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Intramuscular Hemangioma of the Leg

Intramuscular hemangioma. A 12-year-old male patient complains of pain in the right calf since he was eight years old, unrelated to trauma and progressively worsening over this period. He sought medical attention where he was diagnosed with “ growing pains ”. He was treated with painkillers and recommended rest, with no improvement in his condition. He took x-rays of the right leg, which, according to the patient’s mother, showed no changes.

Over the years, the pain complaint intensified and only improved with forced knee flexion or external compressive bandaging, performed by the patient himself. In the last six months the pain has become disabling, preventing walking. A palpable bulge appeared in the posterior region of the left leg, which reduced in size in the morning and increased at the end of the day. The patient reported a reduction in the volume of the palpable mass with elevation of the limb.

Figura 1: Radiografia da perna direita, visão de frente, evidenciando discreta calcificação no terço proximal, que aparenta ser intra-ósseo. Essa impressão desaparece quando se observa a imagem da radiografia em perfil.
Figure 1: Radiograph of the right leg, frontal view, showing discrete calcification in the proximal third, which appears to be intraosseous. This impression disappears when looking at the X-ray image in profile.
Figura 2: Radiografia da perna direita, perfil, evidenciando calcificações em tecidos moles, na região posterior e proximal da perna. Essa imagem é sugestiva de tumor vascular que sofre calcificação.
Figure 2: Radiograph of the right leg, profile, showing calcifications in soft tissues in the posterior and proximal region of the leg. This image is suggestive of a vascular tumor undergoing calcification.
On 09/09/2014, a Doppler ultrasound of the right leg was performed, which showed a hypovascular lesion, with probable phleboliths, located in the proximal and medial portion of the soleus muscle belly. Given this finding, the attending physician made the diagnostic hypothesis of a soft tissue tumor and referred the patient to our reference service.
Figura 3: lesão hipovascular ao doppler, com prováveis flebólitos, localizada na porção proximal e medial do ventre muscular solear, sugestiva de hemangioma.
Figure 3: hypovascular lesion on Doppler, with probable phleboliths, located in the proximal and medial portion of the soleus muscle belly, suggestive of hemangioma.
Figura 4: A lesão aparenta ser hipovascular, do ponto de vista arterial. Trata-se de provável hemangioma que é formado por lagos venosos e portanto muito vascularizado. Isso é importante quando se opta pela ressecção, pois pode levar a grandes sangramentos, quando é operada.
Figure 4: The lesion appears to be hypovascular, from an arterial point of view. It is a probable hemangioma that is formed by venous lakes and is therefore very vascular. This is important when opting for resection, as it can lead to heavy bleeding when operated on.
Figura 5: Lesão com 6 cm por 1,8 cm por 3,0 cm.
Figure 5: Lesion measuring 6 cm by 1.8 cm by 3.0 cm.
Figura 6: Laudo do Ultrassom
Figure 6: Ultrasound Report
Figura 7: Rm coronal T1, onde se visualiza sinal elevado no ventre muscular medial do músculo sóleo.
Figure 7: Coronal T1 MRI, where high signal is seen in the medial muscle belly of the soleus muscle.
Figura 8: Rm coronal T1, com supressão de gordura e contraste Gadolíneo. A lesão apresenta alto sinal, o que sugere vascularização interna do tumor.
Figure 8: Coronal T1 MRI, with fat suppression and Gadoline contrast. The lesion has a high signal, which suggests internal vascularization of the tumor.
Figura 9: Rm coronal T2, visualizamos lesão de alto sinal no ventre muscular medial do músculo sóleo na perna direita.
Figure 9: Coronal T2 MRI, we visualize a high signal lesion in the medial muscle belly of the soleus muscle in the right leg.
When evaluating the patient’s clinical condition, with pain in the proximal region of the right leg, four years of evolution, progressive worsening, improvement with external compression and elevation of the limb, we made the clinical hypothesis of intramuscular hemangioma and requested an MRI to confirm the diagnosis and plan a possible resection.
Figura 10: Rm axial T2 evidencia lesão de alto sinal, no ventre muscular do soleo medial direito, com aspecto de “cacho de uva”.
Figure 10: Axial T2 MRI shows a high-signal lesion in the muscle belly of the right medial soleus, with a “bunch of grape” appearance.
Figura 11: Rm axial T1 com contraste, lesão apresentando intenso realce, sugerindo que o tumor é altamente vascularizado.
Figure 11: Axial T1 MRI with contrast, lesion showing intense enhancement, suggesting that the tumor is highly vascularized.
The magnetic resonance images showed an expansive and well-defined lesion in the medial belly of the soleus muscle, without contact with the bone and approximately 45 mm from the femorotibial joint line, measuring around 44 mm in its longest axis. The lesion presented hypersignal on T1 and T2 with a “bunch of grapes” appearance in addition to intense contrast enhancement. This suggests a highly vascularized lesion.
Figura 12: Rm axial T2, com lesão de alto sinal no ventre muscular do sóleo medial direito, evidenciando a proximidade do tumor com o feixe vascular tibial posterior.
Figure 12: Axial T2 MRI, with a high-signal lesion in the muscular belly of the right medial soleus, showing the proximity of the tumor to the posterior tibial vascular bundle.
Figura 13: Laudo da ressonância magnética.
Figure 13: MRI report.

Hemangioma is a benign vascular tumor very similar to normal blood vessels. It can be difficult to distinguish between a hemangioma, a hamartoma (embryonic remnant) and a vascular malformation. It is most common in the skin and subcutaneous tissue. When it appears in the muscles, the lower limb is the most common. The presence of pain and edema associated with venous stasis is common.

   With this history, clinical picture and imaging characteristics, one can practically conclude the diagnosis of a vascular lesion, with a high probability of being an intramuscular hemangioma. 

   Given the patient’s disabling pain, surgical treatment to resect the lesion is justified, aiming to alleviate the symptoms. In this situation, the biopsy, despite confirming the histological diagnosis, may be dispensed with. As it is a highly vascularized lesion, a percutaneous biopsy could cause difficult-to-control bleeding, in addition to the possibility of an inconclusive diagnosis of normal vascular tissue.

    Arterial embolization is a form of control for some neoplastic lesions and can eventually be used before surgical resection, to reduce the size of the lesion, symptoms and intraoperative bleeding. In the case of hemangioma, embolization is limited because it is essentially a venous lesion, as confirmed by the preoperative angiography performed.

Figura 14: Arteriografia evidenciando ausência de pedículo vascular entre a lesão e o feixe arterial.
Figure 14: Arteriography showing the absence of a vascular pedicle between the lesion and the arterial bundle.
Figura 15: Nodularos calcificados na região proximal e medial da perna, com mínimo enchimento vascular através de pequenos ramos geniculares e outro proveniente a artéria tibial posterior.
Figure 15: Calcified nodules in the proximal and medial region of the leg, with minimal vascular filling through small genicular branches and another originating from the posterior tibial artery.
Figura 16: Laudo da Angiografia.
Figure 16: Angiography report.
We opted for surgical resection of the lesion. The patient was positioned in the right lateral decubitus position and we performed a medial longitudinal incision on the right leg. Dissection of the pes ansus tendons, release of the medial head of the gastrocnemius and exposure of the soleus muscle belly, where the lesion was located. We performed segmental resection of the soleus involving the lesion followed by reinsertion of the medial head of the gastrocnemius. Post-operatively, we chose to keep the patient immobilized for 6 weeks, to ensure healing of the reinserted gastrocnemius.
Figura 17: Paciente em decubito lateral direito. Incisão de aproximadamente 15 cm na face medial da região proximal da perna, acompanhando a flexão do joelho o que permite o relaxamento de músculos no intra operatório, como o gastrocnemio.
Figure 17: Patient in right lateral decubitus. Incision of approximately 15 cm on the medial surface of the proximal region of the leg, following knee flexion, which allows intraoperative relaxation of muscles, such as the gastrocnemius.
Figura 18: Aprofundamos a incisão com abertura da fáscia longitudinalmente a pele. Observamos a porção medial do gastrocnemio ao fundo e os tendões da pata de ganço cruzando obliquamente o campo cirurgico.
Figure 18: We deepen the incision by opening the fascia longitudinally to the skin. We observed the medial portion of the gastrocnemius in the background and the tendons of the paw obliquely crossing the surgical field.
Figura 19: Dissecção longitudinal do ventre muscular do gastrocnêmio. A lesão encontra-se abaixo desta estrutura, no ventre muscular do Sóleo.
Figure 19: Longitudinal dissection of the gastrocnemius muscle belly. The lesion is located below this structure, in the muscular belly of the Soleus.
Figura 20: Após liberar o ventre muscular do gastrocnêmio, reparamos o tendão proximal, junto a sua origem, com fios de ethbond.
Figure 20: After releasing the muscular belly of the gastrocnemius, we repaired the proximal tendon, close to its origin, with ethbond threads.
Figura 21: Liberação da origem do gastrocnêmio, o que permite maior mobilidade dessa estrutura, fascilitando afasta-la posteriormente. Visualização de parte da lesão no ventre muscular do Sóleo.
Figure 21: Release of the origin of the gastrocnemius, which allows greater mobility of this structure, facilitating its removal later. Visualization of part of the lesion in the soleus muscle belly.
Figura 22: Dissecção da porção proximal da lesão e reparo com fios, para facilitar sua manipulação. Esta lesão é muito vascularizada e a ressecção ampla, apesar de não obrigatória, por ser benigno, evita sangramentos excessivos.
Figure 22: Dissection of the proximal portion of the lesion and repair with threads, to facilitate its manipulation. This lesion is very vascular and wide resection, although not mandatory, as it is benign, prevents excessive bleeding.
Figura 23: O ventre muscular é reparado, dissecado e tensiondado. A lesão, dentro do ventre muscular, será ressecada em bloco. Isso diminui a perda sanguinea e não leva a déficit funcional significativo para o paciente
Figure 23: The muscle belly is repaired, dissected and tensioned. The lesion, within the muscle belly, will be resected en bloc. This reduces blood loss and does not lead to significant functional deficits for the patient.
Figura 24: lesão de aproximadamente seis por dez cm, ressecada em bloco. Grande tamanho para paciente pediátrico, o que explica o efeito de massa e dor.
Figure 24: lesion measuring approximately six by ten cm, resected en bloc. Large size for pediatric patient, which explains the mass effect and pain.
Figura 25: Peça cirúrgica, visão em perfil. Observamos a lesão totalmente envolta por tecidos sadios.
Figure 25: Surgical specimen, profile view. We observed the lesion completely surrounded by healthy tissue.
6 months post-operative. In the video, we showed complete recovery of motor function. The patient walks normally without pain and is able to stand on tiptoe, demonstrating activity of the triceps surae muscle.

Video 1 : One month post-operative. Observe the reduction of the operated right calf, compared to the left. Despite resection of the medial belly of the gastrocnemius, we did not observe any functional deficit.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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