Solitary Capillary Hemangioma of the Lung

A case of resected pulmonary capillary hemangioma with a literature review

Pulmonary hemangiomas are benign, relatively rare tumours. Because computed tomography (CT) findings show a variety of images, it is often difficult to distinguish hemangiomas from lung cancer and other benign tumours. We report a 63-year-old man who was diagnosed with a pulmonary capillary hemangioma (PCH). A right lung basal segmentectomy was performed for diagnosis and treatment. On chest CT, the lesion was shown to be a solid nodule with contrast-enhanced margins. This finding was thought to reflect the dense vascular hyperplasia of the central part of the tumour based on the pathologic findings. Although few studies involving PCH have referred to contrast-enhanced CT, the findings of contrast-enhanced CT might be a valuable indicator for diagnosing PCH.

Solitary Pulmonary Capillary Hemangioma: CT and PET-CT Features with Clinicopathologic Correlation

The aim of this study was to evaluate the CT and PET-CT features of solitary pulmonary capillary hemangioma (SPCH) with clinicopathologic correlations. This retrospective study included 17 patients with histologically proven SPCH from four tertiary institutions. The clinical, pathological and imaging findings of SPCH were reviewed. The CT features assessed included lesion location, size, density, contour, margin, enhancement, presence of air bronchogram, perivascular lucency and pleural retraction, and 18F-fluorodeoxyglucose uptake on PET-CT. Changes in the size during the follow-up period were also evaluated. Imaging features were correlated with the clinicopathologic findings. The mean age of the patients was 47 years (range 30–60 years). All SPCHs were incidentally detected during screening CT examinations (n = 13, 76%) or during cancer work-up (n = 4, 24%). Most SPCHs appeared as part-solid nodules (n = 15, 88%), the remaining appeared as a pure ground-glass nodule or a pure solid nodule, respectively. Most had smooth contours (n = 16, 94%), while one had a lobulated contour. Nine SPCHs (53%) showed ill-defined margins. Air bronchogram was present in ten (59%) SPCHs, and perivascular lucency in two (12%). All SPCHs exhibited hypoattenuation on contrast-enhanced CT and hypometabolism on PET-CT. During the follow-up period (mean 14.8 ± 17.7 months), the lesions showed no change in size or density in ten SPCHs (59%), decreased or fluctuation in size and density in three (18%). SPCH is often incidentally detected in young and middle-aged adults, commonly as an ill-defined part-solid nodule that may accompany air bronchogram, perivascular lucency, and fluctuation in size or density on CT and hypometabolism on PET-CT.

Solitary pulmonary capillary hemangioma mimicking a preinvasive malignant lesion in an asymptomatic middle-aged female patient

Pulmonary capillary hemangiomatosis (PCH) is a rare disease characterized by a proliferation of capillaries in the alveolar septa, bronchial and venous walls, pleura, and regional lymph nodes. However, the etiology of the disease remains unknown due to its rarity. Therefore, we present a case of a solitary PCH lesion without symptoms in a 38-year-old female patient. According to computed tomography, she was diagnosed with lung carcinoma, indicated by a tiny nodule with ground-glass opacity detected in her right upper lung. However, no other lesions were detected on systemic examination. Consequently, partial lung resection was conducted, since the lesion was suspected of lung adenocarcinoma. Pathologic results showed that the thick alveolar septa were caused by capillary growth without cellular atypia and hardly any infiltration of inflammatory cells. Finally, we diagnosed the pulmonary lesion as PCH, although solitary PCH has previously been reported in a few case reports. Therefore, further case studies are essential to clarify the causes of PCH.

A radiomics model can distinguish solitary pulmonary capillary haemangioma from lung adenocarcinoma

OBJECTIVES

Solitary pulmonary capillary haemangioma (SPCH) is a benign lung tumour that presents as ground-glass nodules on computed tomography (CT) images and mimics lepidic-predominant adenocarcinoma. This study aimed to establish a discriminant model using a radiomic feature analysis to distinguish SPCH from lepidic-predominant adenocarcinoma.

METHODS

In the adenocarcinoma group, all tumours were of the lepidic-predominant subtype with high purity (>70%). A classification model was proposed based on a two-level decision tree and 26 radiomic features extracted from each segmented lesion. For comparison, a baseline model was built with the same 26 features using a support vector machine as the classifier. Both models were assessed by the leave-one-out cross-validation method.

RESULTS

This study included 13 and 49 patients who underwent complete resection for SPCH and adenocarcinoma, respectively. Two sets of features were identified for discrimination between the 2 different histology types. The first set included 2 principal components corresponding to the 2 largest eigenvalues for the root node of the two-level decision tree. The second set comprised 4 selected radiomic features. The area under the receiver operating characteristic curve, accuracy, sensitivity, specificity were 0.954, 91.9%, 92.3% and 91.8% in the proposed classification model, and were 0.805, 85.5%, 61.5% and 91.8% in the baseline model, respectively. The proposed classification model significantly outperformed the baseline model (P < 0.05).

CONCLUSIONS

The proposed model could differentiate the 2 different histology types on CT images, and this may help surgeons to preoperatively discriminate SPCH from adenocarcinoma.

Solitary pulmonary capillary hemangioma presenting with a ground glass opacity: A case report & literature review

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Solitary pulmonary capillary hemangioma (SPCH) is a rare benign lung tumor.

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SPCH presents with a ground glass opacity on CT scan.

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Preoperative definitive diagnosis as SPCH is a real challenge.

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Immunohistochemical staining is essential for diagnosis as SPCH.

Introduction

Solitary pulmonary capillary hemangioma (SPCH) is a rare benign lung tumor that clinically resembles early lung cancer and precancerous pulmonary lesions that present with similar imaging manifestations.

Presentation of case

The patient was a 54-year-old Japanese man who was referred to Nagara Medical Center with a ground glass opacity (GGO) lesion within the right upper lung that was incidentally detected on computed tomography. After 8 months of follow-up, video-assisted thoracoscopic segmental resection of the right upper lobe was performed with diagnostic and therapeutic intent. Pathologic examination of the resected specimen demonstrated thickening of the alveolar septum caused by the proliferation of capillary vessels. This lesion was positive for CD31 and CD34 and negative for thyroid transcription factor-1 and cytokeratin on immunohistochemical staining. The tumor was diagnosed as SPCH pathologically.

Discussion

When radiological examination demonstrates a GGO in the lung, SPCH must be considered as one of the differential diagnoses. For a definitive diagnosis, pathological examination of a surgically resected specimen must be conducted.

Conclusion

This study describes a case of SPCH and a review of the literature.

Progressively increasing density of the solid center of a ground-glass nodule in a solitary pulmonary capillary hemangioma: A case report

Solitary pulmonary capillary hemangiomas (SPCHs) are recently recognized, rare benign lesions that form solitary nodules owing to capillary proliferation. These lesions are usually detected incidentally as small ground-glass nodules (GGNs) on computed tomography (CT), and progressively enlarge over time. The radiological distinction from peripheral lung cancers is particularly challenging. However, to date, there have been no reports on progressive changes in the central density of SPCH on CT. An asymptomatic 49-year-old man was referred to our hospital for an abnormal shadow that was detected on chest CT during medical check-up. He was subsequently followed-up with chest CT. The nodule increased in size, and the central area became progressively denser. He underwent surgery 5 years and 10 months after the first visit owing to suspicion of lung cancer. Despite the collapse of the surgical specimen by artifacts, histopathological examination revealed a diagnosis of SPCH; collagenous fibers were found in the walls of the intralesional capillaries. The patient is presently alive without any recurrence, 6 months after the operation. In this case, the SPCH demonstrated a GGN with progressively increasing density of the central solid area on the CT. This remarkable feature made the preoperative distinction from lung cancer particularly difficult.

[A case of multifocal cavernous haemangiomas of the lung, spleen and bone]

INTRODUCTION

Haemangiomas are vascular malformations, frequently cutaneous, hepatic and splenic. Respiratory involvement and multiple localisations are uncommon.

CASE REPORT

We present a rare case of multiple cavernous haemangiomas in a 35 year old woman presenting with repeated haemoptysis. Thoracic CT scanning showed a mass in the left lower lobe associated with lymph node enlargement above and below the diaphragm, heterogeneous splenomegaly and a single spinal lesion without hypermetabolism on PET scanning. Enbronchial ultrasound-guided trans-bronchial needle aspiration was not contributory. Histopathological diagnostic was made firstly by splenectomy with lumbar-aortic curettage and then by lobectomy for haemostasis. A final diagnosis of multiple cavernous haemangiomas involving lung, lymph nodes, spleen and bone was made.

CONCLUSIONS

Bronchopulmonary cavernous haemangiomas associated with extra-thoracic lesions are exceptionally rare and their presentation, suggesting, a malignant cause, often leads to surgical resection for diagnostic and, eventually, therapeutic management. We report an original case of cavernous haemangiomas involving lung, lymph nodes, spleen and bone.

Mesenchymal tumors of the lung: diagnostic pathology, molecular pathogenesis, and identified biomarkers

Lung cancers are mainly composed of epithelial tumors such as carcinomas. Since mesenchymal tumors that arise in the lung are very rare, they have garnered little attention. The 2015 World Health Organization (WHO) classification of lung tumors has undergone revision, not only for carcinomas but also for mesenchymal tumors. The current version now includes PEComatous tumors, myoepithelial tumors, and pulmonary myxoid sarcomas with EWSR1-CREB1 translocation as new disease entities. To date, no review article has comprehensively summarized what is known about pulmonary mesenchymal tumors in accordance with the latest WHO classification. In this review, we attempt to summarize the data about these tumors in line with the 2015 WHO classification (except for pediatric tumors), focusing on their diagnostic pathology, molecular pathogenesis, and identified biomarkers for differential diagnoses. We also address the recently recognized pulmonary mesenchymal tumors that have not yet been included in the WHO classification. An increased understanding of the molecular characteristics of pulmonary mesenchymal tumors has the potential to provide clinicians with the best therapeutic options for patients with these tumors.

Solitary pulmonary capillary hemangioma: Clinicopathologic and radiologic characteristics of nine surgically resected cases

BACKGROUND

Solitary pulmonary capillary hemangioma (SPCH) is an extraordinarily rare capillary derived mesenchymal neoplasm. Although routine morphology and immunohistochemistry are adequate for the diagnosis of classical SPCH in surgical specimens, true gross appearance identification of most tumor themselves and diagnosis for some exceptional cases are still very difficult. Furthermore, preoperative imaging and frozen diagnosis remain a challenge.

METHODS

We reported nine original cases of solitary pulmonary capillary hemangioma and summarized the clinical characteristics of twenty-one reported lesions. Imaging materials were reviewed by the image experts of our hospital. Quick hematoxylin-eosin stained intraoperative frozen sections and routine histological diagnosis were re-confirmed by 3 specialist pathologists with at least 10 years of diagnostic experience in our department. Immunohistochemistry analysis was performed on formalin fixed archival tissue. The surgical methods, following up information and prognosis were retrospectively analyzed.

RESULTS

In imaging, three tumors showed solid nodules, three cases displayed mix ground glass nodules, two nodules were pure ground glass density, and one case was a cystic-solid mass. Macroscopically, solitary pulmonary capillary hemangiomas were ill-defined soft hemorrhagic lesion with pale yellow or dark brownish cut surface. Two cases had a clear boundary and seven lesions were poorly demarcated. Typical morphological features were densely proliferating thin-walled capillaries composing of single layer of flatten or cuboidal endothelial cells within the thickened alveolar septa. One case was mistaken for a histiocytogenic lesion during freezing. The cystic-solid lesion showed a hyperplasia capillary network along the submucosal interstitium of bronchioles. Immunohistochemically, tumor endothelial cells were positive for ERG, Fli-1, CD31, CD34 and Vimentin and negative for CK, α-SMA, TTF-1, HMB45, S-100 and CD68. Lobectomy was performed on seven cases, wedge resection and segmentectomy were proceeded in two patients respectively. Follow up information showed no evidence of complication or recurrence.

CONCLUSIONS

Solitary pulmonary capillary hemangioma has special imaging and various histological features and must be distinguished from small benign lung lesions and preinvasive cancer. Although the prognosis of this tumor is good after surgical resection, the correct interpretation of the gross appearance and radiographic findings are still important. Choosing appropriate resection mode depends on accurate evaluation preoperative and intraoperative.

Solitary pulmonary capillary hemangioma: An under-recognized pulmonary lesion mimicking early lung cancer on computed tomography images

OBJECTIVES

Solitary pulmonary capillary hemangioma (SPCH) is a rare lung tumor typically presenting as pure or part-solid ground-glass nodules (GGNs) on computed tomography (CT), which clinically resembles early lung cancer.

MATERIALS AND METHODS

In addition to 10 recently diagnosed patients with SPCH, 71 benign lung nodules that were surgically resected between January 2013 and December 2017 were reviewed by thoracic pathologists to identify any previously unrecognized SPCH cases. Finally, 6 tumors (8.5%; 6/71) were determined to be SPCH. Elastic fiber stain (orcein stain) as well as immunohistochemistry for cytokeratin, CD31, and thyroid transcription factor 1 were performed for confirmation. Clinical and radiological data were analyzed.

RESULTS

All 16 SPCH lesions were unrecognized or misdiagnosed by general pathologists. The SPCH ranged in size from 3 to 15 mm, and a predominance among women (68.8%; 11/16) was noted. Pathologically, all SPCH lesions were nodular with a higher vascular density than the adjacent lung tissue. Decreased cytokeratin staining and disrupted elastic fibers were clearly observed in all SPCH lesions.

CONCLUSIONS

SPCH lesions mimic early lung cancer on CT; they are largely unrecognized by general pathologists and are diagnosed as other nonspecific benign lesions. With careful histologic examination, SPCH can be successfully diagnosed using cytokeratin/CD31 immunohistochemistry and elastic fiber staining.

Solitary pulmonary capillary hemangioma presents as ground glass opacity on computed tomography indicating adenocarcinoma in situ/atypical adenomatous hyperplasia: A case report

Solitary pulmonary capillary hemangioma (SPCH) is a rare type of benign lung tumor, which must be distinguished from early lung cancer and precancerous lesions of the lung that manifest in a similar way upon imaging. The current study describes a case of SPCH and a review of the literature is performed. The patient was a 40-year-old Chinese woman who was referred to the Liaoning Cancer Hospital and Institute (Shenyang, China) in October, 2015 with a cough without obvious inducement. Computed tomography (CT) demonstrated pure ground glass opacity (GGO) in the right upper lung. Following systemic anti-inflammatory therapy over 6 months, the lesion did not exhibit any change on CT and was suspected to be an adenocarcinoma in situ (AIS) or atypical adenomatous hyperplasia (AAH). Video-assisted thoracic surgery wedge resection was subsequently performed. Frozen section diagnosis revealed a benign tumor without atypical epithelial cells. Subsequent to surgery, paraffin sections demonstrated that the tumor contained narrow alveolar cavities, thickened alveolar septa and a clear boundary separating it from healthy lung tissue. Furthermore, the proliferation lumens in the alveolar septa were lined with a single layer of flat cells. Immunohistochemical staining revealed that the flat cells were positive for cluster of differentiation CD31 and CD34, and negative for thyroid transcription factor-1 and cytokeratin. The proliferation of capillary vessels lead to the thickened alveolar septa and the tumor was diagnosed as SPCH. When imaging examination demonstrates a GGO in lung, SPCH must be considered in the differential diagnosis of AIS/AAH. As the prognosis of these lesions is entirely different, a pathological examination must be conducted to ensure a correct diagnosis.

Pulmonary capillary hemangiomatosis: a focus on the EIF2AK4 mutation in onset and pathogenesis

Pulmonary capillary hemangiomatosis (PCH) is a pulmonary vascular disease that mainly affects small capillaries in the lung, and is often misdiagnosed as pulmonary arterial hypertension or pulmonary veno-occlusive disease due to similarities in their clinical presentations, prognosis, and management. In patients who are symptomatic, there is a high mortality rate with median survival of 3 years after diagnosis. Both idiopathic and familial PCH cases are being reported, indicating there is genetic component in disease etiology. Mutations in the eukaryotic translation initiation factor 2α kinase 4 (EIF2AK4) gene were identified in familial and idiopathic PCH cases, suggesting EIF2AK4 is a genetic risk factor for PCH. EIF2AK4 mutations were identified in 100% (6/6) of autosomal recessively inherited familial PCH and 20% (2/10) of sporadic PCH cases. EIF2AK4 is a member of serine/threonine kinases. It downregulates protein synthesis in response to a variety of cellular stress such as hypoxia, viral infection, and amino acid deprivation. Bone morphogenetic protein receptor 2 (BMPR2) is a major genetic risk factor in pulmonary arterial hypertension and EIF2AK4 potentially connects with BMPR2 to cause PCH. L-Arginine is substrate of nitric oxide synthase, and L-arginine is depleted during the production of nitric oxide, which may activate EIF2AK4 to inhibit protein synthesis and negatively regulate vasculogenesis. Mammalian target of rapamycin and EIF2α kinase are two major pathways for translational regulation. Mutant EIF2AK4 could promote proliferation of small pulmonary arteries by crosstalk with mammalian targets of the rapamycin signaling pathway. EIF2AK4 may regulate angiogenesis by modulating the immune system in PCH pathogenesis. The mechanisms of abnormal capillary angiogenesis are suggested to be similar to that of tumor vascularization. Specific therapies were developed according to pathogenesis and are proved to be effective in reported cases. Targeting the EIF2AK4 pathway may provide a novel therapy for PCH.

Pulmonary capillary hemangiomatosis associated with connective tissue disease: a report of 4 cases and review of the literature

Pulmonary hypertension (PHTN) can be seen in patients with connective tissue disease (CTD). The typical pathology associated with CTD is interstitial fibrosis and hypertensive pulmonary arteriopathy. We describe 4 patients with CTD and PHTN unexpectedly found to have pulmonary capillary hemangiomatosis (PCH) at explant after lung transplantation or autopsy. Pulmonary capillary hemangiomatosis is defined as a proliferation of capillaries in alveolar walls and can clinically cause PHTN. We detail the pathologic findings of PCH, describe the differential diagnosis, and present a review of the literature on the possible association of PCH with CTD. Although PCH may present clinically as PHTN, it is critical to differentiate between the typical CTD-associated interstitial fibrosis with hypertensive pulmonary arteriopathy and PCH because the treatment is different. We provide the largest case series to date and highlight the need for pathologists to have a high level of suspicion for PCH in patients with CTD.

Recurrent pulmonary capillary hemangioma: dynamic contrast-enhanced CT and histopathologic findings

We report the dynamic contrast-enhanced CT and histopathologic findings of a rare case of recurrent pulmonary capillary hemangiomas. The findings consisted of peripheral nodular enhancement at the early arterial phase and a subsequent "central filling-in" enhancement pattern on the delayed scans, which was identical to the well-known enhancement pattern of hemangiomas of the liver. Although there was no evidence of histological malignancy, pulmonary capillary hemangiomas manifested as multiple nodular lesions and showed postoperative recurrence.

Primary vascular tumors of the lungs: a review

Unlike their counterparts in other organ systems, primary vascular neoplasms of the lung are rare. Most of these lesions have only been reported as isolated case studies or small series. When dealing with malignant lesions, metastasis from extrapulmonary sites will have to be excluded before a primary location in the lungs can be confirmed. In this review, the clinicopathologic, immunophenotypical, ultrastructural, and molecular biologic characteristics of primary vascular tumors of the lungs are discussed. The tumoral conditions that will be addressed include hemangioma, lymphangioma, epithelioid hemangioendothelioma, angiosarcoma, and Kaposi's sarcoma. Their respective differential diagnoses will also be discussed.

Pulmonary capillary hemangiomatosis-like foci detected by high resolution computed tomography

We report a case of pulmonary capillary hemangiomatosis-like foci (PCH-like foci), presenting as multiple ground-glass opacities (GGOs) on high resolution computed tomography (HRCT). The patient underwent a left lingual segmentectomy to make a definite diagnosis of these GGOs on chest CT. Histological findings were similar to PCH; however, there were no clinical symptoms or findings of pulmonary hypertension. Accordingly, PCH-like foci was diagnosed.

Solitary pulmonary infantile hemangioma in an infant with atrial septal defect

Pulmonary infantile hemangiomas are extremely rare in infancy and childhood. We describe a case of a 22-month-old infant who presented with repeated chest infections. Imaging studies revealed a solitary parenchymal lung lesion in the left upper lobe, an atrial septal defect, and mild right ventricular dilatation. Various investigations failed to delineate the precise nature of the lung lesion and it was resected. Histological examination of the lung lesion showed an infantile hemangioma, which expressed glucose transporter-1 protein, GLUT-1, a marker of infantile hemangiomas. This case represents a unique coexistence of 2 lesions, both of which resulted in right-sided overload, contributed to mainly by the atrial septal defect causing increased volume and, to a lesser extent, by the pulmonary hemangioma resulting in increased pressure. This case also emphasizes the fact that infantile hemangioma, although rare, should be considered as a differential diagnosis of solitary lung lesions.

Pulmonary capillary hemangiomatosis imaging findings and literature update

Pulmonary capillary hemangiomatosis (PCH) is a rare and an only recently described vascular disease. As one of the causes of primary pulmonary hypertension, the need for the establishment of helpful diagnostic radiological criteria for this condition has become imperative. However, the unstable hemodynamic condition of patients with primary pulmonary hypertension often denies pathological sampling as a definitive diagnostic tool. This diagnostic dilemma can be fatal to those patients with PCH treated for pulmonary hypertension because a fatal pulmonary edema may occur. We report a case of PCH in a 26-year-old patient who died of severe circulatory compromise while undergoing transplant evaluation. A discussion of the computed tomography findings, a review of the pathological features, and a review of the relatively limited imaging literature available on this subject are conducted.