Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Hemangioma
Hemangioma
Frank J. Frassica MD
BasicsDescription
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This benign tumor of vascular origin usually affects the skeletal system, but it also may occur in the soft tissues (1,2).
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Found in all age groups, this tumor most commonly is diagnosed in the middle decades of life.
Epidemiology
Incidence
This tumor is uncommon.
Prevalence
No substantial gender difference has been noted.
Risk Factors
None are known.
Genetics
No known correlation exists.
Etiology
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The cause is unknown.
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Hemangioma is considered a benign lesion without metastatic potential.
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Many pathologists consider it a hamartoma, rather than a true neoplasm.
DiagnosisSigns and Symptoms
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It may present with local pain and swelling of insidious onset and indolent progression.
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Soft-tissue hemangioma often presents without pain but with intermittent swelling.
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Occasionally, pathologic fracture may be the initial presentation.
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Hemangioma in the vertebra may lead to vertebral collapse, with local pain and neurologic findings.
Physical Exam
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When palpated, soft-tissue hemangiomas have a fluctuant or springy feel.
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They are composed of a large number of blood vessels, which compress when palpated and then refill with blood.
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Hemangiomas often increase in size when the limb is placed in the dependant position.
Tests
Lab
No diagnostic serum tests
Imaging
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Soft tissue:
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Lesions in the soft tissue may erode the adjacent bone and may show characteristic “phleboliths” on radiographs.
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These lesions are easily confused with a variety of other lesions.
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Soft-tissue hemangiomas are best imaged with gadolinium contrast-enhanced MRI.
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Round, vascular channels that have a serpiginous shape and that enhance
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Contain large amounts of fat
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Bone:
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Lesions frequently are multiple, expansile, and trabeculated and show little periosteal reaction.
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The typical radiographic appearance is osteopenia, with parallel vertical streaks described as a “corduroy cloth” appearance.
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The radiographic appearance is variable, from “soap bubble” to purely lytic appearance.
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Multiple lesions and the lack of periosteal reaction may provide clues to the diagnosis.
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Pathological Findings
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Tumors are grossly bloody and traversed by bony trabeculae.
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Microscopically, conglomerates of thin-walled capillaries filled with red cells typically are seen.
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Lymphatics also may be prominent.
Differential Diagnosis
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Myeloma
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Infection
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Bone cyst
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Malignant primary bone neoplasm
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Metastatic disease
P.173
TreatmentGeneral Measures
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Soft-tissue hemangiomas can recur after surgical excision.
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Surgery should be avoided when possible.
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Compressive dressings can aid in nonoperative treatment.
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Sclerosing therapy (using alcohol) is the preferred method of treatment.
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Hemangiomas of bone seldom need surgical treatment.
Special Therapy
Physical Therapy
Not indicated.
Surgery
Surgery should be avoided unless biopsy is needed.
Follow-upPrognosis
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Good overall
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Recurrence not uncommon
Complications
Pathologic fracture
Patient Monitoring
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Patients with bone lesions seldom need treatment unless pathologic fracture occurs.
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Soft-tissue lesions are monitored with serial physical examinations and MRI scans every 3–6 months.
References
1. McCarthy
EF, Frassica FJ. Primary bone tumors. In: Pathology of Bone and Joint
Disorders: With Clinical and Radiographic Correlation. Philadelphia: WB
Saunders, 1998:195–275.
EF, Frassica FJ. Primary bone tumors. In: Pathology of Bone and Joint
Disorders: With Clinical and Radiographic Correlation. Philadelphia: WB
Saunders, 1998:195–275.
2. Weiss
SW, Goldblum JR. Benign tumors and tumor-like lesions of blood vessels.
In: Weiss SW, Goldblum JR, eds. Enzinger and Weiss’s Soft Tissue
Tumors, 4th ed. St. Louis: Mosby, 2001:837–890.
SW, Goldblum JR. Benign tumors and tumor-like lesions of blood vessels.
In: Weiss SW, Goldblum JR, eds. Enzinger and Weiss’s Soft Tissue
Tumors, 4th ed. St. Louis: Mosby, 2001:837–890.
MiscellaneousCodes
ICD9-CM
228.0 Hemangioma
Patient Teaching
Patients with soft-tissue lesions are instructed to avoid provocative activities such as prolonged standing.
FAQ
Q: Is surgery necessary for soft-tissue hemangiomas?
A: Surgery usually is not necessary or effective. Local recurrence is common after surgical treatment.
Q: Is a biopsy necessary to establish the diagnosis of intramuscular hemangioma?
A:
Most intramuscular hemangiomas have characteristic features on MRI scan
so that biopsy is not necessary to establish the diagnosis.
Most intramuscular hemangiomas have characteristic features on MRI scan
so that biopsy is not necessary to establish the diagnosis.