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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 65-67

Intramuscular cavernous hemangioma of brachioradialis muscle


Department of Pathology, Santosh Medical College, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India

Date of Submission17-Apr-2022
Date of Decision21-Apr-2022
Date of Acceptance25-Apr-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Mayurika SubodhKumar Tyagi
Department of Pathology, Santosh Medical College, Santosh Deemed to be University, Ghaziabad - 201 009, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sujhs.sujhs_19_22

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  Abstract 


Soft-tissue hemangiomas are a common neoplasm of the angiomatous lesion origin that appear chiefly during childhood and is responsible for approximately 7% of the benign tumors. They are the most common angiomatous lesions that primarily affect women more than men. Intramuscular cavernous hemangiomas are rare in the limbs (0.8% of all hemangiomas), and <20% are mainly found in the head-and-neck region. In general, it is more common in young adults who have suffered from any kind of trauma. The frequency of hemangiomas is higher in the masseter muscle, whereas in very few cases, it is also observed in the buccinator muscle. An 18-year-old male presented at the tertiary care hospital with swelling in the right elbow measuring 1 cm × 1 cm. The swelling seemed to be arising from the right brachioradialis muscle. A benign cyst above the muscle plane was determined on the ultrasound examination. Furthermore, the excision biopsy sample collected for the histopathological examination showed irregularly dilated blood vessels lined with walls of varying thickness within the muscular plane. Based on the microscopic findings, the diagnosis of intramuscular cavernous hemangioma was made. The intramuscular cavernous hemangioma is a rare entity that makes it difficult to diagnose even with radiological investigations.

Keywords: Cavernous, fine needle aspiration cytology, hemangioma, vascular lesion


How to cite this article:
Pathre A, Bajpai M, Singh S, Garg PK, Tyagi MS. Intramuscular cavernous hemangioma of brachioradialis muscle. Santosh Univ J Health Sci 2022;8:65-7

How to cite this URL:
Pathre A, Bajpai M, Singh S, Garg PK, Tyagi MS. Intramuscular cavernous hemangioma of brachioradialis muscle. Santosh Univ J Health Sci [serial online] 2022 [cited 2022 Aug 11];8:65-7. Available from: http://www.sujhs.org/text.asp?2022/8/1/65/351567




  Introduction Top


Abnormal proliferation of blood vessels termed hemangiomas makes up 7% of all benign tumors.[1] Specifically, intramuscular hemangiomas, a rare but important cause of musculoskeletal pain, account for <0.8% of all hemangiomas.[2] In general, hemangioma is characterized by increased endothelial cell turnover that commonly appears after birth, grows rapidly, and then involute over the years. Hemangiomas are divided into five categories, depending on the predominant histology type. These categories include capillary, cavernous, arteriovenous, venous, and mixed type. Out of these categories, capillary hemangiomas are considered the most common type. Even though the growth of new mass with chronic pain is common in most cases, muscle contracture may also present, with the lower extremity being the most common region of involvement.[3],[4] Calcified round soft tissue may be identified on X-ray, termed phleboliths, but the best choice of diagnostic procedure would be magnetic resonance imaging.[5] Conservative management, systemic corticosteroids embolization, radiation, sclerotherapy, and surgery are some of the few treatment options currently used to treat symptomatic intramuscular hemangiomas. Nonoperative treatments may also decrease the symptoms as the malformation involutes; this includes activity modification, compression garments, extremity elevation, nonsteroidal anti-inflammatory drugs, and physical therapy. Therefore, surgical intervention is advisable in cases with rapid growth, experiencing intractable pain, risk of necrosis in the local skin, thrombocytopenia, cosmetic or functional impairment, along with speculation of malignancy.


  Case Report Top


An 18-year-old male reported to us with a right elbow swelling for the past 1 year. The swelling was gradual in onset and presented with minimal pain. Pain is often exacerbated with the exercise of the involved muscle. There was no history of potential trauma and infection. Family history was also noncontributory. On examination, the swelling was 1 cm × 1 cm in size and appeared to be arising from the brachioradialis muscle. The swelling showed mild tenderness with soft to firm in consistency. A provisional diagnosis of fibroma was made. Ultrasonographic examination revealed benign cystic swelling, measuring 1 cm × 0.8 cm, into the muscle plane in the right elbow region with no significant vascularity within and around the lesion giving an impression of a benign lesion.

Fine-needle aspiration cytology (FNAC) was performed twice, which revealed only bloody aspirate confirmed under the microscope and was categorized as unsatisfactory for evaluation. Because of radiology and cytology limitations to provide a conclusive diagnosis, excisional biopsy for histopathological examination was advised. The excision was done under local anesthesia and sent for histopathological examination. The gross specimen showed a solitary soft-tissue mass, soft to firm, bluish-white in color, irregular in shape, and measuring 1 cm × 1 cm × 0.8 cm. Cut section was hemorrhagic. Histopathological examination of the prepared sections showed irregularly dilated blood vessels lined with walls of varying thickness within the muscular plane. Flattened endothelium lining the endothelium was seen [Figure 1] and [Figure 2]. On the comprehensive evaluation of the clinical features, radiology, and cytology, a definitive diagnosis of intramuscular cavernous hemangioma of the right brachioradialis muscle was made.
Figure 1: Shows dilated cyst-like spaces filled with blood (H and E stain, × 100)

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Figure 2: Show irregularly dilated blood vessels lined with walls of varying thickness within the muscular plan (H and E stain, × 400)

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  Discussion Top


Soft-tissue hemangiomas are common neoplasms of benign nature.[6],[7] Angiomatous lesions are the most common type, and they account for 7% of the benign tumors in the general population.[7] Hemangiomas are the most frequently diagnosed in children as soft-tissue neoplasms. Women are more often affected than men. Pain is the main symptom in the majority of the cases, with the lower extremity being the most common region of involvement.[4],[8] Hemangioma is characterized by increased endothelial cell turnover that usually appears after birth, grows rapidly, and then involute over the years. Hemangiomas are divided into five categories, depending on the predominant type of histology. These categories include capillary, cavernous, arteriovenous, venous, and mixed type. Out of these categories, capillary hemangiomas are considered the most common type. They are usually found in the skin, subcutaneous tissue, or vertebral bodies during the first few years of life.[9] Cavernous hemangiomas present with many dilated and congestive vessels with a flattened endothelium. Calcification is common. In the majority of the cases, surgical intervention is required. Arteriovenous hemangiomas present as an abnormal communication between arteries and veins, leading to a variable degree of shunting.[10]

Intramuscular hemangiomas are very rare, accounting for <1% of all hemangiomas. The masseter muscle is the most frequent muscle, accounting for 5% of all intramuscular hemangioma. The first case of intramuscular cavernous hemangioma naming it as an “erectile tumor,” was reported by Liston in 1843.[11] Intramuscular hemangiomas represent congenital vascular malformations developmentally and are considered hamartomatous lesions and thought to arise from abnormal embryonic rests. Another theory suggested their origin could be attributed to the growth of a latent hemangiomatous lesion resulting from trauma.[4],[12] Intramuscular hemangiomas are usually seen in the first three decades of life with no gender predilection. They present as a slow-growing mass without any signs and symptoms indicating its vascular nature. An absence of thrills, bruits, compressibility, pulsation, and overlying skin is also expected.[4] Making a diagnosis of intramuscular hemangioma is quite challenging as they exhibit minimal signs on clinical examination. Even imaging techniques are not very useful and may show more extensive lesions than suspected.[13],[14] These lesions are slow-growing and rarely metastasize, with a more than 9% recurrence rate after surgical removal. Ultrasound is considered the first line of imaging for diagnosis showing high vascularity and abundant blood flow.[14],[15],[16] However, in the present case, ultrasound did not show any features characteristic of the diagnosis. After that FNAC was performed to provide a cytological diagnosis. FNAC was attempted twice. On both the attempts, FNAC yielded only blood which was confirmed microscopically. Due to insufficient cellularity, FNAC smears were categorized as unsatisfactory. Discordance between clinical features, radiology, and cytology to confirm a diagnosis leads to excision biopsy and histopathological examination. Histopathology sections showed characteristic features with irregularly dilated blood vessels lined with walls of varying thickness within the muscular plan. After combining the clinical feature findings and microscopic findings, the final diagnosis of intramuscular cavernous hemangioma was made. On re-evaluation of FNAC smears, it was observed that the blood was indeed fresh blood from the hemangioma and correlated with the diagnosis.


  Conclusion Top


The intramuscular cavernous hemangioma is rare, making it difficult to diagnose even with radiological investigations. However, a comprehensive evaluation of clinical features and pathological investigations aids in the diagnosis. Bloody aspirates in the FNAC in a proper clinical setting may point toward hemangioma diagnosis. Therefore, it should invariably be kept in the differential diagnosis of soft-tissue tumors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors thanks to the patient for giving consent for the case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tang P, Hornicek FJ, Gebhardt MC, Cates J, Mankin HJ. Surgical treatment of hemangiomas of soft tissue. Clin Orthop Relat Res. 2002;399:205-10.  Back to cited text no. 1
    
2.
Allen PW and Enzinger FM.Hemangioma of skeletal muscle. An analysis of 89 cases. Cancer 1972;29:8-22.  Back to cited text no. 2
    
3.
Rai HR, Ballal A, Mohan K, Rajsankar NR. Cavernous haemangioma in the gastrocnemius muscle: A rare presentation in the geriatric age group. Nitte Univ J Health Sci 2014;4:101.  Back to cited text no. 3
    
4.
Dilsiz A, Aydin T, Gursan N. Capillary hemangioma as a rare benign tumor of the oral cavity: a case report. Cases J 2009;2:8622.  Back to cited text no. 4
    
5.
Greenspan A, McGahan JP, Vogelsang P, Szabo RM. Imaging strategies in the evaluation of soft-tissue hemangiomas of the extremities: correlation of the findings of plain radiography, angiography, CT, MRI, and ultrasonography in 12 histologically proven cases. Skeletal radiology 1992;21:11-8.  Back to cited text no. 5
    
6.
Dinehart SM, Kincannon J, Geronemus R. Hemangiomas: evaluation and treatment. Dermatol Surg 2001;27:475-85.  Back to cited text no. 6
    
7.
Olsen KI, Stacy GS, Montag A. Soft-tissue cavernous hemangioma. Radiographics 2004;24:849-54.  Back to cited text no. 7
    
8.
Rai HR, Ballal A, Mohan K, Rajsankar NR. Cavernous haemangioma in the gastrocnemius muscle: A rare presentation in the geriatric age group. Nitte Univ J Health Sci 2014;4:101  Back to cited text no. 8
    
9.
Afsar FS, Oziz E, Hamdioglu Y, Karasoy I, Uguz B. Intramuscular haemangioma of the masseter muscle in a 9-year-old girl. Acta Angiol 2007;13:42-6.  Back to cited text no. 9
    
10.
Doddanna SJ, Dawar G, Rallan NS, Agarwal M. Intramuscular cavernous hemangioma: A rare entity in the buccinator muscle. Indian J Dent Res 2014;25:813-5.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Zengin AZ, Celenk P, Sumer AP. Intramuscular hemangioma presenting with multiple phleboliths: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:e32-6.  Back to cited text no. 11
    
12.
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. 12
    
13.
Buetow PC, Kransdorf MJ, Moser RP Jr, Jelinek JS, Berrey BH. Radiologic appearance of intramuscular hemangioma with emphasis on MR imaging. AJR Am J Roentgenol 1990;154:563-7.  Back to cited text no. 13
    
14.
Aghaghazvini L, Pirouzi P, Rasuli B. Intramuscular cavernous hemangioma of the vastus intermedius muscle with knee joint extension: A Case Report. J Iran Med Counc 2019;2:104-7.  Back to cited text no. 14
    
15.
Ferri E, Pavon I, Armato E. Intramuscular cavernous hemangioma of the sternocleidomastoid muscle: an unusual neck mass. Otolaryngol Head Neck Surg 2007;137:682-3.  Back to cited text no. 15
    
16.
Pritchard DL. Surgical management of common benign soft-tissue tumors. In: Simon MA, Springfield DS, editors. Surgery for Bone and Soft Tissue Tumors. Philadelphia' Lippincott-Raven; 1998. p. 525-40.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]



 

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