Diagnostic and Interventional Imaging (2015) 96, 495—498
RADIOLOGIC PATHOLOGIC CORRELATION /Gastrointestinal imaging
Mesenteric cavernous hemangioma: Imaging-pathologic correlation S. Si-Mohamed a,∗, S. Aufort b, L. Khellaf c, J. Ramos c, P. Gasne d, L. Durand c a
Radiology, 8, rue de l’Herberie, 34000 Montpellier, France Radiology, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France c Anatomical pathology, Gui-de-Chauliac hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France d Abdominal surgery, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France b
KEYWORDS Hemangioma; Mesenteric tumours; Magnetic resonance imaging; Pathology
∗
Case study A 50-year old female with no remarkable medical history consulted her doctor because of persistent epigastric pain. The clinical examination was unremarkable and laboratory tests were normal. Ultrasonography revealed a subumbilical, homogeneous, echogenic mass with an axial diameter of 5 cm. The mass had regular margins, posterior acoustic enhancement, and no visible vascularisation on colour Doppler imaging. Computed tomography (CT) of the abdomen and pelvis before and after administration of iodinated contrast material showed a tissue mass located in the mesentery with regular margins, no calcification, no communication with the bowel loops, and attenuation values of 70 HU before injection. After intravenous administration of iodinated contrast material, CT demonstrated discontinuous, peripheral nodes that enhanced centripetally, with a dynamic pattern of enhancement identical to that of the aorta and which persisted during the delayed phase. Multiple vessels were visible within the mass including a branch of the superior mesenteric artery, but there was no thrombosis or obstruction (Fig. 1). No enlarged lymph node was visible.
Corresponding author. E-mail address: salim [email protected] (S. Si-Mohamed).
http://dx.doi.org/10.1016/j.diii.2015.01.006 2211-5684/© 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
496
Figure 1. Asymptomatic mesenteric hemangioma in a 50-year-old woman. CT image of the mid abdomen in the sagittal plane during the enteric phase of enhancement shows a well-circumscribed mass of the mesentery (white arrow), with peripheral nodular enhancement that has narrow channels of communication with the superior mesenteric artery (black arrow) and vein (arrowhead).
MR imaging showed high signal intensity lesion on T2weighted sequences (Fig. 2) and low signal intensity on diffusion-weighted MR images (B50 and B1000) with no drop in apparent diffusion coefficient value (ADC = 1.9 * 10—3 mm2 /sec) on diffusion-weighted images. The oval mass also showed regular margins and contained threadlike formations, which were suggestive of vascular structures extending from the mesenteric vessels. On unenhanced T1-weighted images, the lesion was homogenous with intermediate signal intensity. After intravenous administration of gadolinium-chelate, the enhancement pattern was similar to that seen on CT (Fig. 3).
Figure 2. T2-weighted (TR/TE = 850/102 ms, flip angle = 180◦ ) MR image in the axial plane demonstrates a lesion with a higher signal intensity than fat, similar to that of a hepatic hemangioma (arrow).
S. Si-Mohamed et al.
Figure 3. Mesenteric cavernous hemangioma. a: fatgradient-echo (TR/TE = 3.67/1.85 ms, suppressedT1-weighted flip angle = 10◦ ) MR image in the axial plane during the enteric phase shows progressive enhancement with peripheral nodular enhancement (arrow); b: fat-suppressed T1-weightedgradient-echo (TR/TE = 3.67/1.85 ms, flip angle 10◦ ) MR image in the axial plane during the delayed phase shows persistent enhancement with centripetal fill-in, greater than during the enteric phase (arrow).
Percutaneous biopsy was not considered in view of the vascularisation of the lesion, difficulty of access, and its relationships to the large mesenteric vessels. Surgical resection was thus decided. Intraoperatively, a mesenteric mass with no extension to the bowel loops was
Figure 4. Laparoscopic view. The lesion is located in the mesentery without extension to the gastrointestinal tract wall.
Mesenteric cavernous hemangioma: Imaging-pathologic correlation found (Fig. 4). The mass was resected along with 20 cm of the jejunum. Histopathological examination of the resected specimen revealed a well-marginated vascular lesion. The lesion was made of multiple dilated cavities lined with flattened endothelium with no nuclear atypia that were separated by septa of fibrous connective tissue. The vessel lumen showed thrombosis and contained numerous red blood cells (Fig. 5). Immunolabelling for CD31, which is vascular endothelium-specific, was positive in the cytoplasm. It was however negative for the lymphatic endothelial marker D2-40. Smooth muscle actin marked the smooth muscle component of the vessel walls. The lesion was definitely diagnosed as a cavernous hemangioma of the mesentery. Follow-up at 1 year showed no recurrence of the lesion.
Figure 5. Photograph shows histopathological features (HE stain, original magnification ×20) of the lesion that contains large cavities filled with red blood cells and bordered by endothelium resting on an abundant fibrous stroma.
Discussion The lesion reported showed clinical, radiological and histological features similar to those of cavernous hemangiomas found in the abdomen including hepatic hemangioma [1,2]. Like these, it was clinically asymptomatic with no internal hemorrhage or infection and no mass effect on adjacent organs. On ultrasonography, the lesion was hyperechoic with posterior acoustic enhancement. On CT, it demonstrated tissue density and enhancement pattern characteristic of angiomas. MR imaging showed no restriction on diffusionweighted images and typical high signal intensity on T2-weighted images similar to typical pattern of hemangiomas. Unusually, a rich vascular component made up of superior mesenteric vessels is present making it necessary to excise a portion of the superior mesenteric artery during surgery. Histologically, the lesion showed multiple dilated cavities with vessel lumina that showed thrombosis in places and contained red blood cells. CD31 immunolabelling, a specific marker for vascular endothelium, was positive [3,4].
497
A review of the literature found a few cases of mesenteric cavernous hemangioma [5,6]. They do not have any characteristic imaging or histological features. By contrast, multiple cases of cavernous hemangioma were found in the liver [1,2], and more rarely in unusual locations including gastrosplenic ligament [7], small bowel [8], colon, and rectosigmoid junction [9]. A percutaneous biopsy was considered in our patient because it is often recommended in hepatic angioma with atypical presentation [10]. However, percutaneous biopsy was disregarded because of a deep location and high risk of iatrogenic complication. Surgical excision was thus chosen, taking into account the possibility of complications such as hemorrhage or secondary infection. According to Freeny et al., the rate of complications linked to size in hepatic hemangiomas is between 4.5% and 19.7%. There are two types of complications: on the one hand, complications that are specific to the lesion such as thrombosis or inflammation; and on the other, more general and systemic complications such as hemorrhage, volvulus, or compression of adjacent organs [1,11]. On imaging, if a mesenteric mass is identified, this must lead to a consideration of the differential diagnoses, distinguishing the fluid lesions, consisting of cystic lymphangioma and mesothelial lesions, from solid masses including desmoid tumour, solitary fibrous tumour, peritoneal carcinosis, and leiomymomatosis, and also from fat-containing lesions such as teratoma and lipoma [12,13]. In our patient, the lesion was purely solid with no cystic or fatty component. This was confirmed by imaging, with ultrasonography showing a hyperechoic echostructure, CT demonstrating a lesion with soft tissue attenuation values, and MRI showing an intermediate signal intensity on T1-weighted images with centripetal enhancement after injection of a contrast medium and no drop in signal intensity on out-of-phase T1weighted sequences. When considering only solid tumours, three groups can be distinguished on the basis of enhancement patterns. Predominant enhancement during the arterial phase suggests gastrointestinal stromal tumour, Castleman’s disease, solitary fibrous tumour, and splenosis nodule. Predominant enhancement during the enteric phase, suggests desmoid tumour, actinomycosis, carcinomatosis nodule or solitary fibrous tumor. Finally, poor enhancement on both suggests lymphoma, inflammatory pseudotumour or endometriosis. In our patient, the lesion showed predominant enhancement during the arterial phase. However, gastrointestinal stromal tumor is hypervascular and well demarcated, communicates with the bowel loop and shows extraluminal growth. The angioma-type pattern of enhancement and the high signal intensity on T2-weighted images were not consistent with Castleman’s disease. Our patient had no history of trauma, surgery, infection or splenic tumor and the enhancement pattern was not identical to that of the spleen. In addition, these nodules are found around the gastrosplenic or splenorenal ligaments or the space around the diaphragm so that the diagnosis of splenosis nodule was excluded. Solitary fibrous tumor is usually asymptomatic, until it leads to a mass effect. In addition, it is hypervascular with a necrotic center and tends to present small peripheral vessels rather than large- and medium-calibre vessels like in our patient.
498
Conclusion The diagnosis of mesenteric hemangioma should be considered in the presence of a mesenteric tumor that presents clinical, imaging and pathological features that are identical to those of hepatic hemangioma. The diagnosis is definitely confirmed by histopathological analysis.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Klotz T, Montoriol PF, Da Ines D, Petitcolin V, Joubert-Zakeyh J, Garcier JM. Hepatic haemangioma: common and uncommon imaging features. Diagn Interv Imaging 2013;94(9):849—59. [2] Vilgrain V, Boulos L, Vullierme MP, Denys A, Terris B, Menu Y. Imaging of atypical hemangiomas of the liver with pathologic correlation. Radiographics 2000;20(2):379—97. [3] Shepherd NA, Warren BF, Williams GT. Wiley: Morson and Dawson’s gastrointestinal pathology. 5th edition Wiley-Blackwell; 2013. p. 742—3 [p. 448—9]. [4] Fenoglio-Preiser CM. Gastrointestinal pathology: an atlas and text. 2nd edition Lippincott Williams and Wilkins; 1998. p. 1203—5.
S. Si-Mohamed et al. [5] Takamura M, Murakami T, Kurachi H, Kim T, Enomoto T, Narumi Y, et al. MR imaging of mesenteric hemangioma: a case report. Radiat Med 2000;18(1):67—9. [6] Suga H, Tsuruta O, Ono N, Okabe Y, Masuda J, Wada Y, et al. A case of mesenteric cavernous hemangioma showing interestingly image study. Nihon Shokakibyo Gakkai Zasshi 2005;102(1):31—6. [7] Chin KF, Khair G, Babu PS, Morgan DR. Cavernous hemangioma arising from the gastro-splenic ligament: a case report. World J Gastroenterol 2009;15(30):3831—3. [8] D’Armiento FP, Cardillo M, D’Antonio M, Purri P. Hemangioma of the small bowel. Case report. Panminerva Med 1989;31(3):148—50. [9] Sylla P, Deutsch G, Luo J, Recavarren C, Kim S, Heimann TM, et al. Cavernous, arteriovenous, and mixed hemangiomalymphangioma of the rectosigmoid: rare causes of rectal bleeding — case series and review of the literature. Int J Colorectal Dis 2008;23(7):653—8. [10] Cronan JJ, Esparza AR, Dorfman GS, Ridlen MS, Paolella LP. Cavernous hemangioma of the liver: role of percutaneous biopsy. Radiology 1988;166(1 Pt 1):135—8. [11] Freeny PC, Vimont TR, Barnett DC. Cavernous hemangioma of the liver: ultrasonography, arteriography, and computed tomography. Radiology 1979;132(1):143—8. [12] Sheth S, Horton KM, Garland MR, Fishman EK. Mesenteric neoplasms: CT appearances of primary and secondary tumors and differential diagnosis. Radiographics 2003;23(2):457—73. [13] Diop AD, Fontarensky M, Montoriol PF, Da Ines D. CT imaging of peritoneal carcinomatosis and its mimics. Diagn Interv Imaging 2014;95(9):861—72.
RADIOLOGIC PATHOLOGIC CORRELATION /Gastrointestinal imaging
Mesenteric cavernous hemangioma: Imaging-pathologic correlation S. Si-Mohamed a,∗, S. Aufort b, L. Khellaf c, J. Ramos c, P. Gasne d, L. Durand c a
Radiology, 8, rue de l’Herberie, 34000 Montpellier, France Radiology, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France c Anatomical pathology, Gui-de-Chauliac hospital, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France d Abdominal surgery, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France b
KEYWORDS Hemangioma; Mesenteric tumours; Magnetic resonance imaging; Pathology
∗
Case study A 50-year old female with no remarkable medical history consulted her doctor because of persistent epigastric pain. The clinical examination was unremarkable and laboratory tests were normal. Ultrasonography revealed a subumbilical, homogeneous, echogenic mass with an axial diameter of 5 cm. The mass had regular margins, posterior acoustic enhancement, and no visible vascularisation on colour Doppler imaging. Computed tomography (CT) of the abdomen and pelvis before and after administration of iodinated contrast material showed a tissue mass located in the mesentery with regular margins, no calcification, no communication with the bowel loops, and attenuation values of 70 HU before injection. After intravenous administration of iodinated contrast material, CT demonstrated discontinuous, peripheral nodes that enhanced centripetally, with a dynamic pattern of enhancement identical to that of the aorta and which persisted during the delayed phase. Multiple vessels were visible within the mass including a branch of the superior mesenteric artery, but there was no thrombosis or obstruction (Fig. 1). No enlarged lymph node was visible.
Corresponding author. E-mail address: salim [email protected] (S. Si-Mohamed).
http://dx.doi.org/10.1016/j.diii.2015.01.006 2211-5684/© 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
496
Figure 1. Asymptomatic mesenteric hemangioma in a 50-year-old woman. CT image of the mid abdomen in the sagittal plane during the enteric phase of enhancement shows a well-circumscribed mass of the mesentery (white arrow), with peripheral nodular enhancement that has narrow channels of communication with the superior mesenteric artery (black arrow) and vein (arrowhead).
MR imaging showed high signal intensity lesion on T2weighted sequences (Fig. 2) and low signal intensity on diffusion-weighted MR images (B50 and B1000) with no drop in apparent diffusion coefficient value (ADC = 1.9 * 10—3 mm2 /sec) on diffusion-weighted images. The oval mass also showed regular margins and contained threadlike formations, which were suggestive of vascular structures extending from the mesenteric vessels. On unenhanced T1-weighted images, the lesion was homogenous with intermediate signal intensity. After intravenous administration of gadolinium-chelate, the enhancement pattern was similar to that seen on CT (Fig. 3).
Figure 2. T2-weighted (TR/TE = 850/102 ms, flip angle = 180◦ ) MR image in the axial plane demonstrates a lesion with a higher signal intensity than fat, similar to that of a hepatic hemangioma (arrow).
S. Si-Mohamed et al.
Figure 3. Mesenteric cavernous hemangioma. a: fatgradient-echo (TR/TE = 3.67/1.85 ms, suppressedT1-weighted flip angle = 10◦ ) MR image in the axial plane during the enteric phase shows progressive enhancement with peripheral nodular enhancement (arrow); b: fat-suppressed T1-weightedgradient-echo (TR/TE = 3.67/1.85 ms, flip angle 10◦ ) MR image in the axial plane during the delayed phase shows persistent enhancement with centripetal fill-in, greater than during the enteric phase (arrow).
Percutaneous biopsy was not considered in view of the vascularisation of the lesion, difficulty of access, and its relationships to the large mesenteric vessels. Surgical resection was thus decided. Intraoperatively, a mesenteric mass with no extension to the bowel loops was
Figure 4. Laparoscopic view. The lesion is located in the mesentery without extension to the gastrointestinal tract wall.
Mesenteric cavernous hemangioma: Imaging-pathologic correlation found (Fig. 4). The mass was resected along with 20 cm of the jejunum. Histopathological examination of the resected specimen revealed a well-marginated vascular lesion. The lesion was made of multiple dilated cavities lined with flattened endothelium with no nuclear atypia that were separated by septa of fibrous connective tissue. The vessel lumen showed thrombosis and contained numerous red blood cells (Fig. 5). Immunolabelling for CD31, which is vascular endothelium-specific, was positive in the cytoplasm. It was however negative for the lymphatic endothelial marker D2-40. Smooth muscle actin marked the smooth muscle component of the vessel walls. The lesion was definitely diagnosed as a cavernous hemangioma of the mesentery. Follow-up at 1 year showed no recurrence of the lesion.
Figure 5. Photograph shows histopathological features (HE stain, original magnification ×20) of the lesion that contains large cavities filled with red blood cells and bordered by endothelium resting on an abundant fibrous stroma.
Discussion The lesion reported showed clinical, radiological and histological features similar to those of cavernous hemangiomas found in the abdomen including hepatic hemangioma [1,2]. Like these, it was clinically asymptomatic with no internal hemorrhage or infection and no mass effect on adjacent organs. On ultrasonography, the lesion was hyperechoic with posterior acoustic enhancement. On CT, it demonstrated tissue density and enhancement pattern characteristic of angiomas. MR imaging showed no restriction on diffusionweighted images and typical high signal intensity on T2-weighted images similar to typical pattern of hemangiomas. Unusually, a rich vascular component made up of superior mesenteric vessels is present making it necessary to excise a portion of the superior mesenteric artery during surgery. Histologically, the lesion showed multiple dilated cavities with vessel lumina that showed thrombosis in places and contained red blood cells. CD31 immunolabelling, a specific marker for vascular endothelium, was positive [3,4].
497
A review of the literature found a few cases of mesenteric cavernous hemangioma [5,6]. They do not have any characteristic imaging or histological features. By contrast, multiple cases of cavernous hemangioma were found in the liver [1,2], and more rarely in unusual locations including gastrosplenic ligament [7], small bowel [8], colon, and rectosigmoid junction [9]. A percutaneous biopsy was considered in our patient because it is often recommended in hepatic angioma with atypical presentation [10]. However, percutaneous biopsy was disregarded because of a deep location and high risk of iatrogenic complication. Surgical excision was thus chosen, taking into account the possibility of complications such as hemorrhage or secondary infection. According to Freeny et al., the rate of complications linked to size in hepatic hemangiomas is between 4.5% and 19.7%. There are two types of complications: on the one hand, complications that are specific to the lesion such as thrombosis or inflammation; and on the other, more general and systemic complications such as hemorrhage, volvulus, or compression of adjacent organs [1,11]. On imaging, if a mesenteric mass is identified, this must lead to a consideration of the differential diagnoses, distinguishing the fluid lesions, consisting of cystic lymphangioma and mesothelial lesions, from solid masses including desmoid tumour, solitary fibrous tumour, peritoneal carcinosis, and leiomymomatosis, and also from fat-containing lesions such as teratoma and lipoma [12,13]. In our patient, the lesion was purely solid with no cystic or fatty component. This was confirmed by imaging, with ultrasonography showing a hyperechoic echostructure, CT demonstrating a lesion with soft tissue attenuation values, and MRI showing an intermediate signal intensity on T1-weighted images with centripetal enhancement after injection of a contrast medium and no drop in signal intensity on out-of-phase T1weighted sequences. When considering only solid tumours, three groups can be distinguished on the basis of enhancement patterns. Predominant enhancement during the arterial phase suggests gastrointestinal stromal tumour, Castleman’s disease, solitary fibrous tumour, and splenosis nodule. Predominant enhancement during the enteric phase, suggests desmoid tumour, actinomycosis, carcinomatosis nodule or solitary fibrous tumor. Finally, poor enhancement on both suggests lymphoma, inflammatory pseudotumour or endometriosis. In our patient, the lesion showed predominant enhancement during the arterial phase. However, gastrointestinal stromal tumor is hypervascular and well demarcated, communicates with the bowel loop and shows extraluminal growth. The angioma-type pattern of enhancement and the high signal intensity on T2-weighted images were not consistent with Castleman’s disease. Our patient had no history of trauma, surgery, infection or splenic tumor and the enhancement pattern was not identical to that of the spleen. In addition, these nodules are found around the gastrosplenic or splenorenal ligaments or the space around the diaphragm so that the diagnosis of splenosis nodule was excluded. Solitary fibrous tumor is usually asymptomatic, until it leads to a mass effect. In addition, it is hypervascular with a necrotic center and tends to present small peripheral vessels rather than large- and medium-calibre vessels like in our patient.
498
Conclusion The diagnosis of mesenteric hemangioma should be considered in the presence of a mesenteric tumor that presents clinical, imaging and pathological features that are identical to those of hepatic hemangioma. The diagnosis is definitely confirmed by histopathological analysis.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Klotz T, Montoriol PF, Da Ines D, Petitcolin V, Joubert-Zakeyh J, Garcier JM. Hepatic haemangioma: common and uncommon imaging features. Diagn Interv Imaging 2013;94(9):849—59. [2] Vilgrain V, Boulos L, Vullierme MP, Denys A, Terris B, Menu Y. Imaging of atypical hemangiomas of the liver with pathologic correlation. Radiographics 2000;20(2):379—97. [3] Shepherd NA, Warren BF, Williams GT. Wiley: Morson and Dawson’s gastrointestinal pathology. 5th edition Wiley-Blackwell; 2013. p. 742—3 [p. 448—9]. [4] Fenoglio-Preiser CM. Gastrointestinal pathology: an atlas and text. 2nd edition Lippincott Williams and Wilkins; 1998. p. 1203—5.
S. Si-Mohamed et al. [5] Takamura M, Murakami T, Kurachi H, Kim T, Enomoto T, Narumi Y, et al. MR imaging of mesenteric hemangioma: a case report. Radiat Med 2000;18(1):67—9. [6] Suga H, Tsuruta O, Ono N, Okabe Y, Masuda J, Wada Y, et al. A case of mesenteric cavernous hemangioma showing interestingly image study. Nihon Shokakibyo Gakkai Zasshi 2005;102(1):31—6. [7] Chin KF, Khair G, Babu PS, Morgan DR. Cavernous hemangioma arising from the gastro-splenic ligament: a case report. World J Gastroenterol 2009;15(30):3831—3. [8] D’Armiento FP, Cardillo M, D’Antonio M, Purri P. Hemangioma of the small bowel. Case report. Panminerva Med 1989;31(3):148—50. [9] Sylla P, Deutsch G, Luo J, Recavarren C, Kim S, Heimann TM, et al. Cavernous, arteriovenous, and mixed hemangiomalymphangioma of the rectosigmoid: rare causes of rectal bleeding — case series and review of the literature. Int J Colorectal Dis 2008;23(7):653—8. [10] Cronan JJ, Esparza AR, Dorfman GS, Ridlen MS, Paolella LP. Cavernous hemangioma of the liver: role of percutaneous biopsy. Radiology 1988;166(1 Pt 1):135—8. [11] Freeny PC, Vimont TR, Barnett DC. Cavernous hemangioma of the liver: ultrasonography, arteriography, and computed tomography. Radiology 1979;132(1):143—8. [12] Sheth S, Horton KM, Garland MR, Fishman EK. Mesenteric neoplasms: CT appearances of primary and secondary tumors and differential diagnosis. Radiographics 2003;23(2):457—73. [13] Diop AD, Fontarensky M, Montoriol PF, Da Ines D. CT imaging of peritoneal carcinomatosis and its mimics. Diagn Interv Imaging 2014;95(9):861—72.
