- A 48-year-old HIV-positive female presented with a cough, night sweats, fatigue, and back pain. CT scan revealed scattered ground glass opacities and a 25mm circumscribed left lower lobe nodule. Bronchoscopy and biopsy identified the nodule as a sclerosing hemangioma, a rare benign lung tumor most common in middle-aged women. Sclerosing hemangiomas can present various histological patterns and usually require surgical resection for diagnosis due to their unclear radiographic appearance.

1. Radiology Conference
Dr. Rajiv Malhotra
May 22, 2008

2. History
• 48 yo female who was referred to
pulmonary clinic for an abnormal cxr and
CT scan
• cxr was initially ordered for chest pain,
cough, sputum production and night sweats
• abnormality described as a circumscribed
mass in the left lower lobe, prompted CT
scan

3. Review of Systems
• Positives
• fatigue, back pain, doe w 1/2 flight of
stairs, sob in humid weather, cough,
occasional hemoptysis, occasional night
sweats
• Negatives
• fevers, chills, wt change, wheezing, nausea,
vomiting, diarrhea, reflux, rash, bleeding/
bruising, arthritis

4. History
• PMH
• HIV (cd4 423), htn
• Meds
• atiprla
• hctz 25
• Allergies
• NKDA
• Immun
• flu ‘06, pneumo ‘03

5. History
• FH
• cad
• SH
• neg tob, etoh
• neg drugs
• neg pets
• no exposures
• PPD
• neg 7/07

6. Exam
• 5’3”, 226#, 81, 136/74, 94%RA
• no lad, no bruits
• wheezing sup segment left lower lobe
• rrr, +s1/s2, no m/g/r
• soft nt, no g/r/r
• skin without lesions
• no c/c/e
• Labs - no sig findings

7. Chest CT

8. Chest CT

9. Chest CT

10. Chest CT

11. Chest CT

12. Chest CT

13. Chest CT

14. Chest CT

15. Chest CT

16. Summary
• 48 yo HIV+ female with a CD4 count of
423, c/o of productive cough, night sweats,
fatigue, back pain and doe. CT scan w/
scattered ground glass opacities and left
lower lobe 25mm circumscribed nodule
• Differential??

17. Differential
• Infectious
• pcp, viral pneumonia, atypical pneumonia,
fungal, MAC
• Malignancy
• papillary adeno, bac, carcinoid,
hamartoma, hemangioma, AVM,
angiosarcoma

18. Bronchoscopy
• bronch revealed no airway abnormalities,
no lesions and no secretions, some
erythema anterior basal and medial basal
segments LLL
• BAL and brushings performed in LLL
• brushing/washings - no malignant cells,
hemosiderin-laden macrophages
• gram stain, afb, fungal cx, viral cx - neg
• resp cx - mixed resp flora

19. Thoracic Surgery
• Left VATS and wedge resection
• obvious nodule as lung decompressed,
described as a round, discrete rubbery
mass

20. Pathology
• Gross Description
• smooth pleural surface without fibrosis
or dimpling
• subpleural consolidation
• Immunochemistry
• EMA,Vimentin positive
• CD31 scattered positivity
• HMB-45, CK AE1/AE3 and CD68
negative

21. Sclerosing Hemangioma
• originally described in 1956 by Liewbow
and Hubbell and called sclerosing
hemangioma
• considerable debate regarding the cellular
origin
• currently believed to be alveolar
pneumocytes
• nomenclature may be inaccurate

22. Sclerosing Hemangioma
• predominantly affects females with a mean
age of 42 years old, although most patients
are over 50
• commonly right-sided
• usually asymptomatic, but some present
with hemoptysis, cough, chest pain, dyspnea
and back pain

23. Sclerosing Hemangioma
• usually subpleural, well-defined,
circumscribed hemorrhagic nodule
• four histological patterns; solid,
hemorrhagic, papillary and sclerotic
• usually contain a mixture of at least three
of these patterns

24. Sclerosing Hemangioma
• solid
• papillary
• hemorrhagic
• sclerotic

25. Sclerosing Hemangioma
Solid Pattern
• large nests and
sheets of round cells
• cuboidal cells
expressing
cytokeratin

26. Sclerosing Hemangioma
Papillary Pattern
• closely packed round
cells lined by
cuboidal cells similar
to solid pattern
• surface cells express
surface protein B
• stromal cells express
vimentin

27. Sclerosing Hemangioma
Hemorrhagic Pattern
• large dilated blood-
filled spaces/channels
• round cells are found
within the
interstitium

28. Sclerosing Hemangioma
Sclerotic Pattern
• collagenous fibers
and infiltration of
inflammatory cells

29. Sclerosing Hemangioma
• originally thought to be of endothelial
origin, hence the nomenclature
• other proposed histogenesis; mesothelial
and mesenchymal
• recent immunohistochemistry supports
epithelial origin

30. Sclerosing Hemangioma
• overall classified as a benign primary
pulmonary tumor
• although rare cases of lymph node mets
have been demonstrated
• current literature supports thoracotomy
with wedge resection
• if intraoperative frozen section is
inconclusive anatomic resection with
systemic lymph node dissection is
recommended

31. References
• Spencer’s Pathology of the Lung. New York, NY: McGraw-Hill, 1996
• Liebow AA, Hubbell DS. Sclerosing hemangioma (histiocytoma,
xanthoma) of the lung. Cancer 1956; 9: 53-75.
• Jungraithmayr W et al. Sclerosing hemangioma of the lung: A benign
tumor with potential for malignancy? Ann Thorac Cardiovasc Surg 2006;
12: 352-354.
• Iyoda A et al. Clinicopathological analysis of pulmonary sclerosing
hemangioma. Ann Thorac Surg 2004; 78: 1928-1931.
• Kitagawa H et al. Sclerosing hemangioma of the lung with cystic
appearance. Jpn J Clin Oncol 2003; 33: 360-363.
• Lee S et al. Bilateral multiple sclerosing hemangiomas of the lung.
Chest 1992; 101: 573-573.
• Mori, Shyunichi. Sclerosing hemangioma of the lung. Dis Chest 1968; 54:
71-74.