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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 et al.; licensee BioMed Central Ltd. 2014
Received: 11 May 2014
Accepted: 28 August 2014
Published: 21 October 2014
Chronic expanding hematoma is a rare persistent hematoma that can sometimes be misdiagnosed as a malignant tumor due to its clinical and radiological features.
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.
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.
Chronic expanding hematoma (CEH) is a rare lesion that was first defined by Reid et al. in 1980 . CEH is characterized by its persistence and increasing size over a period of more than a month after the initial hemorrhage, whereas most hematomas in skeletal muscle may arise with or without any identifiable trauma and gradually expand over days to weeks, followed by a decrease in size or disappearance within a few months. Therefore, CEH can be misdiagnosed as a malignant soft tissue sarcoma because of its clinical characteristics such as a large size and slowly progressive enlargement [1, 2]. Two-[18F]fluoro-2 deoxy-D glucose positron emission tomography (FDG-PET) is an evolving diagnostic modality used for tumor detection, staging, therapeutic monitoring and follow-up evaluations for the treatment and management of various malignant tumors [3, 4].
Here we present a case of CEH in the lower extremity. The lesion exhibited significantly increased FDG uptake on FDG-PET, mimicking the characteristics of a soft tissue sarcoma accompanied by hematoma.
Reid et al. first used the term ‘chronic expanding hematoma’ for hematomas that persisted and increased in size for more than a month after the initial hemorrhage event . Such lesions often simulated neoplastic growth. On the other hand, it has been reported previously that some soft tissue sarcomas, including synovial sarcoma, epithelioid sarcoma, extraskeletal Ewing sarcoma, and malignant fibrous histiocytoma, sometimes exhibit the radiological features of a hematoma. Such clinical and radiological features often make the accurate diagnosis of pure hematoma difficult. The mechanisms that determine the formation of CEH are not well understood. Labadie and Glover theorized that breakdown of leukocytes, hemoglobin, platelets, and fibrin results in an inflammatory process that effectively damages the capillaries of the capsule, increasing the permeability of the vascular wall and causing bleeding from dilated microvessels underneath the fibrous capsule .
Fluorodeoxyglucose positron emission tomography imaging characteristics of chronic expanding hematoma
Although the treatment of CEH is still a matter of debate, most authors have recommended surgical resection. Aspiration or drainage of the material may not remove the clot contents fully, and undoubtedly will not remove the fibrous wall that might retain fluid. Additionally, aspiration of the fluid or incomplete excision could lead either to an unconfirmed diagnosis or to recurrence . Hanagiri et al. reported that the surgical procedure should be complete resection, because incomplete resection might result in massive bleeding from a hypervascular subcapsular lesion . Therefore, it seems that complete surgical resection, including the pseudocapsule, is the best treatment option for CEH.
In summary, we have presented a case of CEH showing significantly increased FDG accumulation, which could have had the potential for misdiagnosis as a soft tissue sarcoma.
Written informed consent for publication of this case report and any accompanying images was obtained from the patient. A copy of the written consent form is available for review by the Editor-in-Chief of this journal.
The authors would like to express their deepest gratitude to Dr. Aoi Sukeda and Dr. Akihiko Yoshida for their insightful comments regarding the pathological findings of this study.
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