3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 729
CASE SERIES
Thyroid Hemangiomas Diagnosed on Sonography Sung Hee Park, MD, Soo Jin Kim, MD, Hyun Kyung Jung, MD
Primary thyroid hemangiomas are extremely rare, and only a few cases have been previously reported. Primary hemangiomas are developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals. Thyroid hemangiomas are generally considered difficult to diagnose preoperatively because of their low incidence and nonspecific imaging findings. Here we report 2 cases of thyroid hemangiomas that were diagnosed correctly on preoperative sonography. Our cases showed similar sonographic findings, such as well-circumscribed hypoechoic lesions with internal channellike linear lines, and bloody content was aspirated during fine-needle aspirations. Our report shows that thyroid hemangiomas can be diagnosed correctly by sonography with or without confirmation of bloody content in the lesions by fine-needle aspiration. Key Words—computed tomography; fine-needle biopsy; hemangioma; sonography; superficial structures; thyroid; vascular malformations
Received July 15, 2013, from the Department of Radiology, Thyroid Center, Chung-Ang University Hospital, Seoul, Korea (S.H.P., S.J.K.); and Department of Radiology, Inje University Haeundae Paik Hospital, Busan, Korea (H.K.J.). Revision requested August 1, 2013. Revised manuscript accepted for publication August 5, 2013. Address correspondence to Sung Hee Park, MD, Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjakgu, Seoul 156-755, Korea. E-mail: [email protected] Abbreviations
CT, computed tomography doi:10.7863/ultra.33.4.729
H
emangiomas are benign vascular tumors that commonly manifest in childhood, with a predilection to the head and neck regions. Primary hemangiomas of the thyroid glands are extremely rare, and only a few cases have been previously reported. They are developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals. Accurate preoperative diagnosis of thyroid hemangiomas is known to be difficult because of their low incidence and, more importantly, their nonspecific sonographic findings. This report describes 2 cases of thyroid hemangiomas that were diagnosed by sonography and fine-needle aspiration cytologic examination. We discuss characteristic sonographic features of thyroid hemangiomas to improve the success rate of preoperative diagnosis. These cases demonstrate that thyroid hemangiomas can be diagnosed correctly by sonography with confirmation of bloody content in the lesion by fine-needle aspiration.
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:729–733 | 0278-4297 | www.aium.org
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 730
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
Case Descriptions Case 1 A 24-year-old woman underwent thyroid sonography for a routine examination. Sonography revealed an angularly shaped hypoechoic lesion in the mid to lower portion of the right thyroid. Within the hypoechoic lesion were numerous linear echogenic septal lines (Figure 1, A and B). Power Doppler examination showed increased blood flow in the lesion (Figure 1C). On fine-needle aspiration, only fresh bloody content was aspirated. The fine-needle aspiration cytologic result was reported as unsatisfactory,
with no follicular cells and only inflammatory cells. These unusual sonographic findings were suggestive of a vascular anomaly such as hemangioma. The patient then underwent computed tomography (CT). Enhanced CT (Figure 1, D and E) showed a strongly enhancing lesion in the right medial thyroid gland that extended posteriorly to the tracheothyroidal recess. The enhancing lesion measured up to 3.2 cm in height on coronal images. We concluded that this lesion was compatible with a thyroid hemangioma. On follow-up sonography after 6 months and 1 year, this lesion showed no interval change. At that time, she underwent a right hemithyroidectomy, and pathologic
A Figure 1. Case 1. A and B, Sonography showed a 3.7 × 1.3-cm angularly shaped hypoechoic lesion (arrows) in the mid to lower portion of the right thyroid. Within the hypoechoic lesion, there were numerous linear echogenic septal lines. C, Power Doppler imaging showed multifocal increased blood flow in the lesion. C and D, Enhanced CT showed a strongly enhancing lesion (arrows) in the right medial thyroid that extended posteriorly to the tracheothyroidal recess. The enhancing lesion measured up to 3.9 cm in height on the coronal image.
D
B
E
C
730
J Ultrasound Med 2014; 33:729–733
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 731
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
examination revealed an approximately 3.8-cm cavernous hemangioma in the thyroid on the surgical specimen. Case 2 A 22-year-old woman was referred to our hospital because of an abnormality detected on sonography at another hospital. She underwent thyroid sonography in our hospital, which showed a 2.1 × 3.3-cm well-defined hypoechoic lesion in her right thyroid with multiple hyperechoic internal linear lines (Figure 2, A and B). Color Doppler images showed multifocal peripheral vascularities within the hypoechoic structure (Figure 2C). An additional 0.6-cm suspicious malignant nodule was found in the lower portion of the right thyroid. Fine-needle aspiration cytologic examination was performed for both lesions. The results for the 0.6cm nodule indicated papillary thyroid carcinoma. During fine-needle aspiration of the 3.3-cm hypoechoic lesion, only bloody content was aspirated, and the cytologic result was unsatisfactory, showing inflammatory cells only. Preoperative CT showed a poorly enhancing lesion with a microlobulated margin in the upper portion of the right thyroid (Figure 2D). The lesion measured 3.2 cm in height (Figure 2E). We performed a total thyroidectomy for thyroid malignancy. After the operation, pathologic examination revealed a 0.8-cm papillary thyroid carcinoma in the right lower thyroid and a cavernous hemangioma in the upper portion of the right thyroid. Histologic examination revealed dilated vascular anatomic channels, a lumen filled with blood cells, and papillary endovascular structures distributed throughout the specimen (Figure 2F).
Discussion Thyroid hemangiomas are extremely rare, and there are only a few cases reported in literature reviews.1–3 Most thyroid hemangiomas are not palpable and are diagnosed incidentally during imaging examinations. A hemangioma is a benign vascular tumor of 2 common types, capillary and cavernous, based on the size of the vessels involved. In most cases, thyroid hemangiomas are secondary to trauma or fine-needle aspiration biopsy. Secondary hemangiomas have been described as pseudomalformations, representing vascular proliferation after organization of a thyroid hematoma.4 Two case reports described exuberant vascular proliferation in the thyroid occurring secondary to fineneedle aspiration.4 Organization of the hematoma generally results in complete resolution, but it can give rise to vascular and fibroblastic proliferative changes that resemble a cavernous hemangioma.4 Our patients had no history of trauma, fine-needle aspiration, biopsy, or other invasive
J Ultrasound Med 2014; 33:729–733
procedures in the neck; therefore, we believe that our cases were primary thyroid hemangiomas. Primary hemangiomas are extremely rare developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals.5 Previous studies reported that preoperative diagnosis of a thyroid hemangioma is difficult because there are no specific pathognomonic findings on sonography, fine-needle aspiration cytologic examination, or even CT. Heterogeneous signal intensity and a serpentine pattern on magnetic resonance imaging are considered highly suggestive of cavernous hemangiomas.6 However, there are a few reports of sonographic findings of hemangiomas in other superficial organs such as the breast. These studies reported that hemangiomas were lobulated, well-circumscribed masses, usually with heterogeneous or complex echogenicity due to the presence of multiple vascular channels and phleboliths.7,8 Our cases of thyroid hemangiomas showed well-circumscribed hypoechoic lesions with internal multiple linear septations on sonography, which were very similar to previously reported sonographic findings of hemangiomas. Another sonographic characteristic of a superficially located hemangioma is the compressibility of the blood-filled lesion unless it is fully thrombosed.9 During the sonographic examinations, our lesions were compressible under the probe, and the lesion volume decreased after the bloody content was aspirated on fine-needle aspiration. We think that these lesions were vascular malformations such as hemangiomas based on the characteristic sonographic findings and confirmation of bloody content during fine-needle aspiration. Innumerable internal septations on sonography may be related to the presence of multiple small vascular channels seen pathologically in hemangiomas, and large blood-filled spaces or sinuses have been previously reported in cavernous hemangiomas.7 Our cases were pathologically confirmed to be cavernous hemangiomas after surgery. Pathologically, cavernous hemangiomas are typically discrete multiloculated lesions containing evidence of hemorrhage in various stages of evolution. They lack smooth muscle and elastic fibers and are lined by a single layer of endothelium and differing quantities of subendothelial fibrous stroma.6 In most reported series, cavernous hemangiomas underwent periodic rapid growth, but in our first case, there was no interval change on follow-up sonography after 6 months or 1 year. Coarse calcifications are often suggested to be a reliable sign of hemangiomas. However, in our cases, there was no sign of calcifications in the lesions on sonography or CT. Fine-needle aspiration cytologic examination seems to be inconclusive in the diagnosis of hemangiomas because it reveals only blood. Multiple fine-needle aspiration biopsies have not been shown to be useful in obtain-
731
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 732
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
Figure 2. Case 2. A and B, Sonography showed an approximately 2.1 × 3.3-cm well-defined hypoechoic lesion (arrows) with internal multiple septations. C, Color Doppler imaging showed multifocal peripheral vascularities within the lesion. D, Enhanced CT showed a poorly enhancing lesion (arrows) with a lobulated margin on the axial image. E, The lesion (arrows) was 3.3 cm in height on the sagittal image. F, Histologic examination of the specimen showed multiple irregular dilated and anastomosed vascular anatomic channels with intraluminal blood cells distributed throughout the specimen, consistent with a hemangioma (hematoxylin-eosin, original magnification ×40). A
E
B
C
F
D
732
J Ultrasound Med 2014; 33:729–733
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 733
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
ing sufficient cellular material. However, we think that confirmation of bloody content by aspiration could be very helpful for preoperative diagnosis of thyroid hemangiomas when combined with characteristic sonographic findings. Core needle biopsy is usually contraindicated in hemangiomas because of the high risk of bleeding,10 but many hemangiomas have been diagnosed by core needle biopsies in intramuscular sites and the breast,8,11 and some authors suggest that core needle biopsy is a safe diagnostic procedure for hemangiomas.11 The definite diagnosis of a thyroid hemangioma is based on histologic findings. Complete surgical excision is usually recommended when a hemangioma is diagnosed. Although there is the widespread perception that preoperative diagnosis of thyroid hemangiomas on sonography is difficult because there are no specific pathognomonic findings, we suggest that a more careful interpretation of sonograms with reference to characteristic imaging findings, such as a well-circumscribed hypoechoic structure with innumerable internal septations, may lead to a precise preoperative diagnosis of a thyroid hemangioma. In addition, although fine-needle aspiration cytologic results are usually insufficient, confirmation of bloody content during aspiration can further support a diagnosis of a thyroid hemangioma. The presence of heterogeneous signal intensity and a serpentine pattern on magnetic resonance imaging is usually considered diagnostic for hemangiomas.12 Other imaging modalities such as single-photon emission CT, digital subtraction angiography, and red blood cell scans can provide additional information in the diagnosis of hemangiomas; however, such examinations are often not performed routinely because of their high cost and nonavailability, as in the cases described here. Accurate preoperative diagnosis allows better preoperative planning, and adequate preoperative characterization is very important because bleeding is common in hemangiomas; in one series,13 intraoperative blood loss was in excess of 2 L. A previous report emphasized the importance of ensuring that the integrity of a thyroid hemangioma is maintained to minimize blood loss during surgery.14 This report describes 2 cases of thyroid hemangiomas that were diagnosed on sonography. These cases demonstrate that thyroid hemangiomas can be diagnosed correctly by sonography with or without confirmation of bloody content in the lesions by fine-needle aspiration.
2. 3. 4. 5.
6. 7.
8.
9.
10. 11.
12.
13. 14.
S. Cavernous hemangioma of the thyroid. Thyroid 2005; 15:1199–1201. Rios A, Rodríguez JM, Martínez E, Parrilla P. Cavernous hemangioma of the thyroid. Thyroid 2001; 11:279–280. Datta R, Venkatesh MD, Nilakantan A, Joseph B. Primary cavernous hemangioma of thyroid gland. J Postgrad Med 2008; 54:147–148. Tsang K, Duggan MA. Vascular proliferation of the thyroid: a complication of fine-needle aspiration. Arch Pathol Lab Med1992; 116:1040–1042. Kumar R, Gupta R, Khullar S, Dasan B, Malhotra A. Thyroid hemangioma: a case report with a review of the literature. Clin Nucl Med 2000; 25:769–771. Agaba EA. Primary cavernous hemangioma of the thyroid gland. South Med J 2010; 103:601. Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the breast: mammographic, sonographic, and MRI appearances. AJR Am J Roentgenol 2005; 184:331–338. Mesurolle B, Sygal V, Lalonde L, et al. Sonographic and mammographic appearances of breast hemangioma. AJR Am J Roentgenol 2008; 191:W17–W22. Fornage BD. Sonography of soft tissue masses. In: Syllabus, Formation Médicale Continue. Vol 2. Paris, France: Formation Médicale Continue: 2007; 751. Colakoğlu O, Taşkiran B, Yazici N, Buyraç Z, Unsal B. Safety of biopsy in liver hemangiomas. Turk J Gastroenterol 2005; 16:220–223. Salzman R, Buchanan MA, Berman L, Jani P. Ultrasound-guided coreneedle biopsy and magnetic resonance imaging in the accurate diagnosis of intramuscular haemangiomas of the head and neck. J Laryngol Otol 2012; 126:391–394. Memis A, Arkun R, Ustun EE, Kandiloglu G. Magnetic resonance imaging of intramuscular haemangiomas with emphasis on contrast enhancement patterns. Clin Radiol 1996; 51:198–204. Pickleman JR, Lee JF, Straus FH II, Paloyan E. Thyroid hemangioma. Am J Surg 1975; 129:331–333. Michalopoulos NV, Markogiannakis H, Kekis PB, Papadima A, Lagoudianakis E, Manouras A. Primary cavernous hemangioma of the thyroid gland. South Med J 2010; 103:674–675.
References 1.
Kumamoto K, Sugano K, Hoshino M, Utsumi Y, Suzuki S, Takenoshita
J Ultrasound Med 2014; 33:729–733
733
CASE SERIES
Thyroid Hemangiomas Diagnosed on Sonography Sung Hee Park, MD, Soo Jin Kim, MD, Hyun Kyung Jung, MD
Primary thyroid hemangiomas are extremely rare, and only a few cases have been previously reported. Primary hemangiomas are developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals. Thyroid hemangiomas are generally considered difficult to diagnose preoperatively because of their low incidence and nonspecific imaging findings. Here we report 2 cases of thyroid hemangiomas that were diagnosed correctly on preoperative sonography. Our cases showed similar sonographic findings, such as well-circumscribed hypoechoic lesions with internal channellike linear lines, and bloody content was aspirated during fine-needle aspirations. Our report shows that thyroid hemangiomas can be diagnosed correctly by sonography with or without confirmation of bloody content in the lesions by fine-needle aspiration. Key Words—computed tomography; fine-needle biopsy; hemangioma; sonography; superficial structures; thyroid; vascular malformations
Received July 15, 2013, from the Department of Radiology, Thyroid Center, Chung-Ang University Hospital, Seoul, Korea (S.H.P., S.J.K.); and Department of Radiology, Inje University Haeundae Paik Hospital, Busan, Korea (H.K.J.). Revision requested August 1, 2013. Revised manuscript accepted for publication August 5, 2013. Address correspondence to Sung Hee Park, MD, Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjakgu, Seoul 156-755, Korea. E-mail: [email protected] Abbreviations
CT, computed tomography doi:10.7863/ultra.33.4.729
H
emangiomas are benign vascular tumors that commonly manifest in childhood, with a predilection to the head and neck regions. Primary hemangiomas of the thyroid glands are extremely rare, and only a few cases have been previously reported. They are developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals. Accurate preoperative diagnosis of thyroid hemangiomas is known to be difficult because of their low incidence and, more importantly, their nonspecific sonographic findings. This report describes 2 cases of thyroid hemangiomas that were diagnosed by sonography and fine-needle aspiration cytologic examination. We discuss characteristic sonographic features of thyroid hemangiomas to improve the success rate of preoperative diagnosis. These cases demonstrate that thyroid hemangiomas can be diagnosed correctly by sonography with confirmation of bloody content in the lesion by fine-needle aspiration.
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:729–733 | 0278-4297 | www.aium.org
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 730
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
Case Descriptions Case 1 A 24-year-old woman underwent thyroid sonography for a routine examination. Sonography revealed an angularly shaped hypoechoic lesion in the mid to lower portion of the right thyroid. Within the hypoechoic lesion were numerous linear echogenic septal lines (Figure 1, A and B). Power Doppler examination showed increased blood flow in the lesion (Figure 1C). On fine-needle aspiration, only fresh bloody content was aspirated. The fine-needle aspiration cytologic result was reported as unsatisfactory,
with no follicular cells and only inflammatory cells. These unusual sonographic findings were suggestive of a vascular anomaly such as hemangioma. The patient then underwent computed tomography (CT). Enhanced CT (Figure 1, D and E) showed a strongly enhancing lesion in the right medial thyroid gland that extended posteriorly to the tracheothyroidal recess. The enhancing lesion measured up to 3.2 cm in height on coronal images. We concluded that this lesion was compatible with a thyroid hemangioma. On follow-up sonography after 6 months and 1 year, this lesion showed no interval change. At that time, she underwent a right hemithyroidectomy, and pathologic
A Figure 1. Case 1. A and B, Sonography showed a 3.7 × 1.3-cm angularly shaped hypoechoic lesion (arrows) in the mid to lower portion of the right thyroid. Within the hypoechoic lesion, there were numerous linear echogenic septal lines. C, Power Doppler imaging showed multifocal increased blood flow in the lesion. C and D, Enhanced CT showed a strongly enhancing lesion (arrows) in the right medial thyroid that extended posteriorly to the tracheothyroidal recess. The enhancing lesion measured up to 3.9 cm in height on the coronal image.
D
B
E
C
730
J Ultrasound Med 2014; 33:729–733
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 731
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
examination revealed an approximately 3.8-cm cavernous hemangioma in the thyroid on the surgical specimen. Case 2 A 22-year-old woman was referred to our hospital because of an abnormality detected on sonography at another hospital. She underwent thyroid sonography in our hospital, which showed a 2.1 × 3.3-cm well-defined hypoechoic lesion in her right thyroid with multiple hyperechoic internal linear lines (Figure 2, A and B). Color Doppler images showed multifocal peripheral vascularities within the hypoechoic structure (Figure 2C). An additional 0.6-cm suspicious malignant nodule was found in the lower portion of the right thyroid. Fine-needle aspiration cytologic examination was performed for both lesions. The results for the 0.6cm nodule indicated papillary thyroid carcinoma. During fine-needle aspiration of the 3.3-cm hypoechoic lesion, only bloody content was aspirated, and the cytologic result was unsatisfactory, showing inflammatory cells only. Preoperative CT showed a poorly enhancing lesion with a microlobulated margin in the upper portion of the right thyroid (Figure 2D). The lesion measured 3.2 cm in height (Figure 2E). We performed a total thyroidectomy for thyroid malignancy. After the operation, pathologic examination revealed a 0.8-cm papillary thyroid carcinoma in the right lower thyroid and a cavernous hemangioma in the upper portion of the right thyroid. Histologic examination revealed dilated vascular anatomic channels, a lumen filled with blood cells, and papillary endovascular structures distributed throughout the specimen (Figure 2F).
Discussion Thyroid hemangiomas are extremely rare, and there are only a few cases reported in literature reviews.1–3 Most thyroid hemangiomas are not palpable and are diagnosed incidentally during imaging examinations. A hemangioma is a benign vascular tumor of 2 common types, capillary and cavernous, based on the size of the vessels involved. In most cases, thyroid hemangiomas are secondary to trauma or fine-needle aspiration biopsy. Secondary hemangiomas have been described as pseudomalformations, representing vascular proliferation after organization of a thyroid hematoma.4 Two case reports described exuberant vascular proliferation in the thyroid occurring secondary to fineneedle aspiration.4 Organization of the hematoma generally results in complete resolution, but it can give rise to vascular and fibroblastic proliferative changes that resemble a cavernous hemangioma.4 Our patients had no history of trauma, fine-needle aspiration, biopsy, or other invasive
J Ultrasound Med 2014; 33:729–733
procedures in the neck; therefore, we believe that our cases were primary thyroid hemangiomas. Primary hemangiomas are extremely rare developmental anomalies resulting from the inability of the angioblastic mesenchyme to form canals.5 Previous studies reported that preoperative diagnosis of a thyroid hemangioma is difficult because there are no specific pathognomonic findings on sonography, fine-needle aspiration cytologic examination, or even CT. Heterogeneous signal intensity and a serpentine pattern on magnetic resonance imaging are considered highly suggestive of cavernous hemangiomas.6 However, there are a few reports of sonographic findings of hemangiomas in other superficial organs such as the breast. These studies reported that hemangiomas were lobulated, well-circumscribed masses, usually with heterogeneous or complex echogenicity due to the presence of multiple vascular channels and phleboliths.7,8 Our cases of thyroid hemangiomas showed well-circumscribed hypoechoic lesions with internal multiple linear septations on sonography, which were very similar to previously reported sonographic findings of hemangiomas. Another sonographic characteristic of a superficially located hemangioma is the compressibility of the blood-filled lesion unless it is fully thrombosed.9 During the sonographic examinations, our lesions were compressible under the probe, and the lesion volume decreased after the bloody content was aspirated on fine-needle aspiration. We think that these lesions were vascular malformations such as hemangiomas based on the characteristic sonographic findings and confirmation of bloody content during fine-needle aspiration. Innumerable internal septations on sonography may be related to the presence of multiple small vascular channels seen pathologically in hemangiomas, and large blood-filled spaces or sinuses have been previously reported in cavernous hemangiomas.7 Our cases were pathologically confirmed to be cavernous hemangiomas after surgery. Pathologically, cavernous hemangiomas are typically discrete multiloculated lesions containing evidence of hemorrhage in various stages of evolution. They lack smooth muscle and elastic fibers and are lined by a single layer of endothelium and differing quantities of subendothelial fibrous stroma.6 In most reported series, cavernous hemangiomas underwent periodic rapid growth, but in our first case, there was no interval change on follow-up sonography after 6 months or 1 year. Coarse calcifications are often suggested to be a reliable sign of hemangiomas. However, in our cases, there was no sign of calcifications in the lesions on sonography or CT. Fine-needle aspiration cytologic examination seems to be inconclusive in the diagnosis of hemangiomas because it reveals only blood. Multiple fine-needle aspiration biopsies have not been shown to be useful in obtain-
731
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 732
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
Figure 2. Case 2. A and B, Sonography showed an approximately 2.1 × 3.3-cm well-defined hypoechoic lesion (arrows) with internal multiple septations. C, Color Doppler imaging showed multifocal peripheral vascularities within the lesion. D, Enhanced CT showed a poorly enhancing lesion (arrows) with a lobulated margin on the axial image. E, The lesion (arrows) was 3.3 cm in height on the sagittal image. F, Histologic examination of the specimen showed multiple irregular dilated and anastomosed vascular anatomic channels with intraluminal blood cells distributed throughout the specimen, consistent with a hemangioma (hematoxylin-eosin, original magnification ×40). A
E
B
C
F
D
732
J Ultrasound Med 2014; 33:729–733
3304jum713-740online_Layout 1 3/19/14 11:35 AM Page 733
Park et al—Thyroid Hemangiomas Diagnosed on Sonography
ing sufficient cellular material. However, we think that confirmation of bloody content by aspiration could be very helpful for preoperative diagnosis of thyroid hemangiomas when combined with characteristic sonographic findings. Core needle biopsy is usually contraindicated in hemangiomas because of the high risk of bleeding,10 but many hemangiomas have been diagnosed by core needle biopsies in intramuscular sites and the breast,8,11 and some authors suggest that core needle biopsy is a safe diagnostic procedure for hemangiomas.11 The definite diagnosis of a thyroid hemangioma is based on histologic findings. Complete surgical excision is usually recommended when a hemangioma is diagnosed. Although there is the widespread perception that preoperative diagnosis of thyroid hemangiomas on sonography is difficult because there are no specific pathognomonic findings, we suggest that a more careful interpretation of sonograms with reference to characteristic imaging findings, such as a well-circumscribed hypoechoic structure with innumerable internal septations, may lead to a precise preoperative diagnosis of a thyroid hemangioma. In addition, although fine-needle aspiration cytologic results are usually insufficient, confirmation of bloody content during aspiration can further support a diagnosis of a thyroid hemangioma. The presence of heterogeneous signal intensity and a serpentine pattern on magnetic resonance imaging is usually considered diagnostic for hemangiomas.12 Other imaging modalities such as single-photon emission CT, digital subtraction angiography, and red blood cell scans can provide additional information in the diagnosis of hemangiomas; however, such examinations are often not performed routinely because of their high cost and nonavailability, as in the cases described here. Accurate preoperative diagnosis allows better preoperative planning, and adequate preoperative characterization is very important because bleeding is common in hemangiomas; in one series,13 intraoperative blood loss was in excess of 2 L. A previous report emphasized the importance of ensuring that the integrity of a thyroid hemangioma is maintained to minimize blood loss during surgery.14 This report describes 2 cases of thyroid hemangiomas that were diagnosed on sonography. These cases demonstrate that thyroid hemangiomas can be diagnosed correctly by sonography with or without confirmation of bloody content in the lesions by fine-needle aspiration.
2. 3. 4. 5.
6. 7.
8.
9.
10. 11.
12.
13. 14.
S. Cavernous hemangioma of the thyroid. Thyroid 2005; 15:1199–1201. Rios A, Rodríguez JM, Martínez E, Parrilla P. Cavernous hemangioma of the thyroid. Thyroid 2001; 11:279–280. Datta R, Venkatesh MD, Nilakantan A, Joseph B. Primary cavernous hemangioma of thyroid gland. J Postgrad Med 2008; 54:147–148. Tsang K, Duggan MA. Vascular proliferation of the thyroid: a complication of fine-needle aspiration. Arch Pathol Lab Med1992; 116:1040–1042. Kumar R, Gupta R, Khullar S, Dasan B, Malhotra A. Thyroid hemangioma: a case report with a review of the literature. Clin Nucl Med 2000; 25:769–771. Agaba EA. Primary cavernous hemangioma of the thyroid gland. South Med J 2010; 103:601. Glazebrook KN, Morton MJ, Reynolds C. Vascular tumors of the breast: mammographic, sonographic, and MRI appearances. AJR Am J Roentgenol 2005; 184:331–338. Mesurolle B, Sygal V, Lalonde L, et al. Sonographic and mammographic appearances of breast hemangioma. AJR Am J Roentgenol 2008; 191:W17–W22. Fornage BD. Sonography of soft tissue masses. In: Syllabus, Formation Médicale Continue. Vol 2. Paris, France: Formation Médicale Continue: 2007; 751. Colakoğlu O, Taşkiran B, Yazici N, Buyraç Z, Unsal B. Safety of biopsy in liver hemangiomas. Turk J Gastroenterol 2005; 16:220–223. Salzman R, Buchanan MA, Berman L, Jani P. Ultrasound-guided coreneedle biopsy and magnetic resonance imaging in the accurate diagnosis of intramuscular haemangiomas of the head and neck. J Laryngol Otol 2012; 126:391–394. Memis A, Arkun R, Ustun EE, Kandiloglu G. Magnetic resonance imaging of intramuscular haemangiomas with emphasis on contrast enhancement patterns. Clin Radiol 1996; 51:198–204. Pickleman JR, Lee JF, Straus FH II, Paloyan E. Thyroid hemangioma. Am J Surg 1975; 129:331–333. Michalopoulos NV, Markogiannakis H, Kekis PB, Papadima A, Lagoudianakis E, Manouras A. Primary cavernous hemangioma of the thyroid gland. South Med J 2010; 103:674–675.
References 1.
Kumamoto K, Sugano K, Hoshino M, Utsumi Y, Suzuki S, Takenoshita
J Ultrasound Med 2014; 33:729–733
733
