Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 122-124

Intramuscular Cavernous Hemangioma of the Triceps Muscle


1 Department of Orthopaedics, Integral Institute of Medical Science and Research, Lucknow, Uttar Pradesh, India
2 Consultant Orthopaedic Surgeon, Lucknow, Uttar Pradesh, India

Date of Web Publication8-Oct-2015

Correspondence Address:
Anuj Rastogi
Department of Orthopaedics, Integral Institute of Medical Science and Research, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.166937

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  Abstract 

Hemangiomas are one of the commonest benign soft tissue tumors of vascular origin affecting females more than males. Deep soft tissue hemangiomas are uncommon and usually involve skeletal muscles. Intramuscular hemangiomas commonly involve muscles of the lower extremity and rarely the upper extremity. Clinical diagnosis is often missed/delayed as chronic pain and/or swelling are often the only symptoms. We present a case of intramuscular cavernous hemangioma of the triceps muscle in a young male with brief review of literature.

Keywords: Cavernous hemangioma, intramuscular, triceps muscle


How to cite this article:
Rastogi A, Srivastava N, Vijay V, Agarwal S. Intramuscular Cavernous Hemangioma of the Triceps Muscle. Indian J Vasc Endovasc Surg 2015;2:122-4

How to cite this URL:
Rastogi A, Srivastava N, Vijay V, Agarwal S. Intramuscular Cavernous Hemangioma of the Triceps Muscle. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Oct 23];2:122-4. Available from: http://www.indjvascsurg.org/text.asp?2015/2/3/122/166937


  Introduction Top


Hemangiomas are one of the commonest benign soft tissue tumors of vascular origin with unclear etiology, comprising 7% of all soft tissue tumors.[1],[2] Hemangiomas commonly occur in superficial tissues and occasionally in deep soft tissues.[1],[3],[4]

Intramuscular hemangiomas are the most common form of deep tissue hemangiomas, constituting 0.8% of all hemangiomas.[1],[2],[3],[4],[5],[6],[7] They usually involve muscles of the lower extremities.[1],[2],[3],[8] Upper extremity involvement is uncommon and intramuscular hemangioma of the triceps has been rarely reported in the literature.[1],[3],[4],[8]

Clinical diagnosis is often missed as symptoms are usually mild in the form of chronic dull pain with/without swelling. However, diagnosis is usually made after imaging specially magnetic resonance imaging (MRI) which is the investigation of choice. Surgical excision of the mass is the preferred treatment.

We present a case of intramuscular cavernous hemangioma of triceps in a young male that was successfully excised without any complication.


  Case Report Top


A 18-year-male presented with mild pain and swelling over the posterior aspect of the left arm since 3 months. There was no history of trauma, fever, weight loss or anorexia. General examination was normal with no lymphadenopathy. On local examination, there was swelling over left arm posteriorly which was firm, mobile, nonfluctuant, and nontender. Local temperature was normal and pulsations/bruit were absent. Shoulder and elbow movements were normal. Neurovascular status was iintact, and limb length discrepancy was absent.

Laboratory investigations (hemoglobin, total leucocyte count, differential leucocyte count, erythrocyte sedimentation rate, C-reactive protein, liver functions, renal functions, and blood sugar) and chest X-ray were normal. An x-ray of the left arm showed only a soft tissue swelling. MRI of the left arm [Figure 1]a-d revealed a large (64 mm × 71 mm × 197 mm) mass posteriorly showing hypointense signals on T1 and hyperintense signals on T2-weighted images with multiple areas of calcification (phleboliths) suggestive of intramuscular hemangioma. Color Doppler sonography showed large hypoechoic mass with normal flow in vessels.
Figure 1: Magnetic resonance imaging of triceps hemangioma (a and b) showing hyperintense signals on T2-weighted axial section T2-weighted saggital section, respectively. (c and d) Coronal sections showing hyperintense signals on T2 and hypointense signals on T1-weighted images, respectively

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A clinico-radiological diagnosis of deep soft tissue tumor (most likely intramuscular hemangioma) was made.

Surgical excision of the mass was performed. An attempt was made to marginally excise the mass but due to extensive involvement of triceps with increased risk of bleeding, both lateral and medial heads of triceps were removed en-bloc [Figure 2]a,[Fiugre 2]b,[Figure 2]c].
Figure 2: (a-c) Intraoperative photographs – showing medial and lateral heads of the triceps being removed en-bloc

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Diagnosis of cavernous intramuscular hemangioma was confirmed on histopathology that revealed large dilated interconnected vascular channels traversing the striated muscle fibers, fibro-fatty tissues, and vascular lamina filled with red blood cells, pigmented macrophages. There was no evidence of malignancy/dysplasia [Figure 3]. The patient responded well after surgery.
Figure 3: H and E stained histological section of the biopsy showing large dilated interconnected vascular channels (arrow) traversing through the striated muscle fibres and fibrofatty tissues. Vascular lamina filled with red blood cells and pigmented macrophages

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  Discussion Top


Hemangiomas are benign vascular proliferations and one of the commonest benign soft tissue tumors comprising 7% of all soft tissue tumors.[1],[2] They are usually present in infants and children with females being more commonly affected than males.[1],[4] The etiology is unclear but possibly congenital or traumatic in origin.[1],[2],[4],[8]

The term “hemangioma” is often erroneously used synonymously with vascular malformations, which are usually present at birth, grow proportionally with the child and never involute. They may be arterial, arteriovenous, venous, capillary or lymphatic. Hemangiomas have endothelial hyperplasia with multilaminated basement membrane and rapidly grow during infancy.[1]

Histologically hemangiomas are classified based on the predominant type of vascular channel as follows:[1]

  • Capillary hemangioma: Composed of small vessels lined by flattened endothelium. It is the commonest type and subdivided into juvenile, verrucous and senile types
  • Cavernous hemangioma: Composed of dilated, blood-filled spaces, lined by flattened endothelium with abundant adipose tissue. They do not involute as the capillary hemangioma
  • Arteriovenous hemangioma: Consist of fetal capillary bed with abnormal communication between the arteries and veins
  • Venous hemangioma: Composed of thick walled vessels containing muscles.


Hemangiomas commonly occur in superficial tissues and occasionally in deep soft tissues like liver, skeletal muscles, synovial lining, peripheral nerves and rarely bone.[1],[3],[4]

Intramuscular hemangiomas are probably the commonest form of deep tissue hemangiomas, constituting 0.8% of all hemangiomas.[1],[2],[3],[4],[5],[6],[7] They occur commonly in young adults, majority presenting before 30 years.[1],[2],[3],[4],[7] They usually involve muscles of the lower extremity, most frequently the thigh (36%-quadriceps being the commonest) followed by the calf (17%).[1],[2],[3],[4],[8] Upper extremity involvement is uncommon and intramuscular hemangioma of the triceps has been rarely reported in the literature.[1],[3],[4],[8]

Chronic pain and/or swelling are the most common symptoms. Pain is present in 50–60% of cases and often increases with exercise.[2],[3] Local pressure signs in the form of ulnar and median nerve involvement have been reported.[1],[3]

The X-ray shows a soft tissue mass with occasional phleboliths or “venous stones” which are soft tissue calcifications present in 25–30% of cases and are specific for cavernous hemangiomas.[2],[5],[8] Cortical indentations or periosteal reaction may be present due to pressure effects giving an impression of osteomyelitis or bone tumor.[1],[8]

MRI is the diagnostic modality of choice, as it reliably differentiates hemangiomas from malignant tumors and vascular malformations.[2] It helps in characterization of the substance and delineating the extent of hemangioma. On T1-weighted images, hemangioma appears as low signal intensity mass while on T2-weighted images, it shows areas of high signal intensity due to vascular tissue and intermediate signal intensity due to fat. Venous malformations are isotense to surrounding muscle on T1-weighted and hyperintense on T2-weighted images. MRI may also help to differentiate between types of hemangiomas.[1] Lesions with large cystic spaces are cavernous, arteriovenous hemangiomas show fast-flow serpentine vessels while venous hemangiomas show slow-flow serpentine vessels.[1]

Ultrasound and computed tomography-scan are not much reliable. Angiography is occasionally considered to provide fine vascular details and relationship of the mass with a neurovascular bundle.[1],[2]

Diagnosis is usually made following a clinico-radiological examination. As such, a biopsy is rarely needed. However, confirmation requires open/needle biopsy.[2]

Hemangiomas do not metastasize nor do they undergo malignant transformation.[1],[2],[4],[8],[9]

Various treatment options are available for intramuscular hemangiomas. Majority of the hemangiomas often involute with time and may benefit from conservative treatment.[2] However, intramuscular cavernous hemangiomas do not undergo spontaneous regression.[5]

The definitive preferred treatment is surgical excision as it results in better pain relief and function.[7] It is specially indicated during rapid tumor growth, intractable pain, cosmetic/functional impairment or suspicion of malignancy.[2]

Hemorrhage remains the commonest complication after excision.[2] Adequate excision is imperative to prevent recurrence but can result in debilitating complications.

Recurrence rates after excision have been reported between 18% and 61% and is usually because of inadequate excision.[2],[7],[10] Wang et al. reported a recurrence rate of 2.7% by using preoperative ultrasound-guided hookwire localization to enable complete excision of the tumor.[7]

In cases of recurrence, adjuvant therapy (interferon-α) may be considered.[1]

Cases where excision would result in increased morbidity/deformity, embolization, radiation therapy, sclerotherapy or corticosteroids may be beneficial.[2],[8] Embolization can control pain, decrease the blood loss during surgery and to prevent postoperative recurrence.[2]

Other treatment options reported include radium therapy, topical agents (carbon dioxide snow), cryosurgery, and arterial ligation.[2],[7]


  Conclusion Top


Intramuscular hemangiomas are rare in upper extremity and should always be considered in differential diagnosis of cases with chronic extremity pain and/or soft tissue swelling.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Patten DK, Wani Z, Kamineni S. Intramuscular cavernous haemangioma of the triceps. Int J Surg Case Rep 2011;2:86-9.  Back to cited text no. 1
    
2.
Wierzbicki JM, Henderson JH, Scarborough MT, Bush CH, Reith JD, Clugston JR. Intramuscular hemangiomas. Sports Health 2013;5:448-54.  Back to cited text no. 2
    
3.
Shah SA, Hassan F. Intramuscular hemangioma of the triceps muscle. J Surg Pak (Int) 2012;17:40-2.  Back to cited text no. 3
    
4.
Sett TK, Sett T, De S, De A, Bhar A, Basu D. Intramuscular hemangioma of triceps muscle. Indian J Basic Appl Med Res 2014;3:467-71.  Back to cited text no. 4
    
5.
Melman L, Johnson FE. Intramuscular cavernous hemangioma. Am J Surg 2008;195:816-7.  Back to cited text no. 5
    
6.
Wild AT, Raab P, Krauspe R. Hemangioma of skeletal muscle. Arch Orthop Trauma Surg 2000;120:139-43.  Back to cited text no. 6
    
7.
Wang CS, Wu PK, Chiou HJ, Chen CF, Chen WM, Liu CL, et al. Nonpalpable intramuscular hemangioma treated with hookwire localization and excision. J Chin Med Assoc 2014;77:426-9.  Back to cited text no. 7
    
8.
Ly JQ, Sanders TG, SanDiego JW. Hemangioma of the triceps muscle. AJR Am J Roentgenol 2003;181:544.  Back to cited text no. 8
    
9.
Allen PW, Enzinger FM. Hemangioma of skeletal muscle. An analysis of 89 cases. Cancer 1972;29:8-22.  Back to cited text no. 9
    
10.
Beham A, Fletcher CD. Intramuscular angioma: A clinicopathological analysis of 74 cases. Histopathology 1991;18:53-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Intramuscular Hemangioma of the Forearm with Flexion Contracture
Sunyarn Niempoog,Waroot Pholsawatchai
Case Reports in Orthopedics. 2019; 2019: 1
[Pubmed] | [DOI]



 

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