Mesenteric Cavernous Hemangioma

Home , Lymphangioma

Diagnostic and Interventional Imaging (2015) 96, 495—498

RADIOLOGIC PATHOLOGIC CORRELATION /Gastrointestinal imaging

Mesenteric cavernous hemangioma:

Imaging-pathologic correlation

a,∗ b c c

S. Si-Mohamed , S. Aufort , L. Khellaf , J. Ramos ,

d c

P. Gasne , L. Durand

Radiology, 8, rue de l’Herberie, 34000 Montpellier, France

Radiology, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France

Anatomical pathology, Gui-de-Chauliac hospital, 80, avenue Augustin-Fliche, 34295

Montpellier cedex 5, France

Abdominal surgery, clinique du Parc, 50, rue Émile-Combes, 34170 Castelnau-le-Lez, France

Case study

KEYWORDS

Hemangioma; A 50-year old female with no remarkable medical history consulted her doctor because

Mesenteric tumours; of persistent epigastric pain. The clinical examination was unremarkable and laboratory

Magnetic resonance tests were normal.

imaging; Ultrasonography revealed a subumbilical, homogeneous, echogenic mass with an axial

Pathology 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 reg-

ular 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

496 S. Si-Mohamed et al.

Figure 3. Mesenteric cavernous hemangioma. a: fat-

Figure 1. Asymptomatic mesenteric hemangioma in a 50-year-old

suppressedT1-weighted gradient-echo (TR/TE = 3.67/1.85 ms,

woman. CT image of the mid abdomen in the sagittal plane during ◦

ﬂip angle = 10 ) MR image in the axial plane during the enteric

the enteric phase of enhancement shows a well-circumscribed mass

phase shows progressive enhancement with peripheral nodular

of the mesentery (white arrow), with peripheral nodular enhance-

enhancement (arrow); b: fat-suppressed T1-weightedgradient-echo

ment that has narrow channels of communication with the superior ◦

(TR/TE = 3.67/1.85 ms, ﬂip angle 10 ) MR image in the axial plane

mesenteric artery (black arrow) and vein (arrowhead).

during the delayed phase shows persistent enhancement with

centripetal ﬁll-in, greater than during the enteric phase (arrow).

MR imaging showed high signal intensity lesion on T2-

weighted sequences (Fig. 2) and low signal intensity on

diffusion-weighted MR images (B50 and B1000) with no Percutaneous biopsy was not considered in view of the

drop in apparent diffusion coefﬁcient value (ADC = 1.9 * vascularisation of the lesion, difﬁculty of access, and its

10—3 mm /sec) on diffusion-weighted images. The oval relationships to the large mesenteric vessels.

mass also showed regular margins and contained threadlike Surgical resection was thus decided. Intraoperatively, a

formations, which were suggestive of vascular structures mesenteric mass with no extension to the bowel loops was

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

Figure 4. Laparoscopic view. The lesion is located in the mesen-

image in the axial plane demonstrates a lesion with a higher signal

tery without extension to the gastrointestinal tract wall.

intensity than fat, similar to that of a hepatic hemangioma (arrow).

Mesenteric cavernous hemangioma: Imaging-pathologic correlation 497

found (Fig. 4). The mass was resected along with 20 cm of A review of the literature found a few cases of mesen-

the jejunum. teric cavernous hemangioma [5,6]. They do not have any

Histopathological examination of the resected speci- characteristic imaging or histological features. By contrast,

men revealed a well-marginated vascular lesion. The lesion multiple cases of cavernous hemangioma were found in the

was made of multiple dilated cavities lined with ﬂattened liver [1,2], and more rarely in unusual locations including

endothelium with no nuclear atypia that were separated gastrosplenic ligament [7], small bowel [8], colon, and rec-

by septa of ﬁbrous connective tissue. The vessel lumen tosigmoid junction [9].

showed thrombosis and contained numerous red blood A percutaneous biopsy was considered in our patient

cells (Fig. 5). Immunolabelling for CD31, which is vascu- because it is often recommended in hepatic angioma with

lar endothelium-speciﬁc, was positive in the cytoplasm. atypical presentation [10]. However, percutaneous biopsy

It was however negative for the lymphatic endothelial was disregarded because of a deep location and high risk

marker D2-40. Smooth muscle actin marked the smooth of iatrogenic complication. Surgical excision was thus cho-

muscle component of the vessel walls. The lesion was sen, taking into account the possibility of complications such

deﬁnitely diagnosed as a cavernous hemangioma of the as hemorrhage or secondary infection. According to Freeny

mesentery. Follow-up at 1 year showed no recurrence of the et al., the rate of complications linked to size in hepatic

lesion. 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 lymphan-

gioma and mesothelial lesions, from solid masses including

desmoid tumour, solitary ﬁbrous tumour, peritoneal carci-

nosis, 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 compo-

nent. This was conﬁrmed by imaging, with ultrasonography

showing a hyperechoic echostructure, CT demonstrating a

lesion with soft tissue attenuation values, and MRI show-

Figure 5. Photograph shows histopathological features (HE stain, ing an intermediate signal intensity on T1-weighted images

original magniﬁcation 20) of the lesion that contains large cavities with centripetal enhancement after injection of a contrast

ﬁlled with red blood cells and bordered by endothelium resting on

medium and no drop in signal intensity on out-of-phase T1-

an abundant ﬁbrous stroma.

weighted sequences.

When considering only solid tumours, three groups can

be distinguished on the basis of enhancement patterns.

Predominant enhancement during the arterial phase sug-

Discussion gests gastrointestinal stromal tumour, Castleman’s disease,

solitary ﬁbrous tumour, and splenosis nodule. Predominant

The lesion reported showed clinical, radiological and histo- enhancement during the enteric phase, suggests desmoid

logical features similar to those of cavernous hemangiomas tumour, actinomycosis, carcinomatosis nodule or solitary

found in the abdomen including hepatic hemangioma [1,2]. ﬁbrous tumor. Finally, poor enhancement on both suggests

Like these, it was clinically asymptomatic with no internal lymphoma, inﬂammatory pseudotumour or endometriosis.

hemorrhage or infection and no mass effect on adjacent In our patient, the lesion showed predominant enhance-

organs. ment during the arterial phase. However, gastrointestinal

On ultrasonography, the lesion was hyperechoic with stromal tumor is hypervascular and well demarcated, com-

posterior acoustic enhancement. On CT, it demonstrated municates with the bowel loop and shows extraluminal

tissue density and enhancement pattern characteristic of growth. The angioma-type pattern of enhancement and the

angiomas. MR imaging showed no restriction on diffusion- high signal intensity on T2-weighted images were not consis-

weighted images and typical high signal intensity on tent with Castleman’s disease. Our patient had no history of

T2-weighted images similar to typical pattern of heman- trauma, surgery, infection or splenic tumor and the enhance-

giomas. Unusually, a rich vascular component made up of ment pattern was not identical to that of the spleen. In

superior mesenteric vessels is present making it necessary addition, these nodules are found around the gastrosplenic

to excise a portion of the superior mesenteric artery during or splenorenal ligaments or the space around the diaphragm

surgery. so that the diagnosis of splenosis nodule was excluded. Soli-

Histologically, the lesion showed multiple dilated cavi- tary ﬁbrous tumor is usually asymptomatic, until it leads

ties with vessel lumina that showed thrombosis in places to a mass effect. In addition, it is hypervascular with a

and contained red blood cells. CD31 immunolabelling, a necrotic center and tends to present small peripheral ves-

speciﬁc marker for vascular endothelium, was positive sels rather than large- and medium-calibre vessels like in

[3,4]. our patient.

498 S. Si-Mohamed et al.

Conclusion [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.

The diagnosis of mesenteric hemangioma should be consid-

[6] Suga H, Tsuruta O, Ono N, Okabe Y, Masuda J, Wada Y,

ered in the presence of a mesenteric tumor that presents

et al. A case of mesenteric cavernous hemangioma show-

clinical, imaging and pathological features that are identical

ing interestingly image study. Nihon Shokakibyo Gakkai Zasshi

to those of hepatic hemangioma. The diagnosis is deﬁnitely 2005;102(1):31—6.

conﬁrmed by histopathological analysis.

[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.

Disclosure of interest [8] D’Armiento FP, Cardillo M, D’Antonio M, Purri P. Heman-

gioma of the small bowel. Case report. Panminerva Med

The authors declare that they have no conﬂicts of interest 1989;31(3):148—50.

[9] Sylla P, Deutsch G, Luo J, Recavarren C, Kim S, Heimann

concerning this article.

TM, et al. Cavernous, arteriovenous, and mixed hemangioma-

lymphangioma of the rectosigmoid: rare causes of rectal

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