Updated: 2/27/2019

Hemangioma of Soft Tissue

Topic
Review Topic
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https://upload.orthobullets.com/topic/8069/images/benign cavernous hemangioma x-ray.jpg
https://upload.orthobullets.com/topic/8069/images/clinical image of hand hemangioma.jpg
https://upload.orthobullets.com/topic/8069/images/clinical image of cavernous hemangioma.jpg
https://upload.orthobullets.com/topic/8069/images/hemangioma mri forearm.jpg
https://upload.orthobullets.com/topic/8069/images/Case A - pelvis invasion - parsons_moved.png
https://upload.orthobullets.com/topic/8069/images/gross image of hemangioma.jpg
Introduction
  • Benign vascular neoplasm in soft tissue
    • may be cutaneous, subcutaneous, or intramuscular
    • capillary (superficial) or cavernous (deep)
  • Epidemiology
    • incidence
      • males and females incidence is equal
      • <1% of all benign vascular tumors
    • demographics
      • more common in patients <30 years of age
    • location
      • intramuscular is commonly found deep in the lower extremities
      • most commonly found as isolated lesions, except for diffuse hemangioma, a rare childhood form which extensively involves a single limb
      • common in the hand 
  • Pathophysiology
    • caused by an error in the new formation of a segment of the vascular system
    • hormones may play role in modulation
    • 20% are associated with trauma
  • Prognosis
    • infantile hemangiomas involute by age 7
    • no incidence of malignant transformation
Presentation
  • Symptoms
    • pain of variable intensity depending on activity level
    • symptoms of vascular engorgement if hemangioma is large
      • aching
      • heaviness
      • swelling
  • Physical exam
    • examine patient in both supine and standing position
      • lower extremity lesions will fill up after several minutes of standing q
    • inspection
      • mass of variable size depending on activity level 
Imaging
  • Radiograph
    • may show small phleboliths (calcifications) inside the lesion q 
    • erosion into adjacent bone
  • MRI with gadolinium 
    • differentiates these benign lesions from arteriovenous malformations and angiosarcomas
    • increased signal on T1- and T2- weighted images
    • focal areas of low-signal are a sign of blood flow or calcifications
    • heterogeneous lesion with numerous small blood vessels and fatty infiltration (bag of worms
Studies
  • Histology 
    • gross 
      • varies depending on whether it is capillary type or cavernous type
      • color spectrum varies from red to tan to yellow
    • micro 
      • no malignant cells noted by cellular pleomorphism noted
      • many vascular dilations with large nuclei filled with erythrocytes 
      • vascular lumens infiltrated with muscle fibers (intramuscular type)
      • cavernous shows large vessels with lots of fatty tissue
Differential
  • Other vascular malformations
    • arteriovenous malformations
    • cavernous hemangiomas
    • angiomatosis
    • vascular ectasia
  • Sarcoma
    • important to distinguish from sarcoma
Treatment
  • Nonoperative
    • observation, NSAIDS, vascular stockings, and activity modification
      • indications
        • first line of treatment
        • childhood lesions
    • sclerotherapy or embolization
      • performed by interventional radiology (IR)
      • indications
        • large, painful lesions that fail NSAID and vascular stockings therapy
  • Operative
    • marginal excision
      • indications
        • small lesions of the hand
    • wide surgical resection 
      • indications
        • lesions resistant to nonoperative management
      • outcomes
        • high incidence of local recurrence
Complications
  • Kasabach-Merritt syndrome
    • rare complications caused by entrapped platelets leading to a possbly fatal coagulopathy
 

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Questions (4)
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(OBQ06.119) A 17-year-old male presents to your office with hand swelling and intermittent pain. His pain occurs when his hand is held in a dependent position or when he is swimming. While he was born with a birthmark on his hand, he has noticed it is progressively getting bigger. Clinical photograph, radiographs, and histology are shown. What is the most likely diagnosis? Review Topic

QID: 305
FIGURES:
1

Synovial sarcoma

1%

(13/2108)

2

Epitheliod sarcoma

5%

(95/2108)

3

Angiosarcoma

21%

(445/2108)

4

Benign hemangioma

73%

(1538/2108)

5

Giant cell tumor of tendon sheath

1%

(12/2108)

L 2

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(OBQ04.13) A 30-year-old female presents with a painful posterior knee mass. The mass gets larger and more painful with activity. Examination reveals a boggy soft tissue mass about her knee. Radiograph and MRI are shown in Figures A and B. What is the most likely diagnosis? Review Topic

QID: 124
FIGURES:
1

Synovial sarcoma

22%

(338/1561)

2

Hemangioma

54%

(842/1561)

3

Lipoma

2%

(39/1561)

4

Parosteal osteosarcoma

2%

(27/1561)

5

Pigmented villonodular synovitis (PVNS)

20%

(307/1561)

L 3

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