intramuscular haemangioma

Hemangioma• The term “haemangioma” is commonly misused to

describe any type of vascular abnormality, including vascular malformation.

• Hassanein et al. revealed in a study that the term was incorrectly used in 71.3% of publications on the PubMed database.

• Haemangiomas are hamartomas or developmental

anomalies in which natural cells (in contrast to neoplasms) are present in abnormal numbers.

Definition

A benign skin lesion consisting of dense, usually elevated masses of dilated blood vessels.

The most common benign soft tissue tumour of infancy and childhood comprising 7% of all soft tissue tumours.

The etiology is unclear but possibly congenital in origin

• Blood vessels are tubes of endothelial cells surrounded by layers of smooth muscle cells and connective tissue proteins, which develop as a result of biochemical signals between the two.

• Sometimes this communication fails and abnormal blood vessels form

Blood Vessel Formation

Types of Hemangiomas

• Strawberry Hemangioma• Cavernous (Deep) Hemangioma• Compound Hemangioma

Strawberry Hemangioma

• strawberry red mark found on 1 out of 10 babies

• consists of small closely packed blood vessels

• 95% disappear by the time the child is 10 years old

Cavernous (Deep) Hemangioma• deeply situated red-blue

spongy mass of tissue filled with blood

• grows rapidly in the first six months of age

• composed of larger, more mature vascular elements

• some of these lesions disappear on their own

Consider Treatment

• Treatment should be considered if the hemangioma….

• ulcerates• bleeds• causes functional impairment• causes infection• grows rapidly and

uncontrollably• causes psychological problems

Treatments of Hemangiomas Medical

• steroid injection

• interferon alfa-2a

Surgical

• resection

• laser

Intramuscular haemangioma

Demography

Intramuscular haemangioma is a rare entity accounting for 0.8% of all haemangiomas.

85% of cases having occurred under the age of 30 years,

30% are seen in lower extremities with quadriceps being the most common muscle involved.

Females are slightly more affected

Etiology

Often linked to trauma but much data exists suggesting a congenital origin.

90% of these lesions are misdiagnosed - often deep seated- extremely variable in size and consistency.

progressively enlarge but never metastasize

Clinical Features Swelling and pain, History of trauma (17%)

Noncompressible mass without bruit Bluish discoloration of overlying skin and superficial

dilated veins. Restriction of joint motion. Aspiration of the mass yields blood (confused with

hematoma in the presence of history of trauma)

Complications of the haemangioma

Functional impairment, Skin necrosis of the overlying skin,Bone erosion, Entrapment of vessels and nerves, Cardiac failure, Thrombocytopenia, and Consumptive coagulopathy (Kasabach-Merritt syndrome)

Investigation

Plain radiographs May appear only as a non-specific soft tissue mass

Shows phlebolith in 25–30% of cases.

Periosteal reaction adjacent to the haemangioma may mimic osteomylitis or bone tumour.

Ultrasonograms reveal complex hypoechoic mass and if phleboliths are present,

acoustic shadowing may also be documented.

MRI - is very promising investigation - helps in diagnosing and defining the location and extent.

Angiography if MRI has not provided sufficient information about the relationship between the tumour and a neurovascular bundle.

Treatment

I. Complete surgical excision of the tumor with a surrounding margin of the normal muscle.17–20% of local recurrence rate reported in the literature which is due to inadequate primary surgical excision rather than histological subtype.

II. Compression sclerotherapy using sclerosing agents- ethanol, polidocanol, hypertonic saline, and sodium

morrhuate

III. Radiotherapy IV. Embolization,V. Laser ablation

Literature Review

• Abstract• Haemangiomas are one of the most common soft tissue tumours comprising

7% of all benign tumours. Vascular malformations are often confused with haemangiomas. The etiology is unknown. They are common in infancy and childhood and females are more commonly affected. These tumours may be superficial or deep, and deeply seated lesions, are difficult to diagnose clinically and hence require radiographic assessment. Deep-seated haemangiomas are usually intramuscular, although intra-articular synovial haemangiomas also occur. The commonest anatomic site is the lower limb.

• Despite their vascular origin, haemangiomas do not metastasize or undergo malignant transformation. Many treatment modalities for the symptomatic haemangioma are available but surgical excision is the preferred treatment. We present an unusual case of a dumb-bell intramuscular haemangioma involving the triceps and extending into the cubital tunnel of the elbow, distinguish between haemangiomas and vascular malformations and emphasize the importance of surgical technique in ensuring ulnar nerve safety.

• Keywords: Cavernous haemangioma, Haemangioma, Triceps, Intramuscular haemangioma

• Abstract• Haemangioma is a common benign soft tissue tumour. Intramuscular

haemangiomas may present as a perceived sporting injury. Magnetic resonance imaging is the investigation of choice. Intramuscular haemangioma should be considered in the differential diagnosis of unexplained pain and swelling in a muscle.

• Haemangiomas are common benign soft tissue tumours, comprising 7–10% of all soft tissue tumours.1 Cutaneous haemangiomas, the most common,1 are usually found in childhood. Intramuscular haemangiomas may present later in life as a cause of persistent symptoms and may present as a perceived sporting injury. Diagnostic ultrasound is an appropriate initial imaging modality for suspected haemangioma, although magnetic resonance imaging is the investigation of choice. Intramuscular haemangioma should be considered in the differential diagnosis of unexplained pain and swelling in a muscle.

• Abstract• Skeletal muscle haemangiomas are uncommon soft tissue tumors; more

than 90% are misdiagnosed initially. They present as chronic pain and swelling in a muscle with or without a history of trauma. Plain X-rays, bone scans, computerized tomography (CT) studies, and angiography studies may not always be specific for this tumor. Diagnostic ultrasound is an appropriate initial imaging modality for suspected haemangioma, although magnetic resonance imaging is the investigation of choice. Many treatment modalities for the symptomatic haemangiomas are available of which surgical excision is the most preferred.

• We present an unusual case of pain, swelling, and restriction of movements in the right knee following an episode of trauma in a 12-year-old boy who was being followed for 1 year by a general practioner and later referred to us. The patient was diagnosed to have intramuscular cavernous haemangioma in the vastus medialis by us for which he was treated by surgical excision and followed for 1 year and found to have no recurrence. The clinical features, radiological picture, pathological histology, diagnostic tools, and treatment options have been discussed.

• Intramuscular haemangioma is a rare entity.

• Differential diagnosis of pain and swelling in a muscle includes intramuscular haemangioma

• Ultrasound can diagnose the lesion but may not be able to delineate its extent

• The treatment of choice is total excision

• Sclerotherapy has a role in the management of intramuscular haemangioma when excision is not possible.

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