Aggressive intramuscular hemangiomas in the upper extremity: A case report

Case report: A case of intercostal intramuscular hemangioma with sternal invasion

Background

Intramuscular hemangioma is a vascular malformation occurring in muscle tissues. It is most common in skeletal muscles of limbs, especially lower limbs in childhood. The intercostal intramuscular hemangioma with sternal invasion is very rare.

Case presentation

The 47-year-old female patient was hospitalized due to "suddenly chest pain for 4 days". Chest contrast-enhanced CT indicated bony changes in the sternum, accompanied by soft tissue shadows in the posterior sternum and diaphragmatic angle. After admission, physical examination showed: peristernal tenderness, percussion pain, other no obvious positive signs. PET-CT examination indicated that there was a high possibility of benign sternal changes. No cancer cells were found by sternal puncture. Surgical biopsy was performed and pathological findings were consistent with intramuscular hemangioma.

Conclusion

Intramuscular hemangioma with bone invasion is very rare, imaging examination is difficult to indicate obvious evidence, preoperative diagnosis is difficult, complete surgical resection is very important, more personalized treatment should be provided according to the overall situation of the patient.

Intramuscular Hemangioma of the Triceps Brachii Muscle: A Case Report

Introduction

Intramuscular hemangioma (IMH) is a rare type of benign tumor that represents less than 1% of all hemangiomas. Chronic pain and a palpable mass are the most common symptoms. Due to the atypical clinical characteristics of the disease, accurate diagnosis is difficult. Misdiagnosis of IMH as malignancy can occur due to similarities in imaging features between IMH and malignancy. To diagnose IMH accurately, multiple imaging modalities, including X-ray, MRI, CT, and 18F-FDG PET/CT, can be used. However, the final diagnosis of IMH is confirmed through histopathological examination.

Case

This case reports a 16-year-old girl diagnosed with IMH in the triceps brachii muscle. Seek medical attention due to pain and discomfort in the left shoulder. Initial imaging with contrast-enhanced MRI and CT suggested synovial sarcomata. The moderate uptake of FDG on positron emission tomography/computed tomography (PET/CT) also raised suspicions of malignancy. The pathological findings revealed an intramuscular hemangioma with thrombosis and thrombus organization.

Conclusion

The accurate diagnosis of IMH can be challenging due to the absence of distinct clinical symptoms and imaging findings. When evaluating periarticular intramuscular lesions, IMH should be considered if the MRI shows mixed signals with heterogeneous enhancement. Despite the moderate uptake of FDG seen in some IMH cases, it should not automatically rule out the possibility of IMH. Hence, a combination of imaging modalities and histopathological examination is crucial in ensuring a correct diagnosis of IMH.

The Challenges of Upper Extremity Intramuscular Hemangioma: a Case Study and Systematic Review

BACKGROUND

Intramuscular hemangiomas (IMHs) are rare, benign vascular tumors, comprising 0.8% of all hemangiomas. Upper extremity (UE) IMHs pose diagnostic and therapeutic challenges given their rarity, invasive nature, and potential for neurovascular involvement. We report a comprehensive systematic review of UE IMH management and a challenging case report.

METHODS

A systematic review was performed using PRISMA guidelines. Electronic databases were used to identify papers describing UE IMHs through 2019. Patient demographics, clinical presentation, management, complications, and outcomes were reviewed. Based on operative timing, cases were categorized as either "primary" (excision performed at initial diagnosis) or "secondary" (excision performed after failure of conservative treatment).

RESULTS

Eighteen articles encompassing 25 patients were included in our systematic review. Of those, 18 underwent primary excision and 7 underwent secondary excision. The majority involved the forearm or antecubital region. Complete excision, evaluated by gross examination or pathology, was reported in all primary cases and 71% secondary cases. Primary excisions demonstrated smaller mass size (19.4cm2 versus 165.3cm2) and superior reported functional outcomes (100% versus 33%). Complications were reported in 5% of the primary excisions compared to 71% of the secondary excisions, where 1 complication was a fatal hematoma.

CONCLUSION

The literature concerning UE IMH is limited to mostly case reports and several case series with the potential risk of bias. With careful dissection and microsurgical technique, wide local excision followed by complete reconstruction can be successfully performed at initial diagnosis for UE IMHs. At early stages, smaller lesion size significantly reduces the risk of functional impairment and complications.

Outcomes of Surgery for intramuscular Haemangiomas in the Extremities

PURPOSE

The objective of this case-series study was an assessment of outcomes of surgery for intramuscular haemangiomas in the extremities.

PATIENTS AND METHODS

Three women and one man with a mean age of 28 (23 - 34) years were operated on for intramuscular haemangiomas in the extremities, 3 in the forearms, and 1 in the calf. Three of them, 2 after resection of tumours from the forearm, and one after resection of the tumour in the calf, were available for follow-up assessment at an average of 1.5 (1 - 2) years after surgery. For patients with the tumour in the forearm, preoperative and at the follow-up examination pain was registered with use of the numeric rank scale (NRS), grip strength with the Jamar dynamometer, and function of the extremity with the quickDASH questionnaire. In the patient with the lower limb involvement, pain at the operation site, and efficiency (dexterity) of gait were evaluated.

RESULTS

All 3 patients with a follow-up examination reported significant reduction of pain. With regard to grip strength and hand function, one patient had significant improvement, whereas in the other, there were no real changes compared to preoperative. The patient with the calf involvement had no symptoms and walked normally. Over the follow-up period, no recurrence was noted.

CONCLUSION

The results of this small case-series study show that operative treatment of these rare tumours is safe and effective, however, it may be challenging in some cases.

Pronator Quadratus Hemangioma (PQH): A Rare Case Report and Review

The intramuscular hemangioma is a rare clinical entity in the upper extremity. Pronator quadratus hemangioma poses a considerable morbidity in the functional quality of life of an individual. MRI remains the gold standard modality in diagnosing this rare entity. Additionally, histopathological examination of the lesion corroborates for the same. PQH follows an individualized protocol in the management of the tumour. A 35-year-old female presented with pain over her right wrist from past 1 year which was dull aching, non-radiating, localised to the palmar aspect of distal 1/3rd of the right forearm. There was no history of trauma or infection over the right wrist. Swelling was present over the palmar aspect of distal 1/3rd of right forearm, which was non-pulsatile, non-fluctuant, non-transilluminant, non-compressible, non-reducible and skin over the swelling was pinchable. The movements of the right wrist were painful and restricted. There was no distal neurovascular deficit. The MRI of her right wrist and hand suggested the presence of low flow vascular malformation within pronator quadratus muscle. The patient underwent excision biopsy of pronator quadratus in toto without any neurological complications. No recurrence was noted in the follow-up period for 12 months. The pronator quadratus hemangioma is a rare clinical entity where the natural course of disease and pathophysiology remains controversial. MRI serves as the gold standard in the diagnosis of intramuscular hemangioma. The management of such tumour has to be individualized based on the functional needs of the patient. The natural course of the disease has to be elicited to decrease the morbidity and enhance the functional quality of life of the patient.

Intramuscular hemangioma within the biceps brachii causing the limitations of elbow extension and forearm pronation: A case report

RATIONALE

Intramuscular hemangiomas are rare benign vascular neoplasms, merely accounting for 0.8% of all hemangiomas. Moreover, there are few case reports of intramuscular hemangiomas in the upper extremities.

PATIENT CONCERNS

A 24-year-old male patient presented with a 5-year history of intermittent pain of the right elbow joint. He had observed a swelling of the right cubital fossa over the past 2 years, leading to the limitations of elbow extension and forearm pronation.

DIAGNOSIS

The patient was diagnosed with intramuscular hemangioma of the biceps brachii.

INTERVENTIONS

Surgical excision of the tumor was performed for this patient and postoperative early functional exercises were permitted.

OUTCOMES

The movements of the right elbow and forearm reached the normal range of motion at 5 weeks after surgery. There was no evidence of recurrence during the 5-month follow-up.

LESSONS

Optimal management of intramuscular hemangioma is critical, including precise evaluation, good microsurgical technique and early functional exercises, which may result in a satisfying outcome.