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Orthopedic Surgery for Hemangioma Workup

  • Author: Brian J Kistler, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Dec 11, 2014
 

Laboratory Studies

See the list below:

  • If a patient presents with history, physical examination findings, and imaging study findings consistent with hemangioma, no laboratory studies are necessary.
  • For patients with intramuscular hemangiomas who manifest petechiae, easy bruising, or ecchymoses, consider the diagnosis of Kasabach-Merritt syndrome.
    • In Kasabach-Merritt syndrome, a CBC (for hemoglobin, hematocrit, and platelets) and coagulation studies (eg, prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen, fibrinogen degradation products) are recommended for evaluation.
    • Hemoglobin and hematocrit can be decreased if hemorrhage is significant. Platelet counts can fall to 20,000 or less. Coagulation studies reveal that prothrombin time may be mildly elevated. Serum fibrinogen may be decreased, while fibrin degradation products may be elevated.
  • If tumor-induced osteomalacia is suspected based on radiographic findings, check serum calcium, phosphorus, parathyroid hormone, and alkaline phosphatase. Serum calcium will be in the low-to-normal range, marked hypophosphatemia will be present, parathyroid hormone will be within the reference range, and alkaline phosphatase will be elevated.
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Imaging Studies

Intramuscular hemangiomas

See the list below:

  • Radiography [24, 25]
    • Soft-tissue hemangiomas may be seen on radiographs as soft-tissue shadows, although typically they are isodense with muscle.
    • Soft-tissue hemangiomas may cause benign-appearing periosteal reaction, or chronic cortical thickening and remodeling in adjacent bone, as in the image below.
      Cortical thickening of the tibia adjacent to an in Cortical thickening of the tibia adjacent to an intramuscular hemangioma of the leg.
    • Phleboliths within the soft-tissue mass are diagnostic but are not common. These small, round, calcified densities occur within organizing thrombi within the vascular structures of hemangiomas, as in the image below.
      Radiograph showing phleboliths in an intramuscular Radiograph showing phleboliths in an intramuscular hemangioma of the thigh.
  • MRI [24, 25, 26]
    • After plain radiography, an MRI is the imaging modality of choice for soft-tissue hemangiomas, including those of muscle and synovium, as in the image below.
      T1 and T2 MRI images of intramuscular hemangioma o T1 and T2 MRI images of intramuscular hemangioma of the leg. Note the serpentine quality of the vessels and that the hemangioma is high signal on both T1 and T2. This indicates that the hemangioma is predominantly of water density.
    • Hemangiomas show increased signal on both T1- and T2-weighted images, frequently with areas of signal void. These void areas may be indicative of dense fibrous tissue, thrombi, phleboliths, or regions of high flow.
    • The diagnosis of hemangioma may be made with MRI when these signal characteristics are present and when the serpentine pattern of the vascular structures is depicted, usually with interposed fat as well. The margins of hemangiomas range from very infiltrative and irregular to well marginated.
    • Increased signal with gadolinium enhancement also may be helpful in distinguishing hemangiomas from other soft-tissue masses.
  • Angiography [24, 25]
    • Angiography reveals a highly vascular lesion with vessels oriented parallel to one another.
    • The lesions may be high flow or low flow. This distinction between high flow and low flow can be important in treatment decisions, as high-flow lesions are more likely to benefit from embolization than are low-flow lesions.

Synovial hemangiomas [27]

  • Radiography
    • Synovial hemangiomas result in nonspecific changes on plain radiographs, occasionally including a vague soft-tissue density.
    • Erosion of bone is rarely present.
  • MRI
    • MRI is useful in the diagnosis of synovial hemangiomas.
    • The signal characteristics are similar to those of intramuscular hemangiomas (increased signal on T1 and T2, and depiction of vascular structures).
    • In addition, MRI can provide information as to whether a synovial hemangioma is localized and pedunculated or diffuse, as in the image below. This information helps in planning treatment.
      MRI of a pedunculated synovial hemangioma of the k MRI of a pedunculated synovial hemangioma of the knee. (T2 image with time to repetition [TR]=25.4, time to echo [TE]=9.0/1.)
    • Finally, MRI can be used to diagnose other pathologic processes in the differential diagnosis of a synovial hemangioma (eg, meniscal tear).
  • Angiography: This study reveals pooling over the mass, consistent with a vascular process.

Osseous hemangiomas

See the list below:

  • Radiography: Hemangiomas of bone have different radiographic characteristics in different anatomic locations.
    • In the skull, they produce lytic lesions that are well circumscribed and may have a honeycomb appearance. Frequently, fine, radiating striations are present, creating a sunburst or sunray appearance. The cortex often is expanded in the skull.
    • In the vertebral bodies, the parallel vertical trabeculae have a pathognomonic appearance, often referred to as "corduroy cloth," "honeycomb," or "jailhouse" appearance, as in the image below. The cortex is not expanded in the vertebrae.[28]
      Radiograph of a vertebral hemangioma illustrating Radiograph of a vertebral hemangioma illustrating the corduroy or jailhouse appearance of striations.
    • In the long bones, radiographic findings typically are less specific, with a coarse or bubbly appearance. Occasionally, the appearance may be primarily or completely lytic with a sclerotic rim.
  • Computed tomography
    • CT scan occasionally is used in identification of osseous hemangiomas but generally is not used to evaluate soft-tissue hemangiomas.
    • Vertebral body hemangiomas have a distinctive polka-dot appearance on axial CT scan, as in the image below.
      Axial cut on CT scan illustrating the polka dot ap Axial cut on CT scan illustrating the polka dot appearance of an intraosseous vertebral hemangioma.
  • MRI
    • The characteristic MRI appearance is a hyperintense, mottles, or "starburst" signal on T1-weighted and T2-weighted images.
    • Vertebral hemangiomas can be identified by the jailhouse appearance on sagittal sections, as in the 1st image below, similar to that seen on radiographs) and by the polka-dot appearance seen on axial sections, as in the 2nd image below.
      MRI (sagittal cut) illustrating the jailhouse appe MRI (sagittal cut) illustrating the jailhouse appearance of a vertebral hemangioma.
      Axial cut on CT scan illustrating the polka dot ap Axial cut on CT scan illustrating the polka dot appearance of an intraosseous vertebral hemangioma.
    • A study by Cross et al found that characteristic findings associated with vertebral hemangiomas were absent in 35% of plain films, 20% of CT scans, and 48% of MRI scans of aggressive lesions, resulting in an inability to make an accurate diagnosis.[23]
  • Gorham disease – Radiography: Massive osteolysis is evidenced by what appears to be dissolution of a bone or of adjacent bones in which the ends become tapered, as in the image below. The disease is characterized by intramedullary and subcortical radiolucent foci that appear as “patchy osteoporosis.” The disease slowly progresses in an irregular fashion and may evolve into an extraosseous process. It may present as an intraosseous process demonstrating a “scooped-out” appearance of the bony tissue.
    Radiograph of a patient with Gorham disease showin Radiograph of a patient with Gorham disease showing dissolution of bone.
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Diagnostic Procedures

Intramuscular hemangiomas

See the list below:

  • The differential diagnosis for the clinical and radiographic findings associated with intramuscular hemangiomas includes soft-tissue sarcoma. Therefore, when the clinical and radiographic findings are equivocal, biopsy is indicated, as in the images below.
    Low-power view of the histology of an intramuscula Low-power view of the histology of an intramuscular hemangioma. Note the vascular channels.
    High-power view of the histology of an intramuscul High-power view of the histology of an intramuscular hemangioma. Red blood cells are visible within the vascular channels.
  • Biopsy can be performed by needle or open techniques. Excessive bleeding should be anticipated in most cases.

Osseous hemangiomas

See the list below:

  • The most significant entities in the differential diagnosis of hemangioma of bone are osseous angiosarcoma and metastatic disease. [29]
  • As with soft-tissue hemangiomas, when the clinical and radiographic findings are equivocal, biopsy is indicated.
  • Biopsy can be performed by needle or open techniques. [30]
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Histologic Findings

Hemangiomas may have a spectrum of histologic findings.[31] In a simplistic classification schema, hemangiomas can be divided into capillary (small vessel), cavernous (large vessel), and mixed types. Capillary hemangiomas have abundant vessels approximately 10-100 microns in diameter with walls 1-3 cells thick. The vessels tend to run in parallel. There is a single layer of endothelial cells with no shedding and no anaplasia. Cavernous hemangiomas have a similar appearance, but the lumina are bigger. A cellular type also has been described in which a much higher number of cells are present, distinct lumina are still identifiable, and no shedding or anaplasia is seen. There may be smaller areas within a cellular type that resemble capillary hemangiomas.

Using a more refined classification schema, Enzinger and Weiss divide localized hemangiomas into 7 categories, as follows[32] :

  • Capillary hemangioma, including juvenile
  • Cavernous hemangioma
  • Venous hemangioma
  • Arteriovenous hemangioma (racemose hemangioma)
  • Epithelioid hemangioma
  • Hemangioma of granulation tissue
  • Miscellaneous hemangiomas of deep soft tissue (including many of the hemangiomas important to orthopedists, specifically synovial and intramuscular hemangiomas)

Cells within a hemangioma can be stained for factor VIII; positivity indicates that the cells are endothelial. Recently, each of 3 suggested phases of hemangioma development (proliferative, involuting, and involuted) has been defined histochemically and immunohistochemically by a group in New Zealand. Both CD31 and von Willebrand factor stain vascular endothelial cells in tumors of each phase. Proliferating cell nuclear antigen was predominant in the proliferative and involuting hemangiomas, but negligible in the involuting phase. Mast cells were identified predominately in the involuting phase hemangiomas. Vascular endothelial growth factor was identified primarily during the proliferative phase. Basic fibroblast growth factor was identified during the proliferative and early involuting phases. While these studies generally are not necessary for diagnosis, they provide insight into the biology and development of hemangioma.

Electron microscopy can be used to identify Weibel-Palade bodies. Weibel-Palade bodies are rod-shaped, 0.1-0.3 microns in length, and contain parallel tubules that localize factor VIII-associated antigen. They are relatively specific to endothelial cells.

Intramuscular hemangiomas

Intramuscular hemangiomas may be capillary, cavernous, or mixed in type. Intramuscular hemangiomas can be distinguished from skeletal-muscle angiosarcomas because they do not develop the freely anastomosing sinusoidal pattern seen in certain angiosarcomas. In addition, hemangiomas do not have the nuclear pleomorphism and hyperchromatism seen in angiosarcomas. It may be more difficult to distinguish hemangiomas from hemangioendotheliomas, but hemangioendotheliomas may have shedding and cellular atypia. Hemangiomas can be differentiated from angiolipomas by the absence of lipoblasts in hemangiomas.

Synovial hemangiomas

Synovial hemangiomas are of the cavernous type. The matrix between the vessels may be edematous, myxoid, or focally hyalinized. The cells may contain significant amounts of hemosiderin.

Osseous hemangiomas

Most hemangiomas of bone are cavernous, although they may be mixed capillary and cavernous. There may be reactive new-bone formation, which can appear similar to an osteoblastoma. Hemangioendothelioma of bone may be distinguished by a plumper endothelial lining and varying degrees of cellular atypia.

Gorham disease

Histologic findings in Gorham disease can include benign hemangiomatosis, lymphangiomatosis, or sinusoidal channels of vascular or lymphatic origin.[18] The vascular component appears as densely packed fibrovascular tissue at sites of bony destruction and as capillarylike lumens at sites of bone preservation.

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Contributor Information and Disclosures
Author

Brian J Kistler, MD Resident Physician, Depatment of Orthopedic Surgery, State University of New York, Upstate Medical University at Syracuse

Brian J Kistler, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association

Disclosure: Received honoraria from Synthes for speaking and teaching.

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, Society for Experimental Biology and Medicine, Orthopaedic Research Society, Children's Oncology Group, Musculoskeletal Tumor Society, American College of Surgeons, American Medical Association, Connective Tissue Oncology Society

Disclosure: Received research grant from: National Institutes of Health NIAMS; Orthopaedic Research and Education Foundation; Stryker; Cempra; Wright Medical<br/>Received income in an amount equal to or greater than $250 from: Stryker, Inc (Educational travel to Stryker sponsored meetings)<br/>Received royalty from Lippincott, Williams, and Wilkins for editing/writing textbook; Received grant/research funds from Genentech for clinical research; Received grant/research funds from Orthovita for clinical research; Received grant/research funds from National Institutes of Health for clinical research; Received royalty from UpToDate for update preparation author; Received grant/research funds from Wright Medical, Inc. for clinical research.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Sean P Scully, MD 

Sean P Scully, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, Society of Surgical Oncology

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, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern 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, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Experimental Biology and Medicine, Orthopaedic Research Society, Children's Oncology Group, Musculoskeletal Tumor Society, American College of Surgeons, American Medical Association, Connective Tissue Oncology Society

Disclosure: Received research grant from: National Institutes of Health NIAMS; Orthopaedic Research and Education Foundation; Stryker; Cempra; Wright Medical<br/>Received income in an amount equal to or greater than $250 from: Stryker, Inc (Educational travel to Stryker sponsored meetings)<br/>Received royalty from Lippincott, Williams, and Wilkins for editing/writing textbook; Received grant/research funds from Genentech for clinical research; Received grant/research funds from Orthovita for clinical research; Received grant/research funds from National Institutes of Health for clinical research; Received royalty from UpToDate for update preparation author; Received grant/research funds from Wright Medical, Inc. for clinical research.

Acknowledgements

Danielle A Katz, MD Associate 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.

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Cortical thickening of the tibia adjacent to an intramuscular hemangioma of the leg.
Radiograph showing phleboliths in an intramuscular hemangioma of the thigh.
T1 and T2 MRI images of intramuscular hemangioma of the leg. Note the serpentine quality of the vessels and that the hemangioma is high signal on both T1 and T2. This indicates that the hemangioma is predominantly of water density.
MRI (sagittal cut) illustrating the jailhouse appearance of a vertebral hemangioma.
Axial cut on CT scan illustrating the polka dot appearance of an intraosseous vertebral hemangioma.
T1 (time to repetition [TR]=500, time to echo [TE]=15.0/1) and T2 (TR=3000, TE=15/Ef) images of an intramuscular hemangioma of the leg. This hemangioma is dark on T1 and bright on T2 indicating that this hemangioma likely has fat or other nonliquid products within it.
MRI of a pedunculated synovial hemangioma of the knee. (T2 image with time to repetition [TR]=25.4, time to echo [TE]=9.0/1.)
Radiograph of a vertebral hemangioma illustrating the corduroy or jailhouse appearance of striations.
Radiograph of a patient with Gorham disease showing dissolution of bone.
Low-power view of the histology of an intramuscular hemangioma. Note the vascular channels.
High-power view of the histology of an intramuscular hemangioma. Red blood cells are visible within the vascular channels.
 
 
 
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