CASE 40
By: Dr. Mai Mattar, MD and Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 23-year-old female with long-standing swelling along the palmar aspect of the hand.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
Plain radiography: there are phleboliths within the soft tissue between the third and fourth digits.
Axial T1 and T2FS and post contrast images demonstrating a well-defined, lobulated soft tissue mass insinuating between and displacing the palmar musculature. The mass is of an intermediate signal on T1, with some interspersed fat. It is bright on T2FS with patchy post-contrast enhancement. There is no osseous involvement.
DIFFERENTIAL DIAGNOSIS:
Soft tissue hemangioma.
Hemangioendothilioma.
Vascular malformations.
Synovial sarcoma.
DIAGNOSIS:
Soft tissue hemangioma.
PEARLS AND DISCUSSION:
Soft tissue hemangiomas are better termed soft tissue venous malformation. Most referring physicians know it as hemangioma.
Females are affected more common than males commonly in the pediatric population.
Various locations, including striated muscle, skin, subcutaneous tissue, and synovium.
Imaging as in our case. Ultrasound can have variable appearance and be ill-defined or well defined hypoechoic mass of heterogeneous echotexture with multiple cystic areas. Color Doppler shows low to weak signal on color Doppler.
CT will show ill-defined mass of similar attenuation to muscle.
MRI shows hemangioma as well-defined lobulated heterogeneous lesions with no local invasion. On T1-weighted images they are intermediate to high signal intensity relative to this surrounding muscle. On T2-weighted images high signal intensity dominate. Gradient echo images in the presence of phlebolith will show a blooming artifact. If gadolinium is administered marked enhancement will occur. Some hemangiomas may be associated muscle atrophic changes.
Rarely, hemangiomas may be associated with other pathologic processes, such as the consumptive coagulopathy of Kasabach-Merritt syndrome and tumor-induced osteomalacia. Gorham disease is a process of massive osteolysis, which is believed to be within the spectrum of hemangiomatous disease. Hemangiomas occurring in the setting of multiple enchondromatosis are part of the spectrum of Maffucci syndrome.
Majority do not require medical or surgical intervention.
Laser surgery, percutaneous image guided treatment, and surgical excisions can be done.
FURTHER READING:
Kaplan PA, Williams SM. Mucocutaneous and peripheral soft-tissue hemangiomas: MR imaging. Radiology. 1987;163 (1): 163-6.
Olsen KI, Stacy GS, Montag A. Soft-tissue cavernous hemangioma. Radiographics. 24 (3): 849-54.
Greenspan A, Mcgahan JP, Vogelsang P et-al. 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 Radiol. 1992;21 (1): 11-8.
