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Chronic Expanding Hematoma Mimicking Soft Tissue Neoplasm

Akita University School of MedicineAkita, Japan

To the Editor:It is not well known that hematomas, in some instances, can develop slow expansion.¹ In 1980, Reid and Kommareddi² reported a hematoma that had grown over 1 month, referring to it as a chronic expanding hematoma. If a hematoma that is gradually enlarging appears in an extremity or buttock of a patient without any bleeding tendency, soft tissue neoplasms are clinically suspected.^1-10 This retrospective review of our files describes the clinical, radiologic, and pathologic features of this unusual example of hematoma and mentions the differential diagnosis from soft tissue neoplasms.

To identify a chronic expanding hematoma, the following criteria were applied: the hematoma had expanded gradually over 1 month, no neoplastic changes including hemangioma were detected on any histologic sections, and no bleeding tendency was found.² This study was performed in accordance with the guidelines of the Helsinki II declaration. The study describes nine patients (seven male and two female) from 39 to 72 years of age (median, 60 years). In the nine lesions, four each were in the buttock and thigh, and one lesion was in the calf. Of the nine patients, eight had a painless mass, and only one had a painful mass. Fluctuation of the mass was observed in only two cases. All patients noticed that the mass had expanded gradually throughout their clinical course. Each patient had a history of trauma and prolonged symptoms (range, 3 months to 46 years). At presentation, these enlarging lesions were suggestive of soft tissue sarcomas.

In one patient, pieces of the cannon were seen in the radiographs. Two patients had fractures of the mid femur, and one of them had undergone surgery with metal wire fixation. Linear or spotty calcifications were seen in two cases. Computed tomography showed a well-circumscribed lesion consisting of a thick wall with regular high density and contents with various computed tomography attenuation greater than fat and less than muscle. In T1-weighted magnetic resonance images, the mass revealed a well-circumscribed lesion, and the peripheral rim of the lesion showed low signal intensity. Inner content generally had low signal intensity. In T2-weighted images, the peripheral border was observed as a low-signal linear space. In two cases, a protruding mass that originated from the outer border toward the inner space was prominent, and the mass showed low signal intensity in T1-weighted images and irregular high signal intensity in T2-weighted images. The mass was faintly and irregularly enhanced after intravenous administration of gadolinium. Six (67%) of the nine lesions were located on the fascia, two were intramuscular, and one was intermuscular.

Grossly, the maximal diameter of the lesions ranged from 3 to 55 cm, and their shape was ovoid or fusiform. All lesions had a dense fibrous capsule and were generally cystic. Their contents were brown turbid fluid, coagulate-like amorphous material, and granulation tissue. The granulation tissue occasionally protruded toward the inner cystic space, and mimicked a soft tissue sarcoma. Histologically, six of the nine lesions showed a lamellar structure consisting of three zones. The outer zone consisted of dense and collagenous tissue and small vessels. The inner zone was occupied by amorphous and acellular materials. The middle zone consisted of many small eosinophilic amorphous materials, and xanthogranulomatous foreign body reactions. In three of the nine lesions, the middle zone described above was barely detectable and showed a two-layer structure consisting of a collagenous outer layer and an amorphous inner layer. Cholesterin deposition within the xanthogranulomatous reactive tissue and a small focus of calcification on the outer wall was observed in each of four cases. There was no diffuse or prominent calcium deposition suggesting tumoral calcinosis.

Follow-up study revealed that seven of the nine patients had an uneventful clinical course after marginal excision, and two patients developed recurrent lesions. In one of the two recurrent cases, we encountered an initial lesion with a 5-year history of symptoms and a recurrent lesion of only 3 months’ duration. Both lesions histologically revealed a lamellar structure consisting of three zones and showed xanthogranulomatous reactive processes in their middle zones. In another one of the two cases, recurrent swelling appeared 2 months after the surgery and required aspiration twice. The patient had a good clinical course and no recurrent swelling 2 years after the aspiration.

Chronic expanding hematoma of the extremities and buttock should be differentiated from soft tissue neoplasms, since both may present as a painless, slowly expanding mass, and in radiologic findings, several kinds of soft tissue sarcoma commonly reveal hemorrhagic or cystic changes.^11,12 This study revealed several features that may be useful in differentiation. First, soft tissue sarcoma does not have an apparent relationship with trauma, and in contrast, every patient in our series had a history of trauma. Second, the duration of symptoms may be useful. Almost all of our patients had a duration of over 3 years. In addition, the depth of the lesion yields information on differentiation. Six of the nine patients in our series had a lesion on the fascia. On the other hand, soft tissue sarcomas tend to occur in deeper layers and often show invasive features.¹² However, definite confirmation of the differentiation, of course, should be obtained from biopsy. Therefore, we would recommend an immediate biopsy to determine whether the lesion is a neoplasm or only reaction.

REFERENCES

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8. Lovern RE, Bosse DA, Hartshorne MF, et al: Organizing hematoma of the thigh: Multiple imaging techniques. Clin Nucl Med 12: 661-664, 1987[Medline]

9. Mentzel T, Goodlad JR, Smith MA, et al: Ancient hematoma: A unifying concept for a post-traumatic lesion mimicking an aggressive soft tissue neoplasm. Mod Pathol 10: 334-340, 1997[Medline]

10. Aoki T, Nakata H, Watanabe H, et al: The radiological findings in chronic expanding hematoma. Skeletal Radiol 28: 396-401, 1999[Medline]

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12. Enzinger FM, Weiss SW: Soft Tissue Tumors (ed 2). St. Louis, MO: CV Mosby, 1988, pp 861-881

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