|Ahead of print publication
Resection of a cavernous hemangioma of the posterior mediastinum by sclerotherapy and uniport thoracoscopic surgery
Jin-You Jhan1, Yi-Tso Cheng1, Jui-Chih Cheng1, Bing-Ru Chung1, Nai-Wei Huang1, Bee-Song Chang2
1 Department of Cardiovascular Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation; School of Medicine, Tzu Chi University, Hualien, Taiwan
2 School of Medicine, Tzu Chi University; Department of Thoracic Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
|Date of Submission||04-Aug-2019|
|Date of Decision||12-Sep-2019|
|Date of Acceptance||24-Sep-2019|
|Date of Web Publication||21-Oct-2019|
Department of Thoracic Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien
Source of Support: None, Conflict of Interest: None
A 44-year-old female presented with cavernous hemangioma of the posterior mediastinum. Imaging revealed that it was approximately 2 cm in size and without an arterial supply from either the thoracic aorta or intercostal artery. The patient was treated with intraoperative sclerotherapy and hemangioma resection by uniport thoracoscopic surgery via a small 3-cm surgical wound. The surgical outcome and follow-up were good.
Keywords: Adult, Chest wall, Mediastinal tumor, Thoracoscopy/video-assisted thoracoscopic surgery, Venous disease
|How to cite this URL:|
Jhan JY, Cheng YT, Cheng JC, Chung BR, Huang NW, Chang BS. Resection of a cavernous hemangioma of the posterior mediastinum by sclerotherapy and uniport thoracoscopic surgery. Tzu Chi Med J [Epub ahead of print] [cited 2020 Feb 20]. Available from: http://www.tcmjmed.com/preprintarticle.asp?id=269665
| Introduction|| |
Cavernous hemangioma of the posterior mediastinum is a benign vascular tumor that accounts for approximately 1% of all tumors. Most occur in the skull, central neural system, vertebrae, or liver and rarely in the posterior mediastinum . A few cases involving the posterior mediastinum have been reported near the heads of the ribs ,. The hemangioma in this patient was found near the heads of the left third and fourth ribs.
| Case Report|| |
The patient was a 44-year-old female without any underlying condition. A cavernous hemangioma was accidentally discovered by computed tomography (CT) during a routine health examination. A paravertebral CT scan found a 24 mm × 22 mm × 12 mm mass located in the posterior mediastinum near the heads of the left third and fourth ribs [Figure 1]. The patient was asymptomatic. Uniport thoracoscopic resection of a suspected neurogenic tumor was initiated via a 3-cm surgical wound, but was stopped upon detection of the hemangioma [Figure 2]a. A subsequent angiogram did not find an arterial supply from the aorta [Figure 3]a,[Figure 3]b, [Figure 3]c. After consulting a radiologist, a second uniport thoracoscopic procedure was performed with intraoperative angiography and sclerotherapy with access through the existing 3-cm wound. Angiography performed with direct contrast injected into the tumor showed no contrast extending to the spinal cord or aorta [Figure 3]d. Sclerotherapy was performed with histoacryl tissue coagulant in lipiodol (1:2 ratio) [Figure 2]b. The tumor was resected completely using a harmonic energy device [Figure 2]c. Little blood loss occurred. A chest tube was inserted for drainage in the small 3-cm surgical wound [Figure 2]d. The pathological evaluation of the resected tissue confirmed the diagnosis of cavernous hemangioma [Figure 4]. The patient was discharged on day 3 after the second procedure, and outpatient follow-up confirmed that the patient remains free of symptoms.
|Figure 1: (a) Mild contrast-enhanced at venous phase. (b) No adhesion to lung under lung window.; (c) Coronal section showed tumor around T3~T4 region|
Click here to view
|Figure 2: (a) Vascular tumor was detected under thoracoscopy. The tumor was irregular shape with visible blood vessels. (b) Histoacryl tissue coagulant mixed with lipiodol 1:2 was injected into tumor. (c) Tumor was resected via harmonic energy device. (d) One chest tube and small surgical wound about 3 cm|
Click here to view
|Figure 3: (a) Aortography showed no obvious feeding vessels to tumor. (b) Left internal mammary artery angiography showed no obvious feeding vessels to tumor. (c) Spine artery angiography showed no obvious feeding vessels to tumor. (d) Intraoperative angiography showed contrast only in tumor|
Click here to view
|Figure 4: Cavernous hemangioma is diagnosed with blood vessels and thrombus formation (arrow site) (H and E, ×400)|
Click here to view
| Discussion|| |
Cavernous hemangioma is a rare benign lesion that is difficult to diagnose preoperatively. It seldom occurs in the posterior mediastinum . Treatment options include sclerotherapy, embolization, and surgical resection ,,,. Most previous cases have been treated by open surgery that included relatively large surgical wounds and long recovery times ,. In this patient, resection was achieved by uniport thoracoscopy. Imaging confirmed that there was no blood supply from the aorta, and intraoperative angiography found that no contrast media extended to the spinal cord or aorta. Histoacryl tissue coagulant mixed with lipiodol was used for sclerotherapy. The hemangioma was successfully resected via a small surgical wound and easy to stop bleeding. No previous reports of a cavernous hemangioma of posterior mediastinum treated by intraoperative sclerotherapy and uniport thoracoscopic resection were found in PubMed. In conclusion, cavernous hemangioma of the posterior mediastinum is rare, and surgical resection is an accepted treatment option. Successful resection of cavernous hemangioma with a good surgical outcome was achieved by uniport thoracoscopy with intraoperative sclerotherapy.
Institutional Review Board approval
The report had been approved by the Research Ethics Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, for case report publication. The Institutional Review Board (CR 108-02) agrees to waive the patient consent.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yun T, Suzuki H, Tagawa T, Iwata T, Mizobuchi T, Yoshida S,et al
. Cavernous hemangioma of the posterior mediastinum with bony invasion. Gen Thorac Cardiovasc Surg 2016;64:43-6.
Thakare ND, Sajid S, Shende SP. Giant cavernous hemangioma of rib: A rare presentation. Asian Cardiovasc Thorac Ann 2017;25:70-1.
Shimizu K, Yamashita Y, Hihara J, Seto Y, Toge T. Cavernous hemangioma of the rib. Ann Thorac Surg 2002;74:932-4.
Ampollini L, Carbognani P, Cattelani L, Bilancia R, Rusca M. Cavernous hemangioma of the posterior mediastinum. Ann Thorac Surg 2010;90:e96.
Liu XJ, Qin ZP, Tai MZ. Angiographic classification and sclerotic therapy of maxillofacial cavernous haemangiomas: A report of 204 cases. J Int Med Res 2009;37:1285-92.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]