Vascular Anomalies of the Mediastinum

Abstract

We recently read with interest the case report titled, “Cavernous Hemangioma of the Posterior Mediastinum” by Ampollini and colleagues [1Ampollini L. Carbognani P. Cattelani L. et al.Cavernous hemangioma of the posterior mediastinum.Ann Thorac Surg. 2010; 90: e96Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar], published in The Annals of Thoracic Surgery. In consideration of this article, we would like to make some appropriate comments. Vascular anomalies may be a source of confusion in terms of diagnosis, classification, and treatment. Confusing terminology is still present in the medical literature, despite the classification by Mulliken and Glowacki [2Mulliken J.B. Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics.Plast Reconstr Surg. 1982; 69: 412-422Crossref PubMed Scopus (2603) Google Scholar] that divided vascular lesions into vascular tumors and vascular malformations. This classification was accepted by the International Society for the Study of Vascular Anomalies (ISSVA) in 1992. A common language is needed for the many different medical specialists who are involved in the management of these lesions [3Frieden I. Enjolras O. Esterly N. Vascular birthmarks and other abnormalities of blood vessels and lymphatics.in: Schacner L.A. Hansen R.C. Pediatric Dermatology. 3rd ed. Mosby, St. Louis, MO2003: 833-862Google Scholar]. The term “hemangioma” is used for many red, blue, visceral, and cutaneous vascular lesions. A significant number of patients receive ineffective and potentially harmful treatments based on misdiagnosis. Hemangiomas are common vascular tumors of infancy composed of proliferating endothelial cells, whereas venous malformations consist of dysplastic vessels without the proliferation phase that progressively causes dilatation. The term “cavernous hemangioma” is frequently used to name a venous malformation in adults. Histologic findings in venous malformations consist of large, dilated, blood-filled vessels lined by flattened endothelium, as described in the article by Ampollini and colleagues [1Ampollini L. Carbognani P. Cattelani L. et al.Cavernous hemangioma of the posterior mediastinum.Ann Thorac Surg. 2010; 90: e96Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. We support the diagnosis of venous malformation of the chest wall and not hemangioma for this particular case. Mediastinal hemangiomas are rare and they generally occur in the anterior mediastinum. The majority of children are asymptomatic, with incidental findings on chest roentgenograms. In case of a venous malformation, magnetic resonance imaging shows the lesion to be hyperintense on T2-weighted images and phleboliths may be present. Leaute-Labreze and colleagues [4Leaute-Labreze C. Dumas de la Roque E. Hubiche T. et al.Propranolol for severe hemangiomas of infancy.N Eng J Med. 2008; 358: 2649-2651Crossref PubMed Scopus (1729) Google Scholar] first reported the effect of propranolol on a child with a facial hemangioma. Since then, many more case reports and small cohorts have highlighted the impressive efficacy of propranolol in treating hemangiomas. Sclerotherapy of venous malformations is an effective treatment, although the surgical resection is preferred for localized lesions [5Legiehn G.M. Heran M.K. Venous malformations: classification, development, diagnosis, and interventional radiologic management.Radiol Clin North Am. 2008; 46: 545-597Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar]. ReplyThe Annals of Thoracic SurgeryVol. 92Issue 1PreviewWe appreciated the comment and interest in our article [1] by Fernandez-Pineda and colleagues [2]. They put the emphasis on the different histologic features seen in vascular anomalies of the mediastinum versus cavernous hemangiomas of the mediastinum. As stated by Donnelly and coworkers [3] in 2000, the nomenclature for classifying these lesions is often used interchangeably and most of the time inappropriately. Hemangiomas and vascular malformations are endothelial malformations. The nomenclature used to describe endothelial malformations has been a source of confusion. Full-Text PDF