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Chronic expanding hematoma with a significantly high fluorodeoxyglucose uptake on ¹⁸F-fluorodeoxyglucose positron emission tomography, mimicking a malignant soft tissue tumor: a case report.

Nishida Y, Kobayashi E, Kubota D, Setsu N, Ogura K, Tanzawa Y, Nakatani F, Kato Y, Chuman H, Kawai A - J Med Case Rep (2014)

Bottom Line: He had been aware of the leg swelling for the last eight years.One was a large, well-defined cystic mass (13×9cm) showing high intensity on T1- and T2-weighted images, and the other was a solid mass (3.5×2.5cm, adjacent to the large mass) with high intensity on T1-weighted images.Two-[18F]fluoro-2 deoxy-D glucose positron emission tomography images revealed increased uptake with a maximum standardized uptake value of 15.8 in the solid mass.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Musculoskeletal Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku 104-0045, Tokyo, Japan. ekobayas@ncc.go.jp.

ABSTRACT

Introduction: Chronic expanding hematoma is a rare persistent hematoma that can sometimes be misdiagnosed as a malignant tumor due to its clinical and radiological features.

Case presentation: A 42-year-old Japanese man with a large mass in his leg, suggestive of malignancy, presented to our hospital. He had been aware of the leg swelling for the last eight years. A magnetic resonance imaging scan demonstrated a large mass with two components. One was a large, well-defined cystic mass (13×9cm) showing high intensity on T1- and T2-weighted images, and the other was a solid mass (3.5×2.5cm, adjacent to the large mass) with high intensity on T1-weighted images. Two-[18F]fluoro-2 deoxy-D glucose positron emission tomography images revealed increased uptake with a maximum standardized uptake value of 15.8 in the solid mass. As these findings were considered suggestive of hematoma associated with a malignant lesion, an open biopsy was performed. A pathological examination demonstrated a hematoma with xanthogranuloma, and no malignant cells were evident. Therefore, we resected the tumor including both components, and the histological diagnosis was chronic expanding hematoma. Clinical diagnosis based on 2-[18F]fluoro-2 deoxy-D glucose uptake is sometimes limited by the fact that 2-[18F]fluoro-2 deoxy-D glucose is taken up by not only malignant tumor cells but also macrophages and tissues with granulation or inflammation.

Conclusions: Significantly increased standardized uptake value in the peripheral rim of the lesion on 2-[18F]fluoro-2 deoxy-D glucose positron emission tomography imaging, mimicking a soft tissue sarcoma, should be recognized as a potential diagnostic pitfall in cases of chronic expanding hematoma.

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Histopathological features. (A) The biopsy specimen shows a mixture of hematoma and xanthogranuloma, with no malignant cells. (B-D) A hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes.
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Figure 3: Histopathological features. (A) The biopsy specimen shows a mixture of hematoma and xanthogranuloma, with no malignant cells. (B-D) A hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes.

Mentions: A 42-year-old Japanese man was referred to our hospital because of pain in his right leg. He had first become aware of pain in his leg during a rugby game eight years previously. Although the pain had subsequently improved, his leg had remained swollen for several years, without having suffered any obvious trauma or received any anticoagulant therapy. Before referral to our hospital, he had developed renewed pain in his leg for one month. Upon physical examination, a large hard mass was palpable in his right leg. A magnetic resonance imaging (MRI) scan showed a 13×9-cm cystic mass with high signal intensity on T1- and T2-weighted images between the soleus and lateral gastrocnemius, and a 3.5×2.5-cm solid lesion with high signal intensity on T1-weighted images in the medial gastrocnemius. This solid lesion adjacent to the cystic mass was enhanced on Gd-enhanced T1-weighted images (Figure 1A, B). FDG-PET images revealed increased uptake with a maximum standardized uptake value (SUV) of 15.8 in the solid lesion (Figure 2). As these clinical findings and diagnostic images were considered suggestive of hematoma associated with a malignant lesion, an open biopsy of both components was performed. A pathological examination revealed that the lesions consisted of a mixture of hematoma and xanthogranuloma with no malignant cells (Figure 3A). Therefore, complete resection of the masses was performed based on a diagnosis of CEH after obtaining informed consent. During the operation, no active hemorrhaging or a source of bleeding was identified. The resected specimen was a dark brown, partially organized hematoma surrounded by fibrous tissues. A postoperative pathological examination yielded a diagnosis of hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes in the cystic region (Figure 3B-D). As of eight months after surgery, our patient is in good health with no sign of recurrence.


Chronic expanding hematoma with a significantly high fluorodeoxyglucose uptake on ¹⁸F-fluorodeoxyglucose positron emission tomography, mimicking a malignant soft tissue tumor: a case report.

Nishida Y, Kobayashi E, Kubota D, Setsu N, Ogura K, Tanzawa Y, Nakatani F, Kato Y, Chuman H, Kawai A - J Med Case Rep (2014)

Histopathological features. (A) The biopsy specimen shows a mixture of hematoma and xanthogranuloma, with no malignant cells. (B-D) A hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4209771&req=5

Figure 3: Histopathological features. (A) The biopsy specimen shows a mixture of hematoma and xanthogranuloma, with no malignant cells. (B-D) A hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes.
Mentions: A 42-year-old Japanese man was referred to our hospital because of pain in his right leg. He had first become aware of pain in his leg during a rugby game eight years previously. Although the pain had subsequently improved, his leg had remained swollen for several years, without having suffered any obvious trauma or received any anticoagulant therapy. Before referral to our hospital, he had developed renewed pain in his leg for one month. Upon physical examination, a large hard mass was palpable in his right leg. A magnetic resonance imaging (MRI) scan showed a 13×9-cm cystic mass with high signal intensity on T1- and T2-weighted images between the soleus and lateral gastrocnemius, and a 3.5×2.5-cm solid lesion with high signal intensity on T1-weighted images in the medial gastrocnemius. This solid lesion adjacent to the cystic mass was enhanced on Gd-enhanced T1-weighted images (Figure 1A, B). FDG-PET images revealed increased uptake with a maximum standardized uptake value (SUV) of 15.8 in the solid lesion (Figure 2). As these clinical findings and diagnostic images were considered suggestive of hematoma associated with a malignant lesion, an open biopsy of both components was performed. A pathological examination revealed that the lesions consisted of a mixture of hematoma and xanthogranuloma with no malignant cells (Figure 3A). Therefore, complete resection of the masses was performed based on a diagnosis of CEH after obtaining informed consent. During the operation, no active hemorrhaging or a source of bleeding was identified. The resected specimen was a dark brown, partially organized hematoma surrounded by fibrous tissues. A postoperative pathological examination yielded a diagnosis of hematoma accompanied by accumulation of fibrin, cholesterin crystals, and histiocytes in the cystic region (Figure 3B-D). As of eight months after surgery, our patient is in good health with no sign of recurrence.

Bottom Line: He had been aware of the leg swelling for the last eight years.One was a large, well-defined cystic mass (13×9cm) showing high intensity on T1- and T2-weighted images, and the other was a solid mass (3.5×2.5cm, adjacent to the large mass) with high intensity on T1-weighted images.Two-[18F]fluoro-2 deoxy-D glucose positron emission tomography images revealed increased uptake with a maximum standardized uptake value of 15.8 in the solid mass.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Musculoskeletal Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku 104-0045, Tokyo, Japan. ekobayas@ncc.go.jp.

ABSTRACT

Introduction: Chronic expanding hematoma is a rare persistent hematoma that can sometimes be misdiagnosed as a malignant tumor due to its clinical and radiological features.

Case presentation: A 42-year-old Japanese man with a large mass in his leg, suggestive of malignancy, presented to our hospital. He had been aware of the leg swelling for the last eight years. A magnetic resonance imaging scan demonstrated a large mass with two components. One was a large, well-defined cystic mass (13×9cm) showing high intensity on T1- and T2-weighted images, and the other was a solid mass (3.5×2.5cm, adjacent to the large mass) with high intensity on T1-weighted images. Two-[18F]fluoro-2 deoxy-D glucose positron emission tomography images revealed increased uptake with a maximum standardized uptake value of 15.8 in the solid mass. As these findings were considered suggestive of hematoma associated with a malignant lesion, an open biopsy was performed. A pathological examination demonstrated a hematoma with xanthogranuloma, and no malignant cells were evident. Therefore, we resected the tumor including both components, and the histological diagnosis was chronic expanding hematoma. Clinical diagnosis based on 2-[18F]fluoro-2 deoxy-D glucose uptake is sometimes limited by the fact that 2-[18F]fluoro-2 deoxy-D glucose is taken up by not only malignant tumor cells but also macrophages and tissues with granulation or inflammation.

Conclusions: Significantly increased standardized uptake value in the peripheral rim of the lesion on 2-[18F]fluoro-2 deoxy-D glucose positron emission tomography imaging, mimicking a soft tissue sarcoma, should be recognized as a potential diagnostic pitfall in cases of chronic expanding hematoma.

Show MeSH
Related in: MedlinePlus