AJR 2003; 181:544
© American Roentgen Ray Society
Radiologic–Pathologic Conference of Wilford Hall Medical
Center |
Hemangioma of the Triceps Muscle
Justin Q. Ly1,
Timothy G. Sanders1 and
Jerry W. SanDiego2
1 Department of Radiology and Nuclear Medicine, Wilford Hall Medical Center,
Ste. 1, 2200 Lackland AFB, TX 78236-5300.
2 Department of Pathology, Wilford Hall Medical Center, Bergquist Dr., Lackland
AFB, TX 78236-5300.
Received September 23, 2002;
accepted after revision December 24, 2002.
Address correspondence to J. Q. Ly.
The opinions and assertions expressed herein are the private views of the
authors and are not to be construed as official or as representing the views
of the Air Force or the Department of Defense.
A27-year-old woman presented with an intermittent dull, aching pain in her
left upper arm. Conventional radiography of the left upper extremity was
performed that showed multiple soft-tissue phleboliths within a soft-tissue
density and small, shallow humeral erosions adjacent to the tumor
(Fig. 1A). MR imaging was
performed for further evaluation of these abnormalities and showed an
enhancing soft-tissue mass arising from the triceps muscle, associated
regional cortical erosions, and abnormal intramedullary signal (Figs.
1B,
1C,
1D). Histologic evaluation of
the biopsy specimen revealed proliferation of vascular channels in skeletal
muscle. The final pathologic diagnosis was soft-tissue hemangioma involving
the triceps muscle (Fig.
1E).
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Fig. 1A. —27-year-old woman with soft-tissue hemangioma involving left triceps
muscle. Lateral radiograph of left upper extremity shows numerous phleboliths
in soft tissues posterior to midhumeral diaphysis. Note ill-defined appearance
of increased soft tissue overlying phleboliths and shallow cortical
indentations (arrows) along mid to distal humeral diaphysis.
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Fig. 1B. —27-year-old woman with soft-tissue hemangioma involving left triceps
muscle. Coronal spin-echo T1-weighted MR image of left upper extremity shows
longitudinal extent of predominantly intermediate-signal-intensity soft-tissue
tumor (arrows). Note involvement of mid to distal soft tissues of
left upper arm. Also, note heterogeneous, abnormal marrow signal, believed to
be caused by hyperemia associated with vascular tumor.
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Fig. 1C. —27-year-old woman with soft-tissue hemangioma involving left triceps
muscle. Coronal STIR MR image shows markedly intense lobulated soft-tissue
mass involving large length of triceps muscle. Note again marrow signal
abnormalities along length of visualized humerus.
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Fig. 1D. —27-year-old woman with soft-tissue hemangioma involving left triceps
muscle. Enhanced axial fast spin-echo fat-suppressed T1-weighted MR image
reveals heterogeneously but intensely enhancing hemangioma in triceps
muscle.
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Fig. 1E. —27-year-old woman with soft-tissue hemangioma involving left triceps
muscle. Photomicrograph of histologic specimen shows dense proliferation of
vascular channels adjacent to skeletal muscle. Note that individual
endothelial cells lining vessels are normal in size and appearance.
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Soft-tissue hemangiomas are the most common tumors of childhood. Their
origin remains unclear [1], but
most investigators agree that these benign vascular tumors are congenital.
Soft-tissue hemangiomas usually occur in the extremities, particularly the
lower extremities. Patients usually present either with a mass or with pain.
Classification is based on the histologic appearance, and the tumors are
categorized as follows: capillary, cavernous, arteriovenous, venous, and mixed
[2]. The capillary and
cavernous subtypes are both composed of thin-walled vessels with flattened
endothelium but differ in the caliber of the vessels; capillary hemangiomas
are characteristically very small and cavernous hemangiomas are typically
described as dilated blood-filled spaces. The arteriovenous subtype maintains
a fetal circulation bed between the arteries and veins. Deeper arteriovenous
tumors can be associated with right-to-left shunting of blood, potentially
leading to heart failure. The venous subtype has a thicker wall containing
muscle that is not found in the capillary and cavernous varieties.
Conventional radiographs may reveal an area of increased density suggestive
of a mass, or they may appear normal. The presence of phleboliths,
particularly phleboliths associated with a soft-tissue mass, is specific for
soft-tissue hemangiomas. Cortical or periosteal reaction is not unusual in
areas adjacent to a soft-tissue hemangioma
[3]. This has been hypothesized
to be due to the pressure effect exerted by the vascular mass
[4] and also possibly to the
increased regional blood flow associated with hemangiomas.
MR imaging, with its superior soft-tissue contrast, is useful for further
characterization of the substance and extent of soft-tissue hemangiomas.
T1-weighted images typically show a heterogeneous lobulated mass containing
areas of hyperintense signal resulting from fat. T2-weighted images
classically show a predominantly hyperintense mass. Areas of low signal may be
caused by the presence of smooth muscle, hemosiderin, fibrofatty elements, or
phleboliths. Anechoic areas are representative of fast-flowing blood in
vascular channels. Imaging after gadopentetate dimeglumine injection can
accentuate the serpiginous or serpentine nature of the vascular channels. The
triceps hemangioma in the patient described here showed these characteristic
MR imaging findings and allowed accurate prebiopsy diagnosis.
The definitive treatment is local excision with occasional preoperative use
of embolization to improve hemostasis during the operation. In those patients
in whom excision would result in increased morbidity and deformity,
embolization or radiotherapy may be beneficial. Recurrence is not infrequent,
but there have been no reports of malignant degeneration or metastasis.
Soft-tissue tumors tend to either proliferate or involute over time.
References
- Marchuk DA. Pathogenesis of hemangioma. J Clin
Invest 2001;107:665
–666[Medline]
- Murphey MD, Fairbairn KJ, Parman LM, Baxter KG, Parsa MB, Smith WS.
Musculoskeletal angiomatous lesions: radiologic-pathologic correlation.
Radio-Graphics1995; 15:893
–917[Abstract]
- Sung MS, Kang HS, Lee HG. Regional bone changes in deep soft tissue
hemangiomas: radiographic and MR features. Skeletal
Radiol 1998;27:205
–210[Medline]
- Yao L, Lee JK. Hemangioma of surface of ulna with prominent
sclerosis: a case report. Skeletal Radiol1988; 17:378
–381[Medline]
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