Infiltrating angiolipoma in the foot

A case of infiltrating angiolipoma of the right lower extremity is reported. Angiolipomas are benign neoplasms of adipose tissue with a rich vascular component and are classified as either infiltrating or noninfiltrating. Noninfiltrating angiolipomas are seen in young individuals, present as painful, soft, subcutaneous nodules and are treated by enucleation. Infiltrating angiolipoma is a rare neoplasm with only 23 previously reported cases. These lesions are usually unencapsulated or rarely partially encapsulated and tend to infiltrate bony, neural, muscular, and fibrocollagenous tissue. Treatment of infiltrating angiolipomas is aimed at wide excision with radiotherapy indicated for cases of recurrence.

[Hepatic hemangiomas. The importance of the image]

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

[Solitary angiomyolipoma of the liver]

Today in the age of ultrasonography focal hepatic lesions are diagnosed more often, which are difficult to be classified. Metastases are leading numerically among the malignant tumors, hemangiomas among the benign. We report on a rare case of a hemangiomyolipoma of the liver and the diagnostic difficulties. The final diagnosis was made only after hemihepatectomy.

[Traumatic sinus pericranii. Case report]

The patient was involved in a traffic accident at the age of 1 and the left parieto-occipital scalp was contused without skull fracture. At the age of 5, an extracranial scalp mass was first noticed just beneath the multiple scalp scars. Angiography through the mass revealed that the extracranial mass cavity was connected to the superior sagittal sinus through the emissary veins. The mass located in the subgaleal, epiperiosteal space was totally resected and the connection with the intracranial sinus was closed with bone wax. Histologically, there were many capillaries and some large blood cavities with only one layered endothelium and connective tissue. Therefore, the mass was diagnosed as sinus pericranii and considered to be secondary to previous head trauma because: 1) The patient had a history of head trauma with considerably severe scalp injuries. 2) The extracranial blood sinus was located exactly beneath the traumatic scar. 3) There was no neoplastic tissue histologically. 4) No scalp mass was noticed before the traffic accident. 5) There was an elapsed time between the trauma and the growth of the mass. 6) No scalp nevus such as port-wine stain existed.

Lung scintigraphy in pulmonary capillary hemangiomatosis. A rare disorder causing primary pulmonary hypertension

The authors report the results of lung scintigraphy in two patients with primary pulmonary hypertension caused by pulmonary capillary hemangiomatosis, a rare disorder resulting from the proliferation of histologically normal capillaries in the lung. Perfusion studies revealed a nonhomogeneous pattern with some focal defects, similar to that seen with some other histologic types of primary pulmonary hypertension. The mechanisms underlying this perfusion pattern are unknown.

Hepatic hemangiomas: diagnosis with fusion of MR, CT, and Tc-99m-labeled red blood cell SPECT images

A method of image analysis was developed for correlation of hemangiomas detected at computed tomography (CT) and/or magnetic resonance (MR) imaging with increased blood pool activity evident at single photon emission CT (SPECT) performed after labeling of red blood cells with technetium-99m. Image analysis was performed in 20 patients with 35 known hepatic hemangiomas. After section thickness and pixel sizes of the different studies were matched, intrinsic landmarks were chosen to identify anatomically corresponding locations. Regions of interest (ROIs) drawn on the CT and/or MR images were translated, rotated, and reprojected to match the areas of interest on the corresponding SPECT images by means of a two-dimensional polynomial-based warping algorithm. Analysis of ROIs on 30 SPECT-MR and 20 SPECT-CT pairs of registered images provided absolute confirmation that 34 suspected hemangiomas identified on SPECT images correlated exactly with lesions seen on CT and/or MR images. Accuracy of fusion was within an average of 1.5 pixels +/- 0.8 (+/- 1 standard deviation). The technique enabled diagnostic confirmation of hemangiomas as small as 1.0 cm and proved useful for evaluating lesions located adjacent to intrahepatic vessels.

[Emission-computed tomography in the diagnosis of kidney tumors and cysts]

Emission computed tomography (ECT) was used to examine 48 patients with suspected renal lesions. Sectional images of renal cysts diagnosed in 14 of them were characterized by well-defined outlines surrounded by uniformly declining radiopharmaceutical accumulations. Renal tumors were detected in 25 patients. ECT pattern of the tumor had obscure borders suggesting the tumor invasion into the renal tissue. Accumulation of the radiopharmaceutical round the tumor was less pronounced than in functioning renal tissue. According to ECT findings, 8 subjects were free of urological pathology. It is concluded that ECT is a promising diagnostic tool in urology as it permits sectional visualization of renal neoplasms structure, is highly sensitive, informative and noninvasive. It can identify mass lesions of the kidneys and warrants exhaustive information on functional performance of the renal parenchyma.

Computed tomography attenuation measurements for the characterization of hepatic haemangiomas

The attenuation values of 21 hepatic haemangiomas in 19 patients were measured on non-enhanced computed tomographic (CT) scans and compared with the attenuation of adjacent liver and the inferior vena cava (IVC). The attenuation of hepatic haemangiomas was lower than that of the surrounding liver, but there was no correlation between these two measurements. There was a highly significant correlation between the attenuation of haemangiomas and blood in the vena cava (r = 0.905, p less than 0.001). All the haemangiomas had attenuations within 7 HU of caval blood. By comparison, in 34 hypodense hepatic lesions that did not show contrast-enhanced appearances characteristic of haemangioma, there was no significant correlation between the attenuation of the lesions and the IVC. Nineteen (56%) of these lesions had attenuations differing more than 7 HU from that of caval blood. The influence of this observation on the requirement for dynamic contrast-medium-enhanced and delayed post-contrast CT in the assessment of hepatic lesions is discussed.

[Computed tomography symptomatology of liver hemangiomas]

The paper is concerned with analysis of CT-symptomatology of 72 liver hemangiomas in 43 patients. The authors employed standard and dynamic computerized tomography. All hemangiomas were divided into 2 groups: under 6 cm and over 6 cm. Small hemangiomas were characterized by clear-cut contours and regular density. Zones of low density, regular in structure with clear-cut contours were revealed by CT in hemangiomas over 6 cm. Morphologically, this zone corresponded to a hyaline structure (a hyaline slot) making it possible to differentiate hemangiomas from necrotic tumors. In serious cases dynamic CT with visual evaluation and plotting of time-density graphs was recommended. Visually hemangioma had a picture of contrast medium accumulation, beginning from a focal periphery. Graphically the time of appearance of a contrast medium and the time of reaching a maximum for hemangiomas is delayed as compared to the same intervals of contrast medium accumulation in the liver parenchyma. It tells hemangioma graphs from graphs of other tumors, of which intervals coincide with those of liver parenchyma graphs.

Management of haemangioma of the liver: comparison of results between surgery and observation

Cavernous haemangioma of the liver was diagnosed in 33 patients using hepatic angiography between 1978 and 1988. Thirteen of these patients underwent surgery. There were no deaths after operation; morbidity included upper gastrointestinal bleeding in two patients and liver dysfunction in one. The follow-up study showed no evidence of recurrence in any of the 13 patients up to 143 months after operation. In the operated patients, a small haemangioma was left in the liver of two for anatomical reasons, but the size of these tumours showed no change over 3 years. The remaining 20 patients had no specific treatment for haemangioma and were followed up for between 18 months and 8 years. Of these 20 patients, 19 had tumours of less than 5 cm in size. As there was no enlargement or rupture of haemangiomas of less than 5 cm, it was felt that these could be observed. Cases having a potential for exposure to trauma, rapid tumour growth, or displaying severe symptoms should be considered for surgical treatment; this can be justified due to low morbidity and no mortality.

Symptomatic vertebral hemangiomas

Symptomatic vertebral hemangiomas are rare. Several therapeutic modalities for vertebral hemangiomas with neurologic deficit have been described. Personal experience with laminectomy followed by radiation therapy in four patients and radiation therapy in one patient is reported. Considering our results, literature and theoretical aspects a proposal for treatment of symptomatic vertebral hemangiomas is made.

Computed tomographic findings in two patients with vascular hamartomas

The clinical, computed tomographic (CT) and histological findings of two patients with vascular hamartomas are presented. The appearances on CT of the two lesions were markedly different. Although both lesions were histopathologically benign, one showed a more disorganized architecture on histology and clinically behaved in a more aggressive manner. The CT findings in this case reflected the histological picture and could have been interpreted as a malignant process if viewed in isolation. Review of the literature and the cases presented suggest that the CT appearances of vascular hamartomas can be diverse, and to avoid a misdiagnosis the radiological features should be considered in conjunction with the clinical and histopathological findings.

[A case of brainstem vascular malformation with isolated trochlear nerve palsy as the initial symptom]

We report a 46-year-old, non-hypertensive man who suddenly developed isolated right trochlear nerve palsy. His diplopia was most prominent in the left lower gaze, and partially alleviated by head tilt to the left or by anteflexion of the neck. His CT scans showed a small high density area consistent with a hemorrhage in the lateral side of the right mesencephalic tectum. His MRI (T2-weighted images) showed a lesion consisting of mixed high- and iso-intensity areas with linear low intensity areas. The margin of the lesion was irregular and nodular. Cerebral angiography (prolonged injection) showed small feeding arteries (or capillaries) in the late arterial phase and dilated draining veins in the venous phase. No tumor stain, early draining veins, or capillary brushes were present. We thought he had an angioma (vascular malformation). AVM seemed unlikely. Review of the literature revealed that trochlear nerve palsy caused by a mesencephalic angioma is extremely rare. MRI and cerebral angiography (prolonged injection) seemed useful for the diagnosis of angiomas (Vascular malformations).

False-positive hepatic blood pool scintigraphy in metastatic colon carcinoma

A rare false-positive red blood cell scintigram occurred in a 49-year-old woman with two metastases from a primary adenocarcinoma of the sigmoid colon. Although the blood flow and static planar images were unremarkable, a 1-hour postinjection SPECT study showed a focus of increased activity in the inferior right lobe and a second photopenic focus in the dome. Following a trisegmentectomy, pathologic examination revealed the two metastases with no evidence of a hepatic hemangioma. Microscopy, however, showed a discrete area of nonspecific reactive changes (focal sinusoidal dilation and congestion) immediately adjacent to teh metastasis in the inferior right lobe. It is postulated that the SPECT focus of increased activity occurred secondary to the labeled blood pool within the area of sinusoidal dilation, rather than within the adjacent metastasis.

Hemangioma of the nasal vault: MR and CT features

Six patients with a history of epistaxis (five patients) or nasal obstruction (one patient) were found to have a capillary hemangioma of the nasal vault that involved one or more nasal turbinates. Four patients underwent computed tomographic (CT) examination; two of these also underwent magnetic resonance (MR) imaging. Four others underwent only MR imaging. At CT and MR, all of the lesions were well circumscribed and intensely enhancing, with contralateral deviation of the nasal septum. Remodeling of the surrounding bone was present in three patients. On T1-weighted MR images, the masses were intermediate in signal intensity. Varying degrees of T2 shortening were shown on T2-weighted MR images, with an appearance that suggested the presence of blood products surrounding an inner matrix of higher-signal-intensity tumor. Intense enhancement at CT and MR assisted differentiation of tumor from retained sinonasal secretions. In two patients, external carotid arteriography revealed small foci of pooling contrast material; in one of these patients, arteriovenous shunting was also present. Pathologic examination in all patients demonstrated capillary hemangiomas with varying degrees of fibrosis and hemosiderin deposition.

Life-threatening hematochezia from a rectosigmoid vascular malformation in Klippel-Trenaunay syndrome: long-term palliation using an argon laser

Recurrent severe hemorrhage from intestinal vascular malformations, although extremely rare, may be associated with significant morbidity and mortality. The treatment may require extensive surgical resection, vascular embolization, and repeated blood transfusions. An adolescent boy with the Klippel-Trenaunay syndrome involving the pelvis and left leg presented with recurrent life-threatening hematochezia associated with defecation. Endoscopy documented that the bleeding originated from the submucosal venous angiomata in the region of the hemorrhoidal plexus. An argon laser was used to systematically coagulate the venous angiomata involving the distal 7 cm of the anorectal canal. Postoperative minor rectal bleeding and rectal tenesmus resolved in a few days. The patient has had only one brief episode of hematochezia in more than 4 years of follow-up. The use of the argon laser has provided effective palliation of colorectal vascular malformations with minimal morbidity but more importantly has allowed the preservation of normal anorectal function.

Technetium-99m-d,1-hexamethylpropyleneamine oxime (HMPAO) uptake and glutathione content in brain tumors

Technetium-d, HMPAO SPECT was performed in 70 patients suffering from intracerebral tumors of various histologic types (glioma n = 30, meningioma n = 19, metastases n = 10, angioma n = 3, neuroma n = 2, lymphoma n = 2, neurocytoma n = 1, epidermoid n = 1, gliosis n = 1, cholesteatoma n = 1). Tumor classification was histologically verified in all subjects except in two cases with inoperable angiomas. SPECT was performed under resting state conditions with a dual-head rotating camera (SIEMENS ZLC 37) following intravenous injection of 18-25 mCi 99mTc-d, 1-HMPAO. Regional tracer deposit was expressed in terms of a cerebellar index (CBI). Significantly higher regional HMPAO uptake was found in meningiomas when compared with gliomas of different malignancy (ANOVA p less than 0.05). Within gliomas, regional uptake increased with malignancy (n.s.). In 23 patients, a total of 32 tumor specimens were obtained for histochemical analysis of glutathione (GSH) content using high-pressure liquid chromatography. A significant correlation (least square method, p less than 0.001) between CBIs and GSH values was found, supporting the hypothesis that GSH is the predominant factor for the conversion of the lipophilic complex to hydrophilic derivates.

[Photon-emission tomography (SPECT) in the detection of hepatic hemangiomas of small size]

By means of ultrasonography it is possible to detect hepatic lesions of few millimeters, however, it doesn't give a precise diagnosis. The role of planar scintigraphy in the diagnosis of hepatic hemangioma has already been established, although it has limitations which are partially solved by means of SPECT. 46 patients with different pathologies and 9 healthy volunteers have been studied. In the 19 confirmed hemangiomas, planar scintigraphy showed a sensitivity of 73.6% versus 84.2% for SPECT, mostly due to lesions less than 2.5 cm. Besides that, SPECT allowed a correct visualization of abdominal and intrahepatic major vessels, although lesions less than 1.5 cm are difficult to evaluate.

Right-ventricular hemangioma causing serious outflow-tract obstruction

A 28-year-old woman had a partially nonexertional dyspnea and a murmur of pulmonary stenosis. Echocardiography and magnetic resonance imaging revealed a mass causing a nearly completely pulmonary outflow-tract obstruction. The mass was successfully resected and the pathological diagnosis of a mixed capillary and cavernous polypoid hemangioma was made. This case represents one of the very rare cases of a right-ventricular hemangioma in adults in which obstruction of the outflow-tract was initially evident. Non-invasive diagnosis and an exploratory operation with resection is the procedure of choice.

Symptomatic vertebral haemangiomas: report of two cases

The authors reported two cases of vertebral haemangiomas with spinal cord compression. The first case deteriorated during her pregnancy. Plain radiography of the thoracic spine gave the hint for the diagnosis and computed axial tomography showed the lesion. She was treated via surgical removal with minimal improvement of her paraparesis. The second case was diagnosed after operation because there was no abnormality over the relevant vertebra and the myelogram demonstrated an extradural mass lesion compressing the lower thoracic spinal cord. The patient improved satisfactorily after total removal of the tumour. Both surgical specimens were classical pictures of haemangiomas histologically.