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

Soft tissue hemangioma of the right upper extremity with intraosseous extension and secondary intravascular papillary endothelial hyperplasia

Intravascular papillary endothelial hyperplasia (IPEH), also known as Masson's tumor, is an uncommon exuberant form of organizing thrombus that may occur within a vessel, vascular tumor, or hematoma and may change the imaging appearance to mimic an aggressive process. It must be distinguished pathologically from angiosarcoma. They have been most commonly reported within superficial soft tissue tumors, and rapid growth and effect on bone are rarely described. We present a case of a patient with a soft tissue hemangioma with IPEH with intraosseous extension that presented with a pathologic fracture of her right humerus with an aggressive appearing osseous lesion. CT and MRI demonstrated a multifocal ill-defined soft tissue mass throughout the right upper extremity with underlying cortical tunneling and scalloping of the proximal humerus. Similar imaging findings were also present in the distal humerus and ipsilateral scapula and evolved during her hospitalization. Following percutaneous biopsy revealing hemangioma with features of papillary endothelial hyperplasia with intraosseous extension, the patient died in the ICU secondary to unrelated septic shock. Diagnosis was confirmed at autopsy. Primary and secondary IPEH have been generally characterized as well-defined solitary masses, most often in the superficial soft tissues. This case of a deep soft tissue hemangioma with type II IPEH, intraosseous extension, and imaging findings of regional multicompartmental involvement is very unusual. Reporting of this case in the literature should be beneficial for pathologic correlation with similar confounding masses as well as propose a possible mechanism for intraosseous extension of soft tissue hemangiomas.

Soft Tissue Vascular Anomalies of the Extremities: A Proposed Diagnostic Approach

This narrative review aims to summarise the classification of vascular anomalies, their clinical presentation, and their radiological features to propose a diagnostic algorithm to approach patients with suspected soft tissue vascular anomalies of the extremities. The management of vascular anomalies necessitates a multidisciplinary approach. Clinical presentation and physical examination are sufficient in most cases to achieve a correct diagnosis. This is especially true for small congenital lesions of the skin and subcutaneous tissue. Imaging is used for accurate characterization of these lesions, especially in cases of atypical or vague clinical presentation, and to assess extension in cases of lesions that are larger and localized in deeper tissues.

Nineteen-Year-Old Woman with Symptomatic Intramuscular Thigh Hemangioma-Radiographic Changes and Management: A Case Report

CASE

We report a case of an intramuscular thigh hemangioma in a 19-year-old woman with a several year history of atraumatic thigh pain. Radiographs obtained by her primary care physician demonstrated periosteal bone reaction, prompting referral to Orthopaedic Oncology department. The patient had successful symptomatic management with propranolol.

CONCLUSION

The case highlights the diagnosis and potential treatments. In a stepwise approach to care for symptomatic benign vascular lesions, propranolol has been a proven therapeutic option and may be a useful first-line therapy for symptomatic hemangiomas.

Intramuscular deep forearm hemangioma aggravated by a traumatic event: A case report

INTRODUCTION

Hemangioma is a unique benign vascular tumor. Intramuscular seated lesions tend to cause pain, swelling, and disability in adulthood, especially after a traumatic aggravating event.

PRESENTATION OF CASE

A young, healthy female suffered a previous trauma to her left forearm. Persistent pain developed after it with intermediate swelling that turned out to be a deep-seated hemangioma, which was treated successfully with excision.

DISCUSSION

Though it is often a benign-acting congenital lesion, with several treatment methods, early diagnosis of hemangioma is a dilemma. Expelling other similar malignant lesions is essential. Surgical intervention could be necessary and effective in specific indications.

CONCLUSION

Adequately planned surgery can successfully manage traumatic aggravated intramuscular hemangioma.

Radiological and pathological characteristics of synovial hemangioma of the knee

Synovial hemangioma, a rare benign tumor that occurs most frequently in the knee in children and young adults, has four histological subtypes: Venous, arteriovenous, cavernous and capillary hemangiomas. Since the clinical presentation and radiological findings of synovial hemangioma are non-specific, there is frequently a long period between the onset and the diagnosis. The cases of nine patients, pathologically diagnosed with synovial hemangioma and surgically treated, were retrospectively analyzed. All nine patients had persistent knee pain. In addition, three patients also had a swollen knee with intra-articular hemorrhage. Plain radiography revealed intra-articular phleboliths in two patients. In seven patients, T1-weighted magnetic resonance imaging showed low signal intensity with small signal voids. On T2-weighted imaging, all patients showed high signal intensity containing small signal voids. All patients underwent surgical excision; there was no postoperative recurrence after the final operation, and the knee pain had disappeared at the final follow-up. From the pathological findings, the diagnoses were venous hemangioma, cavernous hemangioma and capillary hemangioma (three patients each).

Cavernous hemangioma of the peripherical nerve: A case report

Cavernous hemangiomas, also known as deep hemangiomas are benign tumors of blood vessels, including normal and abnormal vascular structures, that develop in skin tissue and sometimes even in deep tissues. Its intraneural development in the peripheral nerve is very rare with less than 50 cases reported in the literature. We present a case of a cavernous hemangioma of the medial sural nerve in a patient with symptoms of severe pain and allodynia with complete resolution of symptoms with microsurgery.

Ultrasound imaging as an initial diagnostic method for intramuscular hemangiomas: a narrative review

Intramuscular hemangiomas are benign vascular lesions, often misdiagnosed due to unfamiliarity. They are rare (but not very rare) causes of musculoskeletal pain and diagnosing these tumors may be challenging because of their pertinent non-specific symptomatology. Herein, as a convenient imaging tool, ultrasound examination appears to an important initial method to scan for these lesions after the clinical examination. To date, there are no studies that examined the state-of-the-art as regards the use of ultrasound imaging in the diagnosis of intramuscular hemangiomas. Accordingly, a literature search was performed using PubMed and Web of Science with the purpose to provide a conceptual understanding and awareness as regards the importance/utility of ultrasound imaging as a first step diagnostic tool for intramuscular hemangiomas at different muscles' locations.

Three Distinct Vascular Anomalies Involving Skeletal Muscle: Simplifying the Approach for the General Radiologist

Venous malformations and hemangiomas of the skeletal muscle are separate entities with different clinical presentation, histology, and imaging findings. Recent advances in the field of vascular anomalies and current efforts in the unification of terminology by the International Society for the Study of Vascular Anomalies are pivotal in understanding and differentiating intramuscular venous malformations and intramuscular capillary-type hemangioma. Fibroadipose vascular anomaly is another recently defined vascular anomaly affecting the skeletal muscle, with a distinct clinical presentation, histology, and imaging appearance. These 3 distinct vascular anomalies are reviewed and their histologic features, clinical presentation, imaging appearance, and treatment are discussed.

Synovial Hemangioma of the Wrist With Cystic Invasion of Trapezoid and Capitate Bones

Synovial hemangiomas (SHs) are rare lesions of the joints or tendon sheaths that are difficult to diagnose. We present the case of an 18-year-old man with an SH in the wrist joint. Physical examination revealed a slightly tender, ill-defined, nonpulsatile soft mass, 3 cm × 3 cm in size on the dorsal aspect of the left wrist. Computed tomography showed an irregular, ill-defined, soft tissue mass in the expanded joint space, which was formed by the scaphoid, trapezoid, and capitate bones. Magnetic resonance imaging showed the typical features of SH and also revealed cavitary erosion of the scaphoid, trapezoid, and capitate bones. An open arthrotomy was performed via a dorsal approach, and the mass was excised. The histological examination findings were consistent with the diagnosis of SH.

Soft-Tissue Tumors of the Hand-Imaging Features

Imaging studies of the hands and fingers are common, and radiologists are generally comfortable with traumatic and degenerative conditions which arise frequently in daily practice. However, a variety of common and uncommon soft-tissue tumors also occur in the hand, the appropriate diagnosis of which can be a source of confusion for both clinicians and radiologists. These lesions often have overlapping imaging characteristics; however, a structured approach can help provide a focused differential diagnosis and impact further workup and management. We discuss several such tumors, categorizing them as cystic-appearing, noncystic masses along tendons and aponeuroses, adipocytic tumors, vascular lesions, and miscellaneous lesions with imaging features that can aid diagnosis.

Case study of radial fibrolamellar bone tissues in the outer cortex of basal sauropods

The histology of sauropod long bones often appears uniform and conservative along their evolutionary tree. One of the main aspects of their bone histology is to exhibit a fibrolamellar complex in the cortex of their long bones. Here, we report another bone tissue, the radial fibrolamellar bone (RFB), in the outer cortex of the humeri of a young adult cf. Isanosaurus (Early to Late Jurassic, Thailand) and an adult Spinophorosaurus nigerensis (Early to Middle Jurassic, Niger) that do not exhibit any pathological feature on the bone surface. Its location within the cortex is unexpected, because RFB is a rapidly deposited bone tissue that would rather be expected early in the ontogeny. A palaeopathological survey was conducted for these sampled specimens. Observed RFB occurrences are regarded as spiculated periosteal reactive bone, which is an aggressive form of periosteal reaction. A 'hair-on-end' pattern of neoplasmic origin (resembling a Ewing's sarcoma) is favoured for cf. Isanosaurus, while a sunburst pattern of viral or neoplasmic origin (resembling an avian osteopetrosis or haemangioma) is favoured for Spinophorosaurus. This study highlights the importance of bone histology in assessing the frequency and nature of palaeopathologies. This article is part of the theme issue 'Vertebrate palaeophysiology'.

Multiple Diffused Cavernous Hemangiomas Associated with Venous Calculi Formation in the Right Upper Limb and Back: A Case Report

Cavernous hemangioma, a benign soft tissue and intramuscular tumor, is commonly located in the head, neck, and maxillofacial regions. They can sometimes occur in the limbs and trunk, although rarely. Treatment of cavernous hemangiomas includes surgical and nonsurgical means. Cases of extensive diffused cavernous hemangiomas of an entire limb are rare. In this case presentation, we report the case of chronic diffused cavernous hemangioma associated with venous calculi of the right upper limb and back in a 31-year-old Chinese man. Due to the long history, chronic articular impairments and extensive damage to the skeletal and musculature, surgical amputation of the limb was performed. The aim of this report is to provide further understanding of treatment prioritization and the risks of delayed treatment of cavernous hemangiomas.

Intramuscular Hemangioma of the Forearm with Flexion Contracture

Intramuscular hemangiomas can be an infrequent but important cause of musculoskeletal pain. This report describes a 25-year-old male who presented with pain in the right forearm and contracture of the right hand for 4 years. Physical examination revealed severe tenderness of the midforearm with contracture of the flexor tendons in the index, middle, ring, and little fingers. Conventional radiography of the forearm revealed a soft tissue phlebolith. Magnetic resonance imaging showed a well-defined lobulated mass partially involving the FDP tendon. An intramuscular hemangioma within the deep anterior compartment of the forearm was suspected. Following surgical excision of the hemangioma, the patient's symptoms resolved completely. In conclusion, intramuscular hemangioma can be a rare cause of flexion contracture of the hands and should be considered as a cause of a flexion contracture that fails to respond to conservative treatment.

Arteriovenous Malformations: Syndrome Identification and Vascular Management

PURPOSE OF REVIEW

Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. More recently, the treatment paradigm has shifted to endovascular therapy such that embolization and sclerotherapy are now considered the first line of treatment. Although there is still a role for traditional surgical techniques, it is now most commonly integrated with endovascular therapies in a hybrid fashion. The goal of this review is to provide a greater understanding of the diagnosis and treatment of vascular malformations.

RECENT FINDINGS

Vascular malformations can be high-flow (arteriovenous shunting) or low-flow (venous or lymphatic). Clinical presentation and treatment is different for each. Treatment of high-flow lesions must be directed at reducing or eliminating the nidus, usually via super-selective catheterization and embolization. Low-flow lesions are usually treated by direct injection of sclerosing agents under fluoroscopic or ultrasound guidance. The cornerstone of managing patients with vascular malformations is making the proper diagnosis, which is often challenging. Even after a diagnosis is made, therapy itself may be challenging and generate frustration among patients and providers. Frequently, the treatment of vascular malformations is characterized by only slow and incremental improvements without complete lesion eradication. By combining a thorough understanding of the vascular malformation disease process with an array of endovascular techniques, vascular interventionalists may contribute greatly to the care of these patients.

Synovial Hemangioma of the Knee Management and Excellent Outcome 2 Years after Arthroscopic Synovectomy in a 25-year-old Male with a 20-year History

Introduction:

Synovial hemangioma is a rare condition with <200 published case reports in world literature and is frequently misdiagnosed, leading to diagnostic delay of many years. This delay is even more significant if the patient comes from a rural background with a dearth of medical facilities in the area. This case had a lag of nearly 20 years from the time of onset of symptoms and the required management which is the maximum reported for any synovial hemangioma since most of them have been found and treated in adolescents.

Case Report:

We present a case of an atypical synovial hemangioma in a 25-year-old Indian male from a poor socioeconomic background with a delay of 20 years who had both recurrent knee effusions and long-standing knee pain but kept ignoring his symptoms. It was managed by arthroscopic synovectomy. The patient reported to us after 2 years after the surgery with a painless knee and full range of movement.

Conclusion:

Synovial hemangioma mostly affects the knee joint, showing recurrent bloody effusions without a history of trauma. If there are no intermittent effusions, the diagnosis will be even more difficult. In cases of non-specific symptoms and long-standing knee pain of many years, the diagnosis of a synovial hemangioma should also be considered. In this particular case, magnetic resonance imaging was used to evaluate the patient after the plain radiographs and showed characteristic lace-like or linear patterns. Diagnostic arthroscopy and surgical excision were done in the same sitting, and biopsy was sent to the histopathology laboratory which confirmed our diagnosis. Although this patient had the disease since 20 years and presented late, he had little degeneration of cartilage at the time of arthroscopy. The functional outcome at 2-year follow-up was excellent, and he had no disability, effusion and was pain free.

Neonatal Airway Compromise by a Giant Cervicothoracic Venous Haemangioma

Haemangiomas are most common non-malignant vascular tumours of infancy. Here, we describe an antenatally detected mass over the neck causing compressive respiratory compromise at birth requiring resuscitative measures at birth. The mass showed increased vascularity on Contrast Enhanced Computed Tomography (CECT) with extension upto superior mediastinum. Surgical excision was required following failure to medical measures with steroids and propranolol. Histopathology confirmed it to be a venous haemangioma. This case highlights that these benign lesions may reach large sizes and antenatal detection may help in planning effective delivery and resuscitative measures.

Intramuscular hemangioma causing periosteal reaction and cortical hypertrophy misdiagnosed as osteoid osteoma

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We report a case of intramuscular hemangioma mimicking osteoid osteoma.

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Magnetic resonance image (MRI) is the most precise diagnostic tool for the identification of soft-tissue mass adjacent to the bone.

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Precise preoperative diagnosis is essential to avoid excessive surgery.

Introduction

Intramuscular hemangioma in the periosteal region is rare. Although comprising less than 1% of all hemangiomas, they represent the most common type of intramuscular tumors. When located adjacent to bone, a periosteal reaction can occur. The deep localization of the hemangioma poses the diagnosis difficult. Only 8% to 19% of cases were diagnosed before surgery according to the literature review.

Presentation of case

We present a case of forty-one-year-old female diagnosed with intramuscular hemangioma, mimicking osteoid osteoma, adjacent to the periosteal region of tibia diaphysis treated by surgical excision.

Discussion

When intramuscular hemangioma occurs nearby a bone structure, it can cause cortical, medullary and periosteal bone changes that are frequently misdiagnosed by plain radiography. Due to their infrequency, deep location, and atypical presentation, these lesions are seldom diagnosed at presentation. The hemangioma of the periosteal region can be locally destructive due to compression exerted on neighboring structures. It does not regress spontaneously, and surgical excision is frequently needed.

Conclusion

Intramuscular hemangioma of periosteal region occurs most commonly adjacent to long bones of the lower limb. They can cause hypertrophic periosteal reactions mimicking a periosteal or parosteal tumor. Although osteoid osteoma was considered in the differential diagnosis, MRI with enhancement should be performed to exclude intramuscular hemangioma. This may avoid unnecessary aggressive en-bloc tumor excisions resulting in bone weakness and prolonged rehabilitation.

This case report has been written in line with the SCARE criteria (Agha et al., 2016 [1]).

Misdiagnosis of pathological femoral fracture in a patient with intramuscular hemangioma: A case report

Hemangioma is a common disease; however, intramuscular hemangioma (IH) presenting with a pathological fracture is extremely rare. The present study reports a case of a 46-year-old male patient that suffered from IH of the right thigh, presenting with a pathological femoral fracture. The patient was initially diagnosed with a traumatic femoral fracture, and routine open reduction and internal fixation were performed at a local hospital. However, 20 days subsequent to surgery, gradual swelling and soreness around the incision were observed. The incision eventually ruptured during squatting for bowel movement, which led to extensive blood loss. Based on computed tomography (CT) and deep femoral artery arteriography, IH presenting with a pathological femoral fracture was diagnosed. The patient underwent artery embolization, from which he recovered well. At the 6-month follow-up, the femoral fracture was revealed to have healed, and a CT scan demonstrated no evidence of recurrence; however, continuous observation using CT is required in order to determine the long-term outcome. To the best of our knowledge, this is the first case of a misdiagnosed pathological femoral fracture in a patient with IH reported in the English literature.

Intramuscular Haemangioma of the Extensor Pollicis Brevis Muscle with Periosteal Reaction of the Radius: A Case Report and Review of the Literature

We report the rare case of a histologically proven mixed-type intramuscular haemangioma, adjacent to the periosteum of the radius, that caused a periosteal reaction. We also carried out a review of the literature relevant to this case. A 28-year-old male professional drummer presented with an 8-month history of pain and swelling of the dorsal aspect of the right radius. Diagnosis was established on the basis of plain radiographs and magnetic resonance imaging, and was confirmed by histology. The lesion was treated solely by resection of the soft-tissue mass. The patient remained asymptomatic 4 years post-operatively, with no radiographic signs of recurrence. From a review of the literature, it is evident that the terminology for haemangiomas causing regional bone changes is unclear. A new classification of the intramuscular haemangiomas is proposed in order to distinguish between lesions that, according to current knowledge, exhibit radiological and clinical areas of overlap.

Synovial haemangioma of the knee joint: an unusual cause of knee pain in a 14-month old girl

We report a histologically proven case of synovial haemangioma of the knee in a 14-month old girl who presented to the emergency department with an acute 1-day history of refusing to weight-bear on the right leg and a preceding 3-week history of a right knee lump. Physical examination revealed a non-tender, soft lump over the lateral infrapatellar region. Radiographs revealed a poorly defined soft tissue density over the infrapatellar fat pad and a suprapatellar joint effusion. Ultrasound was used to confirm the presence of a vascular soft tissue mass compatible with a synovial haemangioma within the infrapatellar fat pad which showed both intra-articular and extra-articular extension. There was good correlation of the ultrasound findings with magnetic resonance imaging (MRI), highlighting the potential clinical utility of ultrasound as an alternative imaging modality in establishing the pre-operative diagnosis and extent of a synovial haemangioma about the knee joint.

Intramuscular Ossified Haemangioma: A Rare Case Report

Haemangiomas are benign vascular neoplasm and intra muscular haemangioma constitutes 0.8% of all. Of these intramuscular ossified haemangioma is very rare. Here we are reporting a 30-year-old female admitted in our institute with complaints of pain and swelling in the medial aspect of right thigh for duration of one year. On evaluation CT showed well defined soft tissue lesion with calcification in vastus medialis which on guided aspiration showed numerous RBCs along with clusters of histiocytes with occasional calcified specs seen without presence of granulomas. The swelling was excised and histopathology confirmed intra muscular haemangioma with ossification. We hereby reporting a rare case of calcified intra muscular cavernous haemangioma which should be considered as differential diagnosis in any case of deep seated swelling with unexplained pain.

Intramuscular haemangioma of the tongue

Haemangiomas are one of the most common benign tumours. Clinicians come across haemangiomas of different subtypes at different locations in the body. They are often faced with the question of whether to treat them or leave it to the natural history of the disease. We present a case of the intramuscular variety of haemangioma found in the unusual location of the tongue in a 60-year-old woman. Fine needle aspiration was inconclusive and on magnetic resonance imaging, it mimicked a malignancy, which prompted treatment. We also review the unique pathology of this variety of haemangioma, which defines their treatment. The radiological attributes of the disease and recurrence rates of surgery are also discussed.

Intramuscular hemangiomas

Context:

Intramuscular hemangiomas are common in the general population and often present at medical and surgical clinics. Unfortunately, unfamiliarity with these lesions has led to a high percentage of misdiagnoses, inappropriate workup, and unnecessary referrals.

Evidence Acquisition:

A literature search was performed using Medline, Embase, PubMed, and Cochrane. The relevant articles and referenced sources were reviewed for additional articles that discussed the epidemiology, pathophysiology, investigation, and management of intramuscular hemangiomas. Clinical experience from experts in orthopaedics, musculoskeletal pathology, and musculoskeletal radiology was compared. The selected case studies are shared cases of the authors.

Results and Conclusion:

The pathophysiology of these lesions is not completely understood, but much can be implied from their underlying vascular nature. Isolated lesions are benign tumors that never metastasize but tend to enlarge and then involute over time. Magnetic resonance imaging is the imaging modality of choice. If a systemic disorder or malignancy is not suspected or has been ruled out, conservative management is the treatment of choice for most intramuscular hemangiomas.

A tentorial venous hemangioma presenting as an extra-axial mass in the ambient cistern: a case report

Although venous hemangiomas are one of the most common soft-tissue tumors, venous hemangiomas in the central nervous system are extremely rare. We present an unusual case of venous hemangioma originating from the interdural space of the tentorium. A 32-year-old woman was incidentally found to have extra-axial mass occupying the left ambient cistern. This tumor was observed for the first 4 years as it was completely asymptomatic. Surgical resection was later recommended when the tumor grew. The mass originated from between the two layers of the anteromedial tentorial incisura. There were no findings indicative of previous hemorrhage inside the mass. The matrix of the mass was firm and vascular, resembling a fibrous meningioma. Gross total resection was achieved without any neurological deficit. Pathological examination revealed a dense fibrous connective tissue with a proliferation of vessels marked by thickened walls. A spindle cell proliferation in the vessel walls did not stain with the antibody to S-100 protein. Movat stain demonstrated the venous character of the vessels. These results were histologically compatible with a venous hemangioma. Albeit extremely rare, a venous hemangioma, a distinct clinical and pathological entity from a venous angioma, can present an intracranial mass lesion.

Two cases of synovial haemangioma of the knee joint: Gd-enhanced image features on MRI and arthroscopic excision

Synovial haemangioma of the knee joint is a relatively rare benign condition with around 200 reported cases. We have recently encountered two cases of synovial haemangioma of the knee joint which preoperative MRI had assessed as highly suspect and which arthroscopic resection and subsequent histological examinations confirmed as synovial hemangiomas. Published studies have identified the following as characteristic MRI features of synovial haemangioma: homogenous low intensity to iso-intensity on T1 sequence; and heterogeneous high intensity with low-intensity septa or spots within the lesion on T2 sequence. However, several other intra-knee disorders mimic these characteristics. In our two cases, we found that gadolinium (Gd)-enhanced images, which have been relatively rarely discussed in the literature, were useful for making the diagnosis and for determining the extent of this condition. These images also were very helpful during arthroscopic excision of the lesion. Nonetheless, even after Gd enhancement, differentiating between malignant conditions such as synovial sarcoma and haemangioma solely from MRI findings is still difficult.

MRI manifestations of soft-tissue haemangiomas and accompanying reactive bone changes

OBJECTIVES

Soft tissue haemangiomas are common benign vascular lesions that can be accompanied by reactive changes in the adjacent bone structure. This study aimed to discuss the MRI features of soft-tissue haemangiomas with an emphasis on changes in bone.

METHODS

The radiographic and MRI findings of 23 patients (9 males, 14 females; mean age 25 years; age range 2-46 years) with soft-tissue haemangiomas were analysed retrospectively. MR images were evaluated for location of the lesion, size, configuration, signal features, contrast patterns, proximity to adjacent bone and changes in the accompanying bone. Excisional biopsy was performed in 15 patients.

RESULTS

Radiographs demonstrated phleboliths in 8 patients (34%) and reactive bone changes in 4 (19%). On MRI, T₁ weighted images showed that most of the lesions were isointense or isohyperintense, as compared with muscle tissue; however, on T₂ weighted images all lesions appeared as hyperintense. Following intravenous gadolinium-diethylene triamine pentaacetic acid (DTPA) administration, homogeneous enhancement was observed in 3 lesions and heterogeneous enhancement was seen in 19. No enhancement was observed in one patient. Bone atrophy adjacent to the lesion was observed in four patients.

CONCLUSION

MRI is the most valuable means of diagnosing deep soft-tissue haemangiomas. Bone changes can accompany deeply situated haemangiomas; in four of our patients, we found atrophy of the bone adjacent to the lesion. To our knowledge, this is the first report in the literature regarding atrophy of the bone adjacent to a lesion.

Intramuscular haemangioma of flexor digitorum brevis

Intramuscular haemangioma of the foot is rare. We present two cases of intramuscular haemangioma in the flexor digitorum brevis (FDB). All of our patients presented with painful mass in the sole. Subsequent ultrasound and magnetic resonance imaging suggested intramuscular haemangioma of FDB muscle. We have performed en-bloc excision in both of our cases, and long-term follow up showed no functional deficit or recurrence of the lesion.

Synovial hemangioma of the knee joint in a 12-year-old boy: a case report

INTRODUCTION

Synovial hemangioma is a rare condition and is frequently misdiagnosed, leading to a diagnostic delay of many years.

CASE PRESENTATION

We present a case of an atypical synovial hemangioma in a 12-year-old Caucasian boy with a diagnostic delay of 3 years.

CONCLUSION

It is important to know that synovial hemangioma mostly affects the knee joint, showing recurrent bloody effusions without a history of trauma. If there are no intermittent effusions, the diagnosis will be even more difficult. In cases of nonspecific symptoms and longstanding knee pain the diagnosis of a synovial hemangioma should also be considered in order to avoid diagnostic delay. Magnetic resonance imaging is the main diagnostic tool to evaluate patients with synovial hemangioma, showing characteristic lace-like or linear patterns.Angiography can identify feeder vessels and offers the possibility of embolisation in the same setting. Surgical excision, either done per arthroscopy or per arthrotomy, is recommended as soon as possible to avoid the risk of damage to the cartilage.

Madura foot masquerading as a hemangioma

Mycetoma, also known as Madura foot, is a rare soft-tissue granulomatous infection caused by Actinomyces or true fungi. The MRI “dot-in-circle” sign has been described as a characteristic finding of mycetoma. This sign represents spherical T2 bright masses containing central and intervening low-signal-intensity foci. However, other soft-tissue masses can have similar appearances. We present a case of a Madura foot that was erroneously given the imaging diagnosis of soft-tissue hemangioma due to the presence of serpiginous enhancing masses with the “dot-in-circle” sign (believed to be due to phleboliths).

The role of the plain radiograph in the characterisation of soft tissue tumours

A radiograph is often the first investigation to be requested when a patient presents with limb pain or a mass. Whilst we do not advocate that this is the only investigation to be employed in the evaluation of such patients, a working knowledge of the variety of abnormal findings that can present in the soft tissues on radiographs remains useful. We reviewed the radiographic findings of soft tissue masses from a prospectively compiled database of all such lesions presenting to a specialist orthopaedic oncology service over the past 8 years. Of the cohort of 1,058 individuals with a proven soft tissue tumour, 454 had had a radiograph taken of the affected area. Of these, 281 (62%) patients had a positive radiographic finding. The most common findings were a visible soft tissue mass (n = 141), the presence of calcification (n = 76), fat (n = 32) and evidence of bone involvement (n = 62). More than one finding was sometimes present in the same patient. These findings were present in both benign and malignant tumours. This review article describes the incidence and diagnostic relevance of these plain film findings for suspected soft tissue tumours.

Synovial hemangioma of the knee joint with cystic invasion of the femur: a case report and review of the literature

Synovial hemangioma is a rare benign intra-articular tumor. It may be a cause of pain and recurrent joint swelling in children and young adults. This report presents a 29-year-old patient with a synovial hemangioma in the left knee joint. Magnetic resonance imaging (MRI) showed the typical features of a soft tissue hemangioma and revealed a cystic invasion of the medial femur. The tumor was locally excised and a partial synovectomy was performed. The lesion of the femur was filled with autologous bone from the iliac crest. Histological examination confirmed the diagnosis of a synovial hemangioma. In a review of the recent literature we report the common features of a synovial hemangioma, with emphasis on its diagnosis and therapy.

A rare intramuscular hemangioma - case report

Intramuscular hemangiomas are rare, slow growing, angiomatous tumors, generally asymptomatic, and rarely presenting with complications. We report a rare case of a Hemangioma of the Flexor Digitorum Superficialis in a 13-year-old boy, present since birth and with extensive involvement, necessitating excision of the muscle. The patient is presently doing well, barring minimal weakness in finger flexion.

Unusual knee swelling: a diagnostic dilemma

Haemangioma is a common benign soft tissue tumour. Intramuscular haemangiomas are rare but pose quite a diagnostic challenge. An intramuscular haemangioma can be confused with other soft tissue swellings including abscess. We present a case report of swelling around the knee in an adolescent patient, which was ultimately diagnosed and treated as intramuscular haemangioma of the quadriceps muscle.

Intramuscular hemangioma mimicking myofascial pain syndrome: a case report

Intramuscular hemangioma, an infrequent but important cause of musculoskeletal pain, is often difficult to establish the diagnosis clinically. This report describes a case of a 32-yr-old woman who presented with severe left calf pain for 10 yr. Initial conservative treatments consisting of intramuscular electrical stimulation, herb medication, acupuncture, and intramuscular lidocaine injection under the diagnosis of myofascial pain syndrome in other facilities, failed to alleviate the symptoms. On physical examination, there was no motor weakness or sensory change. Conventional radiography of the leg revealed a soft tissue phlebolith. Conventional angiography study showed hemangioma. Intramuscular hemangioma within the soleus muscle was confirmed by magnetic resonance imaging. Following surgical excision of the hemangioma, the patient's symptom resolved completely. Intramuscular hemangioma is a rare cause of calf pain and should be considered in the differential diagnosis if a patient with muscle pain, particularly if associated with a soft tissue mass, fails to respond to conservative treatment.

Synovial Hemangioma of the Knee: A Case Report

We present a case report of a rare synovial hemangioma of the knee. Magnetic resonance imaging (MRI) demonstrated typical signal characteristics and enhancement. Histologic findings were confirmatory. Imaging characteristics, differential diagnoses and classification are discussed. A review of the relevant literature is provided.

Imaging strategies in intramuscular haemangiomas: an analysis of 20 cases

The purpose of this study was to review the correlation between the imaging studies and the histological findings in the diagnosis of this disease. We retrospectively reviewed 21 lesions in 20 patients (median age, 23.7 years old) who had been diagnosed with cavernous haemangiomas (n=11), capillary (n=6), and mixed (n=3) types. The imaging studies were obtained with plain film radiography (n=20), Tc-99 m bone scans (n=5), angiography (n=7) and magnetic resonance imaging (MRI; n=20). All the patients underwent marginal to wide excision. Based on the imaging studies, the rate of accurate prediction of intramuscular haemangioma using MRI in our study was 90%. Using the preoperative imaging studies and surgical excisions, only one (5%) local recurrence happened 2 years after marginal excision. The remaining patients were free of disease. For the avoidance of recurrence, wide excision is necessary with the help of the imaging studies, which can provide more specific information, making possible the preoperative identification of characteristic features of the tumuor.

Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients

The purpose of our study was to assess prospectively the value of MRI in characterization of soft tissue tumors (STT) and soft tissue tumor-like lesions in a multi-institutional setting by a group of experts. The material consisted of 548 untreated and proven STT or tumor-like lesions originating from a multi-institutional database of STT in which 930 consecutive patients with STT examined by MRI were registered between 1 January 2001 and 28 April 2003. Based on MRI findings, a suitably ordered differential diagnosis was made in consensus by two radiologists (J.L.M.A.G and A.M.D.S). MRI diagnoses were compared with histology results (455 cases, 83%) and/or 6-month follow-up (93 cases, 17%) as reference standards. The correlation between the MRI and histological diagnosis and between the radiological and histological phenotype were statistically determined. One hundred twenty-three patients presented with a malignant STT; 425 patients presented with a benign one. Concerning differentiation between malignant and benign lesions (dignity), a sensitivity of 93%, specificity of 82%, negative predictive value (NPV) of 98% and positive predictive value (PPV) of 60% with accuracy of 85% were obtained. Concerning phenotype characterization, if only the first MRI diagnosis was taken into account, a sensitivity of 67%, specificity of 98%, NPV of 98%, PPV of 70% and accuracy of 96% were obtained. For benign lesions, sensitivity of 75%, specificity of 98%, NPV of 98%, PPV of 76% and accuracy of 97% were obtained. The phenotype's definition of malignant STT had a sensitivity of 37%, a specificity of 96%, NPV of 96%, PPV of 40% and an accuracy of 92%. A correct diagnosis compared with histological assessment was proposed in 227(50%) of the 455 histologically confirmed cases. Despite non-quantified MR parameter evaluation, the results of our prospective study were better than those reported in previous studies and demonstrated the need for a centralized approach to such rare pathology.

Vascular malformations in muscles around the knee presenting as knee pain

Vascular malformations involving the muscles around the knee can be a cause of knee pain. We studied ten such cases. All underwent magnetic resonance (MR) imaging which confirmed the diagnosis. Eight cases underwent wide surgical excision of the lesion, histology of which showed a vascular malformation with predominantly venous element. There was no recurrence in any of the operated cases at the last follow-up. We believe that most of these lesions can be treated successfully by careful preoperative planning aided by MR imaging and a wide-open excision of the lesion.