Figure 1
Sagittal T1-w
MRI- It shows serpentine vessels and enlongated, lobulated infiltrative masses, hypointense on T1w (arrows), intra-articular, and with infiltration of the popliteal fossa and patellar tendon.
Soft-tissue hemangioma: the most frequent tumor of infancy and childhood
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsCampos JT, Ramos R, Rocha DM, Pinto D, Preto AS
Connected authors
17 years, male
Clinical History
17- year-old male patient, with a painless slowly enlarging mass around the knee.
Normal conventional radiography.
Normal conventional radiography.
Imaging Findings
After the normal radiogram, the clinician sent the patient for further diagnostic evaluation and a MRI was performed.
In this case we have T1-weighted images typically showing a heterogeneous lobulated infiltrating mass, predominantly intra-articular, with extra-articular extension.
T2-weighted images show a predominantly hyperintense mass, with flow voids ( high flow or phleboliths). This lesion infiltrates the extensor muscles and tendons, the articular space, including the anterior and posterior cruciate ligaments, the collateral ligaments and the popliteal fossa.
In this case we have T1-weighted images typically showing a heterogeneous lobulated infiltrating mass, predominantly intra-articular, with extra-articular extension.
T2-weighted images show a predominantly hyperintense mass, with flow voids ( high flow or phleboliths). This lesion infiltrates the extensor muscles and tendons, the articular space, including the anterior and posterior cruciate ligaments, the collateral ligaments and the popliteal fossa.
Discussion
Background and clinical perspective
Soft-tissue haemangioma is the most frequent tumour of infancy and childhood. It is one of the most common soft-tissue tumours, constituting 7% of all benign tumours. Soft-tissue haemangiomas are more common in women and may dramatically increase in size during pregnancy. They are usually intramuscular, although synovial haemangiomas (less than 1% of haemangiomas) also occur [1]. Their origin remains unclear, but most investigators agree that these benign vascular tumours are congenital. Soft-tissue haemangiomas usually occur in the extremities, particularly the lower extremities.
Imaging perspective
MR imaging can be used to classify vascular malformations as either low-flow or high-flow lesions, especially when combined with dynamic contrast-enhanced MR angiography [1, 2]. Slow-flow vascular malformations (venous, capillary, cavernous, or mixed) contain large spaces with fine serpentine structures that are usually oriented along the long axis of the extremities, follow a neurovascular bundle, and are sometimes multifocal. High-flow vascular malformations show more prominent serpentine vessels. Faster flow may manifest as areas of flow void with all pulse sequences, as seen in this case [3].
Synovial hemangioma, a rare subtype, is "a benign vascular lesion arising from any structure lined by synovium including the intra-articular region, bursal spaces and tendon sheaths."
Outcome
The definitive treatment is local excision with occasional preoperative use of embolisation to improve haemostasis during the operation. In those patients in whom excision would result in increased morbidity and deformity, embolisation or radiotherapy may be beneficial.
In this patient we are currently waiting for embolisation and discussing the surgical option.
Soft-tissue haemangioma is the most frequent tumour of infancy and childhood. It is one of the most common soft-tissue tumours, constituting 7% of all benign tumours. Soft-tissue haemangiomas are more common in women and may dramatically increase in size during pregnancy. They are usually intramuscular, although synovial haemangiomas (less than 1% of haemangiomas) also occur [1]. Their origin remains unclear, but most investigators agree that these benign vascular tumours are congenital. Soft-tissue haemangiomas usually occur in the extremities, particularly the lower extremities.
Imaging perspective
MR imaging can be used to classify vascular malformations as either low-flow or high-flow lesions, especially when combined with dynamic contrast-enhanced MR angiography [1, 2]. Slow-flow vascular malformations (venous, capillary, cavernous, or mixed) contain large spaces with fine serpentine structures that are usually oriented along the long axis of the extremities, follow a neurovascular bundle, and are sometimes multifocal. High-flow vascular malformations show more prominent serpentine vessels. Faster flow may manifest as areas of flow void with all pulse sequences, as seen in this case [3].
Synovial hemangioma, a rare subtype, is "a benign vascular lesion arising from any structure lined by synovium including the intra-articular region, bursal spaces and tendon sheaths."
Outcome
The definitive treatment is local excision with occasional preoperative use of embolisation to improve haemostasis during the operation. In those patients in whom excision would result in increased morbidity and deformity, embolisation or radiotherapy may be beneficial.
In this patient we are currently waiting for embolisation and discussing the surgical option.
Differential Diagnosis List
Soft tissue haemangioma (synovial type)
pigmented villonodular synovitis (PVNS)
non-specific synovitis
lipoma arborescens
Final Diagnosis
Soft tissue haemangioma (synovial type)
References
[1] Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, and Kransdorf MJ (2004) From the Archives of the AFIP: Benign Musculoskeletal Lipomatous Lesions. RadioGraphics 24:1433 - 1466 (PMID: 15371618)
[2] Teo EL, Strouse PJ, Hernandez RJ (2000) MR Imaging Differentiation of Soft-Tissue Hemangiomas from Malignant Soft-Tissue Masses. AJR 174:1623–1628 (PMID: 10845496)
[3] Vilanova J, Barceló J, Smirniotopoulos J, Pérez-Andrés R, Villalón M, et al (2004) Hemangioma from Head to Toe: MR Imaging with Pathologic Correlation. RadioGraphics 24: 367-385 (PMID: 15026587)
Case information
| URL: | https://www.eurorad.org/case/9690 |
| DOI: | 10.1594/EURORAD/CASE.9690 |
| ISSN: | 1563-4086 |
Figure 2
Sagittal T2w
MRI- T2 fatsat- the arrows point to a hyperintense lobulated infiltrative lesion-haemangioma, intra-articular with infiltration of the cruciate ligaments.
Figure 3
Sagittal T2
MRI- T2 fatsat- Intra-articular lesion with popliteal fossa extention and patelllar tendon infiltration (arrows).
Figure 4
Coronal T2
MRI- T2 fatsat- The images show a infiltrative hyperintense lesion with superficial serpentine vessels with flow voids (arrows), a signal of a high-flow lesion/phlebolliths.
Figure 5
Axial T2
MRI- T2 fatsat- the arrows continue to show the mass extension, with serpentine vessels and infiltrative hemangioma in all knee compartments.
Sagittal T1-w
MRI- It shows serpentine vessels and enlongated, lobulated infiltrative masses, hypointense on T1w (arrows), intra-articular, and with infiltration of the popliteal fossa and patellar tendon.
H S João
H S João
Sagittal T2w
MRI- T2 fatsat- the arrows point to a hyperintense lobulated infiltrative lesion-haemangioma, intra-articular with infiltration of the cruciate ligaments.
H S João
H S João
Sagittal T2
MRI- T2 fatsat- Intra-articular lesion with popliteal fossa extention and patelllar tendon infiltration (arrows).
H S João
H S João
Coronal T2
MRI- T2 fatsat- The images show a infiltrative hyperintense lesion with superficial serpentine vessels with flow voids (arrows), a signal of a high-flow lesion/phlebolliths.
H S João
H S João
Axial T2
MRI- T2 fatsat- the arrows continue to show the mass extension, with serpentine vessels and infiltrative hemangioma in all knee compartments.
H S João
H S João