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Hemangioma of Soft Tissue

- See:
     - Calcinosis:
     - Hemangioma of bone

- Discussion:
    - a benign, vascular tumor that occurs in children, usually in limbs or trunk;
    - hemangioma may be congenital, appearing as solitary tumor that infiltrates local tissue & adjacent neurovascular structures;
    - most common form of hemangioma has infiltrative margins composed of both large and small vessels;
    - most common soft tissue lesions in children are vascular in origin;
    - despite their vascular origin, hemangiomas do not metastisize or undergo malignant transformation;
    - with age, growth of hemangioma will slow and in many cases regress by ages 5-7 years;
    - Kasabach-Merritt syndrome:
          - life threatening syndrome in which hemangiomas occur with thrombocytopenia;
    - diff dx:
           - AV malformations:
                    - ultrasound should help distinguish AVN from hemangioma;
           - Venous Malformations:
                    - may be present at birth but often are not noticed until 1 year of age;
                    - they engorge when dependent, decompress when elevated, & enlarge with trauma, puberty, pregnancy, or use of OC;
           - synovial sarcoma
    - specific types of hemangioma:
           - capillary (small vessel) hemangiomas:
                    - non invasive & usually smaller & more cellular than cavernous hemangiomas;
                    - superficial "strawberry lesion" or deeper blue lesion that proliferates and grows faster than the child by 2 months of age;
                    - this superficial form often does not show deep soft tissue swelling;
                    - shows spontaneous involution by 4-5 yrs of age;
           - cavernous hemangiomas:
                    - invasive tumors which often manifest as a deep soft tissue mass, often involving the thigh;
                    - intramuscular hemangiomas may engorged with blood during activity sometimes causing pain, and in contrast, w/ rest the 
                           swelling and pain abate;
                    - may contain calcifications or phleboliths (seen on x-ray);
                    - check for palpable thrill or audible bruit;
                    - superficial skin changes are often not present;
           - synovial hemangioma:
                    - occurs mainly in the knee and presents as recurrent painful monoarticular hemarthrosis;
                    - mass may diminish in size with elevation;

- Clinical Presentation:
    - look for firm mass, that may demonstrate reddish or blue color depending on tumor depth;
    - mass may vary in size and may become larger (and more painful) w/ physical activity, or w/ standing but may reduce in size (and become 
           less tender) once the patient is flat on the examining table;
           - size will not reduce with simple elevation;
    - look for associated dilated adjacent veins;
    - some patients may demonstrate intermittent bleeding and ulceration;
    - hand:
           - capillary and cavernous
           - not seen at birth, rapid growth, slow involution;
           - starts as small reddish spot & grows to raised lesion
           - most disappear by age 8 (in constrast vascular type hand masses which appear during adulthood will not be due to hemangioma);
           - may ulcerate
           - treatment: supportive, non-operative, expect regression;

- Radiographs:
    - ossification of soft tissue is a characteristic finding;
            - check for phleboliths (smooth, round radiodense areas) and/or periosteal thickening of nearby bone;
                   - phleboliths may also be seen in vascular malformations;
    - venography:
            - best test for showing caverous spaces of hemangioma is venography;
    - bone scans:
            - show little or no increase in radioisotope uptake;
    - MRI:
            - MRI is superior to CT for imaging lesion from surrounding normal tissue;
            - presence of fat & serpentine blood vessels provides distinctive appearance;
            - shows markedly increased signal on T1 images & T2 images;
            - hemorrhage & thrombosis can also cause increase in signal on T1-images;


- Treatment:
    - in most patients non operative treatment is appropriate;
    - patients are provided w/ compression stockings;
    - embolization may be an option for some patients;
    - localized or systemic steroids may be helpful in some cases;
    - in the report by Tang P, et al (2002), the authors report on 89 patients with soft tissue hemangiomas collected over a 20 year period;
          - the authors note that intralesional or marginal excision for symptomatic hemangiomas yielded satisfactory results for pain relief, functional
                 recovery, and avoided recurrence;
          - the authors felt that a hemangioma of the soft tissues is a benign lesion in which more aggressive surgery (wide or radical excision)
                 or other modalities such as radiation usually are not warranted 
           - Surgical treatment of hemangiomas of soft tissue.
    - aggressive stage 3 tumor:
          - requires en bloc wide marginal excision;
          - excision with a smaller margin is associated w/ recurrence rate of 30%

Malignant hemangioendothelioma of bone.

Skeletal changes associated with vascular malformations.

Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment.

Orthopaedic treatment of hemangiomatous hypertrophy of the lower extremity.

Distinguishing Soft-Tissue Hemangiomas From Vascular Malformations Using Technetium-Labeled Red Blood Cell Scintigraphy.

Synovial haemangioma of the knee joint: diagnosis by arthroscopy.

Soft tissue hemangioma is a common soft tissue neoplasm. Eur J Radiol 2004;49:179-181.

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