Review Question - QID 213920

This patient has findings consistent with an incidental (non-symptomatic) intramuscular hemangioma. The first line of treatment for these lesions, if asymptomatic, is observation.

Intramuscular hemangiomas are a type of benign vascular neoplasm. They are commonly found deep within the musculature of the lower extremity, and most commonly are found in patients <30 years old. On MRI, these lesions demonstrate increased signal uptake on both T1 and T2-weighted sequences. Microscopic evaluation is dominated by vascular dilations with large collections of erythrocytes. Initial treatment, especially for incidentally found lesions, consists of observation and supportive therapy. For those patients with symptomatic lesions, sclerotherapy or embolization may be considered. Lastly, resection can be considered for recalcitrant lesions. Marginal resection is typically used for smaller lesions, like those found in the hand, whereas, wide resection is reserved for those with a large soft tissue envelope.

Lidsky et al. reviewed their treatment algorithm for vascular malformations using a multidisciplinary approach. They reported on the different outcomes of conservative care, sclerotherapy, embolization, and surgical resection. They concluded that a multidisciplinary approach to these lesions and employing multiple treatment modalities lead to favorable outcomes.

Goldenberg et al review a unique medical treatment using sirolimus for a complex vascular malformation. They report on a large unresectable lesion, that after the treatment with sirolimus, was small enough to be removed. They conclude that medical therapy should be considered in initially unresectable cases.

Khurana et al review transarterial embolization for the treatment of vascular malformations. They report on the importance of classifying the morphologic structure of the vascular lesion prior to choosing a treatment path. They conclude that even in patients with a non-inclusive nidus, there is value in embolization, as it decreases the high-flow nature of the lesion.

Figure A is the coronal T1-weighted MRI of an intramuscular hemangioma. Figure B is an axial T2-weighted image of this same lesion. Figure C is a low powered microscopic view of a hemangioma demonstrating many dilated collections of erythrocytes.

Incorrect Answers:
Answer 2: Radiation therapy is used for the definitive control of primary malignant bone tumors, as an adjuvant for soft tissue sarcomas, and for palliative treatment of metastatic bone lesions.
Answer 3: Chemotherapy ultimately causes cell apoptosis and is utilized for malignant lesions, not benign intramuscular hemangiomas.
Answer 4: Wide surgical resection is reserved for symptomatic intramuscular hemangiomas that are resistant to nonoperative management.
Answer 5: Marginal resection is the treatment for small soft tissue hemangiomas in the hand that fail conservative treatment.