J Thorac Cardiovasc Surg 2007;133:832-834
© 2007 The American Association for Thoracic Surgery
A different surgical approach for an intrathoracic expanding hematoma
Kalliopi Athanassiadi, MDa,*,
Hans-Peter Reiffen, MD, PhDb,
Nicolas Dickgreber, MD, PhDc,
Florian Laenger, MD, PhDd,
Christa-Maria Eschenbruch, MD, PhDc,
Matthias Wilchelmi, MD, PhDa,
Axel Haverich, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Medical School of Hannover, Hannover, Germany
b Department of Anaesthesiology, Medical School of Hannover, Hannover, Germany
c Department of Pulmonology, Medical School of Hannover, Hannover, Germany
d Department of Pathology, Medical School of Hannover, Hannover, Germany.
Received for publication September 19, 2006; accepted for publication October 23, 2006.
* Address for reprints: Kalliopi Athanassiadi, MD, Department for Thoracic and Cardiovascular Surgery, Medical School of Hannover, Carl-Neuberg Str. 1, 30625 Hannover, Germany. (Email: kallatha{at}otenet.gr).
Chronic expanding hematomas are a rare clinical entity mimicking invasive soft-tissue neoplasms. We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pleural cavity of an 83-year-old patient with a massive hemoptysis who was medically treated for tuberculosis 55 years earlier. A dissection of the calcified mass and extirpation of the hematoma were performed, the whole lung was expanded, the lobar and segmental arteries and bronchi were dissected, and the bronchial arteries were cauterized. In a follow-up of 4 months, the patient presented no recurrence, and a major operation (eg, a pleuropneumonectomy) was not necessary.
Chronic expanding hematomas are a rare clinical entity mimicking invasive soft-tissue neoplasms and producing mediastinal compression, usually in patients with a history of surgery for tuberculosis or tuberculous pleurisy.1,2
We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pleural cavity of a patient with a massive hemoptysis who was medically treated for tuberculosis 55 years earlier.
Clinical Summary
An 83-year-old man was admitted to our department with hemoptysis and chest discomfort. He had a free medical history with the exception of tuberculosis 55 years ago. Chest radiography showed a complete opacification of the right hemithorax, and computed tomography revealed a well-circumscribed encapsulated lesion consisting of a thick calcified wall expanding to the whole pleural cavity and causing mediastinal compression (Figure 1). Bronchoscopy demonstrated arterial bleeding from the right lower lobe, and drug therapy including the topical use of adrenaline was initiated. An angiography performed for embolization could not identify the source of bleeding. Because of recurrent episodes and a massive hemoptysis within 6 days of hospitalization, emergency surgery was performed. The patient underwent a right lateral thoracotomy and a laterodorsal dissection of the calcified mass (Figure 2). The calcified wall was found to be adherent to the underlying lung but was easily dissected from the pleura parietalis. With a puncture, a cystic mass was identified and carefully opened. Extirpation of the hematoma followed (Figure 3), and the whole lung was mobilized from the mediastinum to the pleural cavity. The lobar and segmental arteries and bronchi were dissected, and cauterization of the bronchial arteries was performed. The anesthesiologist fully expanded the lung so that the remaining walls fell together.
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Figure 1. Chest computed tomography: a right intrathoracic mass with a calcified wall compressing the right lung to the mediastinum.
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Histology demonstrated a capsule consisting of hyalinized, hypocellular fibrous tissue. The material in the cavity consisted of dense collagenous tissue, many small eosinophilic amorphous necrotic debris, and red blood cells surrounded by xanthogranulomatous foreign body reactions (Figure 4). Cholesterin deposition was also found within the xanthogranulomatous reactive tissue. In addition, calcification on the outer wall was observed. No bacteria, including mycobacteria, were detected in the lesion.
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Figure 4. Histology: The inner aspect of the organizing hematoma with a loose granulation-tissue like proliferation of fibroblasts with numerous interspersed erythrocytes. A fibrinous exudate can be seen on the surface.
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The patient remained intubated for 48 hours in the intensive care unit. After a complicated postoperative course with bleeding, the patient was discharged 4 weeks later and presented no complications for the next 4 months.
Discussion
Hematomas caused by surgery or trauma usually resolve without sequelae.1 However, there have been a few cases of expanding hematomas, even over a period of 30 years or more, after medical or surgical treatment of tuberculosis. These cases are found more frequently in the Japanese literature1-4 than in the European or American literature.
The pathogenesis is poorly understood. Labadie and Glover5 demonstrated that the breakdown of leucocytes, hemoglobin, platelets, and fibrin results in an inflammatory process that effectively damages the capillaries of a capsule, increasing the permeability of the vascular wall and producing bleeding from dilated microvessels beneath the fibrous capsule. In some cases, erosion of microvessels may cause massive hemoptysis. Despite the calcification of the capsule, it seems that a small degree of elasticity exists, which is the reason hematomas usually expand over a long period of time.
These lesions are difficult to differentiate from soft-tissue sarcomas or other malignancies because many of them also reveal hemorrhagic and cystic changes on radiology.2-4 The best diagnostic tools are computed tomography and magnetic resonance imaging, including guided fine-needle biopsy.
Hanagiri and colleagues4 reported that palliative procedures, such as removal of the inner substance without whole capsule excision, may produce uncontrollable bleeding or recurrence of the hematoma within several years. In cases such as the one reported, the authors believe that a complete excision would have only been possible with a pleuropneumonectomy, which the 83-year-old patient would have not survived. The careful removal of the hematoma along with the mobilization and a partial decortication of the lung, dissection and control of all lobar pulmonary arteries and bronchi, cauterization of the bronchial arteries, and full reexpansion of the lung with a longer intubation period and an intensive physiotherapy immediately postoperatively is the best solution in these elderly patients.
To our knowledge this is the first report of an elderly patient who was treated successfully for an intrathoracic expanding hematoma by cauterization of the bronchial arteries, an older method used in cases of pulmonary bronchiectasis.
References
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- Hanagiri T, Murunaka H, Hashimoto M, Nishio T, Sakai S, Ono M, et al. Chronic expanding hematoma in the chest. Ann Thorac Surg 1997;64:559-561.[Abstract/Free Full Text]
- Labadie EL, Glover D. Physiopathogenesis of subdural hematomas. Part I: Histological and biochemical comparisons of subcutaneous hematomas in rats with subdural hematoma in man. J Neurosurg 1976;45:382-392.[Medline]
