right thorax protruding into the chest wall and the right lung (Figure 2). The left lung was also opacified with infiltrate, indicating contralateral spread of the bleeding. Urgent bronchial arteriography was performed; the dilated bronchial artery and intercostal arteries were embolized with platinum coils and gelatin (Spongel; Yomanouchi Co, Tokyo, Japan). Despite the arterial embolization, hemostasis was not obtained immediately, and the balloon was kept inflated until the next day. Six days later, when the left infiltrate improved, the patient underwent a right pneumonectomy through a median sternotomy. Fresh hematoma was identified within the chronic organized hematoma in the thorax and penetrated into the right lung parenchyma. All the hematoma was extirpated along with pneumonectomy. Operating time was 315 minutes, and blood loss was 2077 mL.
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years. Discussion
Chronic expanding hematoma of the thorax is a rare entity. Affected patients typically have a history of medical or surgical therapy for tuberculosis. Since Iuchi and associates1 reported 5 cases of empyema without pus as organized empyema in 1988, most reports of chronic expanding hematoma of the thorax have been from Japan.2 Recent literature from the United States3,4 indicates a certain incidence of chronic expanding hematoma of the thorax in western countries.
Despite the rare entity arising from the thorax, chronic expanding hematomas occur in many locations. Although most hematomas resolve spontaneously, a few persist for long periods as slowly expanding space-occupying masses.5 The pathogenesis of chronic expanding hematoma is poorly understood. Labadie and Glover6 theorized that this self-perpetuating expanding process is due to the irritant effects of blood and its breakdown products, which cause repeated exudation or bleeding from capillaries in the granulation tissue. Clinically, intermittent episodes of bleeding, probably caused by respiratory motion and coughing, might cause a progressive increase in the volume of hematoma.
The presenting symptom is usually dyspnea related to lung compression or a slowly growing chest wall mass, both of which develop even 30 years or more after thoracotomy for tuberculosis or trauma. These lesions are frequently thought to represent soft tissue sarcoma or other malignant tumors. Surgical procedure has been controversial. Palliative procedures, such as curetting or removal of the inner substance without whole-capsule excision, are reported as a result of the difficulty of the procedure or for fear of possible complications. However, incomplete resection of the hematoma resulted in uncontrollable bleeding from the subcapsular lesion or recurrence of hematoma within several years in some publications.2,7 Complete extirpation, including the capsule, would be desired for cure.
In our patient acute massive hemoptysis was treated with emergency tracheal intubation, balloon occlusion of the bleeding bronchus, and bronchial artery embolization. In the literature neither massive hemoptysis nor emergency management for chronic expanding hematoma of the thorax has been reported. Because the bleeding spread to the contralateral lung, the operation was intentionally delayed until the remaining lung function recovered. Thereafter, the patient successfully underwent a pneumonectomy with extirpation of the hematoma. Division of the hilum first and sequential distal dissection of the lung and hematoma through a median sternotomy might have worked well for bleeding control.
References
This article has been cited by other articles:
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  S. Kunisawa, S. Kosaka, T. Matsukura, T. Nakashima, T. Okabayashi, H. Miyagawa, and Y. Miyake Chronic Expanding Hematoma in Sternum Resected 5 Years After Median Sternotomy Ann. Thorac. Surg., April 1, 2008; 85(4): 1447 - 1448. [Abstract] [Full Text] [PDF]
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 K. Athanassiadi, H.-P. Reiffen, N. Dickgreber, F. Laenger, C.-M. Eschenbruch, M. Wilchelmi, and A. Haverich A different surgical approach for an intrathoracic expanding hematoma J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 832 - 834. [Full Text] [PDF]
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I. S. Sameh, M. ElShabrawii, A. S. Elsaeid, Y. A. Farag, S. Abulela, and M. M. El Salid Rapidly accumulating spontaneous pulmonary hematoma J. Thorac. Cardiovasc. Surg., January 1, 2005; 129(1): 233 - 234. [Full Text] [PDF]
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K. Okubo, T. Okamoto, J. Isobe, and Y. Ueno Reply J. Thorac. Cardiovasc. Surg., January 1, 2005; 129(1): 234 - 235. [Full Text] [PDF]
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