An 85-year-old man with bronchiectasis diagnosed 50 years prior without interval follow-up presented with dyspnea and was found to have a heterogeneous 11-cm paratracheal mass with scattered calcifications. A broad differential of mediastinal masses with potential for calcification was considered, including heterotopic goiter, solitary fibrous tumor of the pleura, post-Histoplasma mediastinal granuloma, teratoma, duplication or bronchogenic cyst, vascular neoplasm, and thymic neoplasm. Bronchoscopy with endobronchial ultrasound revealed diffuse, sluggishly pulsatile spaces along the outer rim of the mass (Figure 1 and Video 1). A network of dilated bronchial arteries was present (Figure 1 and Video 2). Transbronchial needle biopsy of nonpulsatile regions did not yield malignant cells or thyrocytes. Subsequent contrast-enhanced computed tomography of the chest with delayed phase imaging demonstrated findings characteristic of a giant hemangioma (Figures 2 and 3 and Videos 2–4). The patient declined surgical referral.
Figure 1.
(A and B) Maximal intensity projection contrast-enhanced computed tomography of the chest in the coronal plane (A) and axial plane (B), demonstrating an 11-cm right paratracheal mass and a robust network of dilated bronchial arteries extending to surround bronchiectatic airways in both lower lobes (red arrows; see also Video 2). (C and D) Endobronchial ultrasound visualization of large pulsatile blood-filled spaces at the edges of the mass with highly heterogeneous echodensity; an outline of the pulsatile area is highlighted in D (see also Video 1).
Figure 2.
(A–D) Computed tomography of the chest in the axial plane, demonstrating a giant right paratracheal hemangioma without contrast enhancement (A) and with systemic arterial-phase contrast enhancement (B), venous phase contrast (50 s delay; C), and delayed phase contrast (additional 2-min delay; D). The 11-cm mass is heterogeneous in density with scattered internal calcifications. Nodular contrast enhancement is visible at its periphery on delayed images corresponding to blood-filled spaces within the lesion (red arrows). Hemangiomas, which are best characterized in the liver, classically exhibit peripheral nodular contrast enhancement followed by centripetal filling of contrast on delayed images. Magnetic resonance imaging is also highly sensitive and specific for the diagnosis (5). See also Videos 2–4.
Figure 3.
(A–D) Computed tomography of the chest in the coronal plane, demonstrating a giant right paratracheal hemangioma without contrast enhancement (A) and with systemic arterial-phase contrast enhancement (B), venous phase contrast (50 s delay; C), and delayed phase contrast (additional 2-min delay; D). The 11-cm mass is heterogeneous in density with scattered internal calcifications. Nodular contrast enhancement is visible at its periphery on delayed images (red arrows).
Video 1.
Ultrasonographic appearance of the right paratracheal hemangioma by linear endobronchial ultrasound bronchoscope. Pulsatile motion blur highlights blood-filled spaces at the periphery of the lesion, further highlighted by doppler. More distally, the lesion is noted to be highly heterogeneous in echodensity.
Video 2.
Computed tomography scan of the chest in the axial plane with contrast enhancement timed for systemic arterial circulation. A network of robustly dilated, tortuous bronchial arteries is noted. It is not immediately clear whether these bronchial arteries, presumably related to chronic bronchiectasis, played any role in the pathogenesis of the giant hemangioma.
Video 3.
Computed tomography scan of the chest in the axial plane with contrast enhancement timed for venous circulation, highlighting peripheral nodular enhancement of the giant hemangioma.
Video 4.
Computed tomography scan of the chest in the axial plane with delayed contrast enhancement (2 min after venous phase), highlighting peripheral nodular enhancement of the giant hemangioma.
Mediastinal hemangiomas are extremely uncommon. Most are located in the anterior mediastinum and are capillary or cavernous in subtype (1–3). Giant mediastinal hemangiomas up to 25 cm in diameter have been reported (4) and may cause symptoms via compression of vital structures. Such lesions are typically diagnosed by the fourth decade of life and have not been previously observed in individuals past 80 years of age (2). Resection is the treatment of choice (1–3).
Footnotes
The uncompressed videos are accessible from this article’s supplementary material page.
Author Contributions: All authors contributed to the design of this work, interpretation of data, and drafting or revision of the manuscript for important intellectual content; provided final approval of the version to be published; and agree to be accountable for all aspects of the work.
Originally Published in Press as DOI: 10.1164/rccm.201908-1649IM on February 6, 2020
Author disclosures are available with the text of this article at www.atsjournals.org.
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