eMedicine Specialties > Orthopedic Surgery > Neoplasms

Hemangioma: Treatment

Author: Danielle A Katz, MD, Assistant Professor, Department of Orthopedic Surgery, State University of New York Upstate Medical University
Coauthor(s): Timothy A Damron, MD, David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse
Contributor Information and Disclosures

Updated: Nov 17, 2008

Treatment

Medical Therapy

Intramuscular hemangiomas

Observation is appropriate for asymptomatic or mildly symptomatic hemangiomas of skeletal muscle and bone. If symptoms cannot be managed adequately by activity modification and nonnarcotic analgesics, further treatment may be considered. Embolization may be used to provide symptomatic relief of intramuscular hemangiomas.

When surgical excision is planned, embolization also may be used preoperatively to decrease intraoperative blood loss and postoperative recurrence.21 Excision of symptomatic intramuscular hemangiomas can provide permanent relief. However, because complete excision is required for long-lasting satisfactory results, this treatment option generally is restricted to hemangiomas contained within a single muscle belly. Even so, complete resection is not always possible; when incompletely resected, hemangiomas nearly always recur. In addition, surgery can be associated with large-volume blood loss, even when preoperative embolization is employed.

Laser knife excision of hemangiomas is a technique developed to better control intraoperative bleeding. Preoperative ultrasound-guided hookwire localization may aid in defining the extent of a hemangioma during excision. Radiation has been used to treat soft-tissue hemangiomas in surgically inaccessible or potentially dangerous sites.

Synovial hemangiomas

Local pedunculated synovial hemangiomas are removed surgically, often through an arthroscope. More diffuse lesions may be treated with intra-articular low-dose radiation therapy, open excision, or both when sufficiently symptomatic.

Osseous hemangiomas

Hemangiomas of bone rarely require treatment. If symptoms are significant enough to warrant consideration of treatment, it is important to confirm the diagnosis, as more aggressive neoplasms (eg, metastatic renal cell carcinoma) may masquerade as hemangioma.

Radiation may be considered for symptomatic hemangiomas in surgically inaccessible sites, such as vertebral hemangiomas.22 However, some authors have found that selective arterial embolization is safer and more effective in the treatment of symptomatic vertebral lesions.

Open excision of bone hemangiomas rarely is indicated. One such uncommon indication is to decompress the spinal cord when a vertebral hemangioma is causing neurologic deficits.

Hemangiomatosis

Chemotherapy has been used in the treatment of extensive hemangiomatosis, particularly when the vascular proliferation is life or limb threatening.

Gorham disease

Radiation may help control the progression and symptoms of Gorham disease, and steroids have been used with variable success.

Kasabach-Merritt syndrome

Kasabach-Merritt syndrome is treated with supportive measures, particularly transfusion of platelets.23 Steroids also have been used in the treatment of Kasabach-Merritt syndrome, with some success.

Good results of treatment with pentoxifylline were reported by de Prost et al.24 Pentoxifylline acts to restore blood flow and seems to possess antithrombotic activity as well.

Pharmacologic management with interferon alfa-2a has been attempted at as well. Radiation therapy has had variable success. Surgical resection of the hemangioma often is difficult.

Preoperative Details

Angiography is an important aspect of preoperative planning when the vascular supply of the lesion is in question and when preoperative embolization is considered. Embolization of high-flow lesions may be performed by interventional radiology to decrease intraoperative blood loss and to decrease the risk of postoperative recurrence. Low-flow lesions are not treatable by embolization. Instead, sclerosing agents may be used to decrease blood flow through low-flow hemangiomas.

Intraoperative Details

Surgical excision attempts to achieve a marginal border unless the hemangioma is contained within a single muscle belly that can be excised completely to achieve a wide margin. The rate of local recurrence following wide excision has been reported as less than 10%, whereas local recurrence rates after marginal excision range from 25% to much higher. Meticulous hemostasis is essential in the prevention of postoperative hematoma.

Postoperative Details

Postoperatively, the surgical site is wrapped in a compressive dressing. The patient is required to maintain a minimal level of activity. Both of these measures are instituted to prevent the occurrence of postoperative hematoma.

Follow-up

Follow-up is required to assess symptomatic relief and to monitor for possible recurrence.

For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Bruises.

Complications

In both intramuscular and osseous hemangiomas, hemorrhage can occur spontaneously during biopsy or during surgical resection; such hemorrhages can be massive. Furthermore, hemangiomas typically recur following incomplete surgical excision. Some large hemangiomas may result in shunting of the blood to a degree significant enough to cause congestive heart failure.

Rarely, cord compression and neurologic deficits can result from vertebral hemangiomas. Approximately 30% of patients with Kasabach-Merritt syndrome die from hemorrhage or infection. Osteomalacia is an uncommon complication that has been associated with hemangioma.

More on Hemangioma

Overview: Hemangioma
Workup: Hemangioma
Treatment: Hemangioma
Follow-up: Hemangioma
Multimedia: Hemangioma
References
[ CLOSE WINDOW ]

References

  1. Mulliken JB. Cutaneous vascular anomalies. In: McCarthy JG, May JW Jr, Littler JW, eds. Plastic Surgery: Tumors of the Head & Neck and Skin. Philadelphia:. WB Saunders Co;1990:3191-3223.

  2. Godanich IF, Campanacci M. Vascular hamartomata and infantile angioectatic osteohyperplasia of the extremities. J Bone Joint Surg. 1962;44A:815.

  3. Metry D. Update on hemangiomas of infancy. Curr Opin Pediatr. 2004;16:373-377.

  4. Smolinski KN, Yan AC. Hemangiomas of infancy: clinical and biological characteristics. Clin Pediatr (Phila). Nov-Dec 2005;44(9):747-66. [Medline].

  5. Canavese F, Soo BC, Chia SK, Krajbich JI. Surgical outcome in patients treated for hemangioma during infancy, childhood, and adolescence: a retrospective review of 44 consecutive patients. J Pediatr Orthop. Apr-May 2008;28(3):381-6. [Medline].

  6. Holzapfel BM, Geitner U, Diebold J, Glaser C, Jansson V, Dürr HR. Synovial hemangioma of the knee joint with cystic invasion of the femur: a case report and review of the literature. Arch Orthop Trauma Surg. Aug 30 2008;[Medline].

  7. Melman L, Johnson FE. Intramuscular cavernous hemangioma. Am J Surg. Jun 2008;195(6):816-7. [Medline].

  8. Muramatsu K, Ihara K, Tani Y, Chagawa K, Taguchi T. Intramuscular hemangioma of the upper extremity in infants and children. J Pediatr Orthop. Apr-May 2008;28(3):387-90. [Medline].

  9. Devaney K, Vinh TN, Sweet DE. Skeletal-extraskeletal angiomatosis. A clinicopathological study of fourteen patients and nosologic considerations. J Bone Joint Surg Am. Jun 1994;76(6):878-91. [Medline].

  10. Geschickter CF, Keasbey LE. Tumors of blood vessels. Am J Cancer. 1935;23:568, 591.

  11. Watson WL, McCarthy WD. Blood and lymph vessel tumors. A report of 1056 cases. Surg Gynecol Obstet. 1940;71:569-88.

  12. Mirra JM. Vascular tumors. In: Mirra JM, ed. Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Vol 2. Philadelphia:. Lea & Febiger;1989:1336-1377.

  13. Chang J, Most D, Bresnick S, et al. Proliferative hemangiomas: analysis of cytokine gene expression and angiogenesis. Plast Reconstr Surg. Jan 1999;103(1):1-9; discussion 10. [Medline].

  14. Radhakrishnan K, Rockson SG. Gorham's disease: an osseous disease of lymphangiogenesis?. Ann N Y Acad Sci. 2008;1131:203-5. [Medline].

  15. Price NJ, Cundy PJ. Synovial hemangioma of the knee. J Pediatr Orthop. Jan-Feb 1997;17(1):74-7. [Medline].

  16. Griffin N, Khan N, Thomas JM, Fisher C, Moskovic EC. The radiological manifestations of intramuscular haemangiomas in adults: magnetic resonance imaging, computed tomography and ultrasound appearances. Skeletal Radiol. Nov 2007;36(11):1051-9. [Medline].

  17. Vilanova JC, Barceló J, Smirniotopoulos JG, Pérez-Andrés R, Villalón M, Miró J, et al. Hemangioma from head to toe: MR imaging with pathologic correlation. Radiographics. Mar-Apr 2004;24(2):367-85. [Medline].

  18. Greenspan A, Azouz EM, Matthews J 2nd, Decarie JC. Synovial hemangioma: imaging features in eight histologically proven cases, review of the literature, and differential diagnosis. Skeletal Radiol. Nov 1995;24(8):583-90. [Medline].

  19. O'Connell JX, Kattapuram SV, Mankin HJ. Epithelioid hemangioma of bone. A tumor often mistaken for low-grade angiosarcoma or malignant hemangioendothelioma. Am J Surg Pathol. Jun 1993;17(6):610-7. [Medline].

  20. Enzinger FM, Weiss SW. Soft Tissue Tumors. St. Louis:. Mosby-Year Book;1995:579-626.

  21. Cohen AJ, Youkey JR, Clagett GP, et al. Intramuscular hemangioma. JAMA. May 20 1983;249(19):2680-2. [Medline].

  22. Bremnes RM, Hauge HN, Sagsveen R. Radiotherapy in the treatment of symptomatic vertebral hemangiomas: technical case report. Neurosurgery. Nov 1996;39(5):1054-8. [Medline].

  23. Henley JD, Danielson CF, Rothenberger SS, et al. Kasabach-Merritt syndrome with profound platelet support. Am J Clin Pathol. May 1993;99(5):628-30. [Medline].

  24. de Prost Y, Teillac D, Bodemer C, et al. Successful treatment of Kasabach-Merritt syndrome with pentoxifylline. J Am Acad Dermatol. Nov 1991;25(5 Pt 1):854-5. [Medline].

  25. Beham A, Fletcher CD. Intramuscular angioma: a clinicopathological analysis of 74 cases. Histopathology. Jan 1991;18(1):53-9. [Medline].

  26. Buetow PC, Kransdorf MJ, Moser RP Jr, et al. Radiologic appearance of intramuscular hemangioma with emphasis on MR imaging. AJR Am J Roentgenol. Mar 1990;154(3):563-7. [Medline].

  27. Kenan S, Abdelwahab IF, Klein MJ, Lewis MM. Hemangiomas of the long tubular bone. Clin Orthop. Jul 1992;(280):256-60. [Medline].

  28. Maki DD, Craig-Mueller J, Griffiths HJ. Radiologic case study. Intramuscular hemangioma. Orthopedics. Oct 1996;19(10):916, 907-9. [Medline].

  29. Paley D, Evans DC. Angiomatous involvement of an extremity. A spectrum of syndromes. Clin Orthop. May 1986;(206):215-8. [Medline].

  30. Petasnick JP, Turner DA, Charters JR, et al. Soft-tissue masses of the locomotor system: comparison of MR imaging with CT. Radiology. Jul 1986;160(1):125-33. [Medline].

  31. Pritchard DJ. Surgical management of common benign soft-tissue tumors. In: Simon MA, Springfield D, eds. Surgery for Bone and Soft-tissue Tumors. Philadelphia:. Lippincott-Raven Publishers;1998:534-537.

  32. Rogalski R, Hensinger R, Loder R. Vascular abnormalities of the extremities: clinical findings and management. J Pediatr Orthop. Jan-Feb 1993;13(1):9-14. [Medline].

  33. Sherman RS, Wilner D. The roentgen diagnosis of hemangioma of bone. Am J Roentgenol Radium Ther Nucl Med. Dec 1961;86:1146-59. [Medline].

  34. Sung MS, Kang HS, Lee HG. Regional bone changes in deep soft tissue hemangiomas: radiographic and MR features. Skeletal Radiol. Apr 1998;27(4):205-10. [Medline].

  35. Unni KK. Dahlin's Bone Tumors: General Aspects and Data on 11,087 Cases. Philadelphia:. Lippincott-Raven Publishers;1996:307-316.

  36. Unni KK, Ivins JC, Beabout JW, Dahlin DC. Hemangioma, hemangiopericytoma, and hemangioendothelioma (angiosarcoma) of bone. Cancer. Jun 1971;27(6):1403-14. [Medline].

  37. Weinstein JN, Boriani S, Phillips FM, Wetzel FT. Management of benign tumors of the spine. In: Simon MA, Springfield D, eds. Surgery for Bone and Soft-tissue Tumors. Philadelphia:. Lippincott-Raven Publishers;1998:212-214.

  38. Wenger DE, Wold LE. Benign vascular lesions of bone: radiologic and pathologic features. Skeletal Radiol. Feb 2000;29(2):63-74. [Medline].

  39. Wild AT, Raab P, Krauspe R. Hemangioma of skeletal muscle. Arch Orthop Trauma Surg. 2000;120(3-4):139-43. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hemangioma, benign vascular tumor, senile hemangioma, cherry hemangioma, strawberry nevus, visceral hemangioma, intramuscular hemangioma, hemangioma of the bone, hemangiomatosis, skeletal-extraskeletal angiomatosis, vertebral hemangioma, Kasabach-Merritt syndrome, tumor-induced osteomalacia, Gorham disease, disappearing bone disease, osteolysis, hemangiomatous disease, enchondromatosis, Maffucci syndrome, synovial hemangioma, osseous hemangioma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Danielle A Katz, MD, Assistant Professor, Department of Orthopedic Surgery, State University of New York Upstate Medical University
Danielle A Katz, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American College of Surgeons, and Pediatric Orthopaedic Society of North America
Disclosure: Nothing to disclose.

Coauthor(s)

Timothy A Damron, MD, David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse
Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, Children's Oncology Group, Connective Tissue Oncology Society, Musculoskeletal Tumor Society, Orthopaedic Research Society, and Society for Experimental Biology and Medicine
Disclosure: Lippincott, Williams, and Wilkins Royalty Editing/writing textbook; Genentech Grant/research funds Clinical research; Orthovita Grant/research funds Clinical research; National Institutes of Health Grant/research funds Clinical research

Medical Editor

Timothy A Damron, MD, David G Murray Endowed Professor, Department of Orthopedic Surgery, Professor, Orthopedic Oncology and Adult Reconstruction, Vice Chair, Department of Orthopedics, State University of New York Upstate Medical University at Syracuse
Timothy A Damron, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, Children's Oncology Group, Connective Tissue Oncology Society, Musculoskeletal Tumor Society, Orthopaedic Research Society, and Society for Experimental Biology and Medicine
Disclosure: Lippincott, Williams, and Wilkins Royalty Editing/writing textbook; Genentech Grant/research funds Clinical research; Orthovita Grant/research funds Clinical research; National Institutes of Health Grant/research funds Clinical research

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.