Pediatric Soft Tissue Hemangioma

Congenital soft tissue hemangioma

  • Etiology: Vascular consisting of capillaries intermixed with dilated vessels
  • Imaging US: Variable appearance with heterogeneous appearance and calcification and necrosis and variable margins
  • Imaging US Color Doppler: Variable vascularity
  • Imaging US Spectral Doppler: Shunting
  • Imaging MRI:
    — T1WI post contrast: Moderate post-contrast enhancement compared to infantile hemangioma which shows intense enhancement
    — T2WI: Tortuous and varying-sized flow voids
  • DDX: May be misdiagnosed as AV malformation or AV fistula on spectral doppler US due to high flow rates
  • Complications:
  • Treatment: None, excision, embolization, steroids
  • Clinical:
    — Prenatal detection
    — Fully formed and full size at birth and proliferation ceases by birth
    — Rapidly involuting (RICH) with involution over 3-12 months and non-involuting (NICH) with lesion staying stable and partially involuting (PICH) with partial involution of lesion
    — Consumptive coagulopathy which is mild and transient
    — GLUT-1 negative
    — No history of a mass beyond the skin surface

Infantile soft tissue hemangioma

  • Etiology:
    — Highly cellular tumor with lobular architecture and plump endothelial cells that express GLUT-1 antigens throughout life of tumor
    — No capsule
  • Imaging US:
    — In cutaneous and subcutaneous tissue
    — Solid with patchy increased echogenicity
    — Variable margins
  • Imaging US Color Doppler: High vessel density
  • Imaging US Spectral Doppler: Low resistance waveforms
  • DDX:
  • Complications:
    — Tend to be multiple
    — Consider liver US if greater than or equal to 2 soft tissue lesions
  • Treatment: Propranolol (beta blocker), steroids (anti-angiogenesis), cytokines
  • Clinical:
    — Present within 1-3 months after birth – presentation at birth uncommon
    — Proliferation in first weeks to months of life
    — Involution over years
    — No coagulopathy
    — GLUT-1 positive
    — Cherry red (superficial) or blue (deep) depending on depth of lesion
  • Note: If lesion is:
    — Beard distribution – Possible airway compromise due to association with subglottic hemangiomas
    — Periorbital – Growth may compress optic nerve and cause blindness
    — Midline sacrum – Do MRI to rule out spinal dysraphism
    — Unilateral facial distribution – Consider PHACES syndrome

Radiology Cases of Soft Tissue Hemangioma

US of soft tissue hemangioma
Sagittal grayscale US of the right eyebrow (above) shows a solid homogenous soft tissue mass in the subcutaneous tissue that has marked vascularity on color doppler US (below).
US and MRI of soft tissue hemangioma
Transverse color and spectral US of the palpable lesion (above left) shows a discrete well circumscribed soft tissue mass with markedly increased vascularity. Axial T1 MRI without contrast of the spine (below left) shows the palpable mass to be in the subcutaneous tissues and to have low signal intensity, while on the axial T2 MRI (above right) the mass has high signal intensity. Axial T1 MRI with contrast and fat supression (below right) shows the mass to enhance markedly and uniformly.
MRI of soft tissue hemangioma of the scalp
Axial T2 MRI without contrast of the brain (above) shows a well defined lesion in the subcutaneous tissues just to the left of midline that has heterogenous signal intensity. The lesion shows primarily low signal intensity on axial T1 MRI without contrast (below left) and enhances markedly and fairly uniformly on axial T1 MRI with contrast and fat saturation (below right).
Radiograph and CT of soft tissue hemangioma
Lateral radiograph of the airway and axial CT without contrast of the neck shows a large heterogenous mass that displaces and compresses the trachea.

Clinical Cases of Soft Tissue Hemangioma

Clinical image of soft tissue hemangioma of toe
Clinical image shows a large, raised, red, coarse lesion involving almost the entire first toe.
Clinical image of soft tissue hemangioma
Clinical image shows a large, raised, red, coarse lesion involving the lower left lip and associated perioral soft tissues.
Clinical image of orbital soft tissue hemangioma
Clinical image shows a red / purple mass over the superior aspect of the right orbit.