대 한 방 사 선 의 학 회 지 1993 ; 29 (1) : 1 04~ 1 10 Journal of Korean Radiological Society, January, 1993

CT Findings of Sclerosing Hemangioma of the Lung: Two C ases Report

Young Min Han, M.D. , Ho Young Song, M.D., Gyung Ho Chung, M.D. , Chong Soo Kim, M.D. , Dong Geun Lee, M.D. , Ki Chul Choi, M.D.

Deþartment 01 Diαgnostic Radiolo.양， Chonbμk Natioηal University School 01 Mediciηe

- Abstract-

Sclerosing hemangiomas are rare benign neoplasms in pulmonary parenchyme. W e analyzed CT fin­

dings of two cases of sclerosing hemangiomas of the lung in two adult females. Chest radiograph showed

well-circumscribed , round soft tissue mass with calcification in right lower lobe of one patient and without

calcification in right middle lobe of another patien t. A well-circumscribed , round hypodense mass with or

without calcification and moderate or marked contrast enhancement was clearly demonstrated with CT scan

CT findings of contrast enhancement and contour of calcification allow differentiation of sclerosing

hemangioma from other benign neoplasms or postin f1ammotory pseudotumors of the lung ‘

Index Words: Lung, CT 60. 1211

Lung, Sclerosing hemangioma 60. 319

INTRODUCTION

Since it ’ s first report in 1959 by Liebow and

H u bbell (1) , sclerosing hemanigoma ra rel y oc­

curred in the pulmonary parenchyme. 1n Korea, fïve cases of sclerosing hemanigoma have been

reported based on histological fïndings (2 -4) and

one case of sclerosing hemangioma has been

reported based on a radiological fïndin gs which

in cluded a large lobulated , homogeneous soft

tissue mass with a ir meniscus shadow and

calcifïcation (5). Thus far, there have not been

an y reports on enha ncem ent degree , calcifica ­

tion , and contour of the m a ss on CT scans. W e

report two cases of sclerosing hemangioma of the

lung to describe their characteristic CT fïndin gs

which were confïrmed pa thologically .

*전북대학교 의과대학 병리학교실

CASE REPORTS

Case 1

A 50-year-old woma n was admitted with mild

chest discomfort during cou ghing , of several

m onths duration. She had suffe red from

hypotension for 10 years . Before our hospital ad­

mi ssion , she had visited a loc낀 I clinic due to back

and hip joint pain resulting from a fall , a nd

routine chest PA showed a coin lesion in the right

lung. At our hospi tal, physical examinations

were nonspecific and pulmonary function studies

were normal. H er laborato ry tests were normal

and sputum cultures were repeatedly n egative.

Radiographic examination of the chest reveal­

ed a well-circumscribed round m ass with a

di ameter of 3cm in the medial segment of the

right middle lobe (fig. 1) . Chest CT revealed

* Departmeηt 01 p，αthology， Chonbuk Natioηal U:찌versity School 01 Medicine

이 논문은 1992년 9월 17일 접수하여 1992년 11월 13일에 채택되였음.

Received September 17, Accepted November 13, 1992

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Young Min Han, et al : CT Findings of Sclerosing Hemangioma of the Lung

a well-circumscribed , round hypodense mass

(H.U. 10-28) with marked contrast enhancement

(H .U. 98-157) in the medial segment ofthe right

middle lobe (Fig . 2) There was no evidence of

cavitation or calcification , and no mediastinal

lymph node co띠d be detected. No endobronchial

lesion was found on C T. Right poster이ateral

thoracotomy revealed a well-circumscribed ,

round mass , measuring 3. Ocm in diameter , located in the medial segment of the right mid­

dle lobe . A tumor extirpation was performed , and the patient was discharged 18 days after an

uneventful postoperative course. Aside from a

transient episode of right chest pain for six

months postoperatively, she has remained well .

A recent chest radiolograph , obtained seven

Fig. 1. C hest radiographs show a well-circumscribed round soft tissue mass (3 x 3cm) in the medial segment of the right middle lobe

a b

Fig.2. CT scans o[ the chest show a well -circumscribed round hypodense mass in precontrast image (a) and marked contrast enhancement of mass in postcontrast image (b)

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Journal 01 Korean Rad iologica l Society 1993; 29 (1) 1 04~ 1 10

a b

Fig. 3. Microscopic findings is seen (a) as blood-filled cystic space ofvarying caliber which are angiomatou s component (H & E , x 20) and (b) the mass was composed of polygonal cells with relati vely abundant eosinophilic cytoplasm , arranged in a solid pattern (H & E, x 100)

“

Fig. 4. Chest radiographs show a well-circumscribed , slightly lobulated , round soft tissue mass with punc­tate and conglomerated calcification in the anterior basal segment of the right lower lobe

months after the operation , revealed no evidence

of recurrence.

The gross finding was a well-circumscribed , round , solid mass. The cut surface was soft , light­

yellow , and contained small punctate hemor­

rhage foci. Microscopic findings showed blood­

fill ed cystic spaces of varying caliber and com­

posed of polygonal cells with relatively abundant

eos in ophilic cytoplasm , arranged in a solid pat-

tern . The diagnosis was sclerosing hem angiom a

(Fig. 3)

Case 2

A 57-year-old woman was adm itted w ith

known lung mass. She reported suffering from headache and h ypertension for seven years. She

also reported th at rad iogr aphs taken eight years

before had been negative , but that a more re-

106 -

Yo ung Min Han , et al : CT Findings of Sclerosing Hemangioma of the Lung

cent chest radiograph had shown an abnormali­

ty . On admission , ph ysical examination and

laboratory studies were normal. Biochemical tests and pulmonary function studies were normal.

R adiographic examination of the chest reveal­

ed a slightly lobulated , well-defined nodular mass

(4x4cm) , with crescent and ring-shaped punc­

ta te calcifications in the anterior basal segment

of the right lower lobe (Fig. 4). C hest CT reveal­

ed a slightly lobulated and well- circumscribed , spherical hypoden se m ass (H . U. 20 -28) with

sm all dense con glomerated calcifications in the

peripheral portion of the mass and moderate con

trast enhance ment (H.U. 66-75) in the anterior

basal segment of the right lower lobe (Fig. 5)

The pulmonary vessels surrounding the mass

were stretched. No mediastinal lym ph node

enlarge m ent could be d e te ct ed. Ri ght

posterolateral thoracotomy revealed a spheroidal

m ass measuring 3 .5cm in diameter , located in

the anterior basal segment of the right lower lobe.

An enucleation of the mass was performed, a nd

the pat ient was discharged 20 days after an

uneven tful postopera tive course . She rem ained

asymptom atic and showed no evidence of recur­

rence on a chest radiograph obtained one month

afte r surgery .

On gross examination , the mass was

spherical , well-circumscribed and solid and

measured 4 x 3.5 x 3cm. lts cut su rface was firm

and light-yellow, and there were focal calcifica­

tions. Microscopic findings were similar to those

of case 1, but this case showed dystrophic

calcifications in several sites. The diagnosis was

sclerosing he man gioma (Fig. 6).

DISCUSSION

Liebow and Hubbell (1) proposed the term

“ sclerosing hem angiom a' ’ to describe th e

presence of vascular proliferat ion with a m ark­

ed tendency for sclerosis. Sclerosing hem angio­mas have a variegated histologic appeara nce

characterized by an admixture of solid , hemor­

rhagic , papillary , and sclerotic areas in differ­

in g porportions (6)

Previously , sclerosing hemangioma had been cl assified as varia nts of a sin gle ent ity and

variously termed as “ postinflamma tory pseudo­

tumor' ’ histiocytom a , “ fib roxanthorn a" , “ plasma cell gra nuloma" (1 ,4-5 ,7). Sclerosing

hem an giom a can now be distinguished from

above various disease entity both cl inically with

a b

Fig. 5. CT scans of the chest show a well-circumscribed , lobulated , round hypodense mass with punctate and conglomerated calcifications in precontrast image (a) and moderately contrast enhancement in postcon­trast image (b)

m

Journal of Korean Radi이 ogical Society 1993; 29 ( 1) : 1 04~ 1 10

a

Fig. 6. a . Gmss finding shows well-circum scribed , solid wh itish yellow and hemorrhagic foci b . Microscopic finding shows variable sized proliferated blood vessels and surrounding sclerotic interst itium (H & E , x 100).

radiological findings and his tologically (2-3 ,6)

Postinflammatory pseudotumor is a benign le­

sion of the pulmonary parenchyme that grossly

resembles a tumor but shows little or no growth

and histologically appears reactive . The various

terms used to classify postinflammatory

pseudotumor in the literature are based on the

predominant cell type and stroma. These names

include fibrous histiocytoma, fibrous xanthoma, xanthogranuloma, xanthofibroma , and plasma

cell granuloma (9) . Plasma cell granulomas are

common in children , while sclerosing hemangio­

mas are in adult women. They do not usually

have the complexity of papillary growths or

sclerosis as seen in sclerosing heman giomas (6).

Sclerosing hemangiomas markedly enhancing le­

sions with or without punctate and con­

glomerated calcification , but plasma cell

granulomas are usually nonenhancing lesions

without calcification (9)

Pathologically , sclerosing hemangioma

typically consists of a solitary well-defined , round-to-oval nodule ranging in diameter from

1 to 4cm , often possessing a variegated yellow , red and gray appearance on cut section. They

are usually solitary and subpleural. Microscopi­

cally, the tumor is variable in appearance , usual­

ly consisting of a combination of solid or papillary

cellular areas , relatively acellular sclerotic

regions , and dilated blood-fiJJed spaces. The pro

liferating cells are round to oval in sh ape and

contain abundant eosinophilic or clear cytoplasm

and bland nuιlei (7)

Clinically , there is a marked female to male

predominance , approximately 80 per cent of pa

tients being women (6). The marked female

predominance of sclerosing hemangiomas is not

a feature of the histiocytoma group of neoplasm , whereas the predilection of plasma cell granulo­

mas for children is not characteristic of scleros­

ing hemangioma (9). Our cases were females

Age at presentation ranges from 16 to 78 years , most lesions being discovered during the fourth

and fifth decades. The majority of patients are

asymptomatic , the abnormality being discovered

on a screening chest roentgenogram. Occasional­

ly, a history of cough or of recent or remote

hemoptysis has been obtained.

Radiologicall y , sclerosing hemangioma

characteristically presents as a well-defined , homogeneous nodule or mass. Their distribution

somewhat favors the lower lobes in about half

(6). Calcification is unusual and cavitation does

not occur. In a recent report , CT findings of

sclerosing hemangioma were a large lobulated , homogeneous soft tissue mass with multiple scat­

tered small calcifications in the lower lobe of the

left lung . A surrounding air shadow was noted

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Young Min Han , et al : CT Findings of Sclerosing Hemangioma of the Lung

around the mass (5) . 1n our cases , the mass

revealed a well-circumscribed or slightly

lobulated , round hypodense mass with moderate

or marked contrast enhancemen t. 1n one case , eccentrical peripheral portion of the mass reveal­

ed small punctate and conglomerated calcifica­

tions. They did not show air meniscus shadow

or fat density in the mass. 1n regard to calcifica­

tions , differential diagnostic considerations in­

clude granulomas , which often contain central

target-like calcifications, and hamartomas , which

when cartilaginous typically contain popcorn

calcification .

Other slowly growing , nodular lesions of the

lung which should be considered for differential

diagnosis include granulomas , hamartomas , postin f1ammatory pseudotumor, and bronchial

adenomas (7 -11) . More unusual entities to be

excluded are leiomyomas , papillomas, fibromas , lipomas , and endometriosis. The presence of

calcification would more likely suggest

granuloma, postin f1ammatory pseudotumor and

hamartoma, but CT findings can be differen­

tiated from sclerosing hemangioma. Granuloma

usually show satellite lesion around mass and no

contrast enhancement. CT diagnosis of hamar­

tomas usually is based on the detection of fat or

calcium plus fat and relatively low or no contrast

enhancement (10). 1n postin f1ammatory pseudo­

tumor , CT findings show considerable diversi­

ty of appearance. These might include a dense

central calcification , a densely enhancing, thick

marginal rim , or most commonly no enhance­

ment , no calcification, but well defined margin

Occasional cavitation and endobronchial or en­

dotracheal locations have been reported (8)

Lipomas, leiomyomas , and bronchial adenomas

tend to obstruct the tracheobronchial tree much

more frequently. Metastases and papillomas are

commonly multiple , and the latter are often

associated with cavitation, pneumatoceles , and

laryngeal papillomatosis. Leiomyomas favor the lung periphery , and in patients with en­

dometriosis , hemoptysis and pneumothorax may

develop during menstruation . Since hilar

adenopathy and effusion are absent in most

sclerosing hemangiomas , their presence should

suggest the possibility of a primary malignancy

and metastatic malignancy.

1n conclusion , characteristic CT findings of

sclerosing hemangioma are a well-circumscribed, round hypodense mass with moderate or mark­

ed contrast enhancement and with or without

calcification in female patients. Sclerosing

hemangioma of the lung can be differentiated

from other benign neoplasms or postin f1am­

matory pseudotumors of lung .

REFERENCES

1. Li ebow AA , Hubbe!l DS. Sclerosing hemangioma (Histiocytoma , Xanthoma) of the lung. Cancer 1956;9:53-75

2. Park YK , Yang MH. So-called sclerosing hemangioma of the lung;Two cases report with ultrastructural study. J ournal of Korean Medical Science 1989 ;4 (4): 179-183

3. Hong SR , Cho HJ , Pail‘ IK , et al. Sclerosing hemangioma ofthe lung-A report of2 cases. K J . Path. 1986;20 (1):84-90

4. Chung WS , Sun K , Kwark YT, et al. Scleros­ing hemangioma of the lung-A case repor t. The KoreanJournal ofThoracic and Cardiovascular Surgical Society 1987;20 (3):574-577

5. Suh OK , KimJS , Zeon SK, Suh SJ. Computed tomography of sclerosing hemangioma of the lung-A case repor t. The Journal of Korean Radiological Society. 1990;26 (3):525-528

6. Katzenstein AA , Gmelich JT , Carrington CB. Sclerosing hemangioma of the lung; A clini­copathologic study of 51 cases. AmJ Surg Pathol 1980;4:343-356

7. Fraser RG , Pare JAP , Pare PD, Fraser RS , Genereux GP. Diagnosis of diseases of the chest. 3rd ed. Philadelphia:Saunders , 1989;1603-1605

8. Schwartz EE, Katz SM , Mandell GA. Post­inflammatory pseudotumors of lung: Fibrous histiocytoma and related lesions. Radiology 1980; 136:609-613

9. Kaufman RA . Calcified postinflammatory pseudotumor of the lung; CT features- Case report. JCAT 1988;12 (4):653-655

- 109 -

M adewellJE , Feigin DS. Benign tumors of the

lung. Semin Roentgenol 1977 ;12:1 75 -1 86

11

Journal of Korean Radiologica l Society 1993; 29 ( 1) I 04~ 1 10

10. Siegelman SS , Khouri NF , Scott WW , et al.

Pulmonary hamar‘ toma; CT findings. Radiology

1986; 160: 313-3 17

요약〉 〈국문

보고

전북대학교 의과대학 진단방사선과학교실 ， 병리학교실*

한영민 · 송호영 • 정경호 • 검종수 • 이동근* . 최기철

소견 : 2례 혈관종의 전산화단층촬영 폐 경화성

경화성 혈관종은 폐실질에서 발생하는 매우 희귀한 양성종양이다. 저자들은 2명의 성인 여자환자에서 폐 경화성

혈관종의 전산화단층촬영 소견을 분석하였다. 단순사진에서는 잘 구형되는 연부조직의 종괴로 1예에서는 석회화 음

영이 보였으며， 우측 하엽과 중엽에 위치하였다. 전산화단층촬영 소견상 잘 구형되는 원형의 처음영의 종괴로 1예에

서는 석회화 음영이 뚜렷하게 보였고， 중정도 혹은 현저한 조영증강을 보였다. 전산화 단층촬영소견에 의한 석회화

의 양상및 조영증강의 증거는， 폐의 염증반응후 가성종괴 혹은 다른 양성 종괴로부터 폐 경화성 혈관종을 감별할 수

있다.

m 1 , 4