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Copyright 2012 American Academy of Orthopaedic Surgeons
Hemangioma

A hemangioma is a benign (noncancerous) tumor made up of blood vessels. There are many types of hemangiomas, and they can occur throughout the body, including in skin, muscle, bone, and internal organs.

Most hemangiomas occur on the surface of the skin or just beneath it. They often develop on the face and neck, and can vary greatly in color, shape, and size.

Because hemangiomas very rarely become cancerous, most do not require any medical treatment. However, some hemangiomas can be disfiguring, and many people seek a doctor's care for cosmetic reasons. In most cases of hemangioma, treatment does not involve surgery. Instances when surgery may be necessary include for tumors that are deep in muscle or bone, or for tumors on the skin that cause problems with vision, breathing, or eating.

Description

A hemangioma occurs when small blood vessels begin to multiply at an abnormal rate and form a mass or lump. It is possible to have more than one hemangioma.

There are several types of hemangioma. Some of the more common types are described below.

  • Capillary hemangioma. This is the most common type of hemangioma. It is made up of small capillaries that are normal in size and diameter, but high in number. These capillaries form a tightly packed group held together by thin, connective tissue. When it develops in the skin, a capillary hemangioma is often referred to as "superficial." Because of their proximity to the surface of the skin, capillary hemangiomas are typically brighter red in color. They can be small or large, They may be flat to the skin, raised, or protrude out as a nodule. Some appear as a spongy mass that covers an entire extremity (called "diffuse hemangioma" or "angiomatosis").
  • Cavernous hemangioma. In contrast with a capillary hemangioma, a cavernous hemangioma is made up of larger blood vessels that are dilated (widened). The blood vessels are not as closely packed as in a capillary hemangioma, and the spaces (or "caverns") between them are filled with blood. When they develop in the skin, cavernous hemangiomas are often referred to as "deep," and sometimes first appear as a bluish swelling underneath the skin. Like capillary hemangiomas, this type also varies greatly in size.
  • Compound hemangioma. Some hemangiomas are a mix of the capillary and cavernous types.
  • Lobular capillary hemangioma (pyogenic granuloma). These small, red bumps often appear on the hands, face, and arms. Because they contain so many blood vessels, they bleed easily — often with just mild contact. This type of hemangioma is also sometimes referred to as a "pregnancy tumor" because they often appear during pregnancy, typically in the nose and mouth.

Infantile Hemangioma

Hemangiomas of the skin are common in infants — they represent 7% of all benign tumors in infancy and childhood. They are sometimes present at birth, but most typically appear within the first weeks or months of life. Most infant hemangiomas are capillary hemangiomas, although cavernous and compound types do occur. Girls are affected slightly more often than boys.

Common infantile hemangiomas follow the same growth pattern: a period of rapid growth, often during the first year, followed by a period of tumor shrinkage (called involution). How long it takes for the tumor to reach full-size and then shrink varies greatly, but most tumors have finished involution by the time the child reaches puberty.

Most of these hemangiomas will shrink completely on their own and require no treatment. However, some hemangiomas can cause problems with vital functions like breathing, eating, and seeing, and require some form of treatment. In addition, because these tumors can grow to be large and often appear on the face, neck, and scalp, a child's emotional needs must be considered when determining treatment options.

In addition, hemangiomas that are present at birth (called congenital hemangioma), follow a different growth pattern. These hemangiomas are fully grown at birth and either completely involute during a baby's first year (called rapidly involuting congenital hemangioma), or they do not involute at all (called non-involuting congenital hemangioma).

Hemangiomas In Muscle, Bone, and Internal Organs

Although not as common as hemangiomas of the skin, hemangiomas do develop in other tissues, including muscle and bone.

Intramuscular hemangioma. Hemangiomas in muscle tissue can develop at any age, but most often occur in young adults. Capillary hemangiomas are more common in muscle than cavernous and compound types. Any muscle can be involved.

Because they are located within the muscle, these hemangiomas often show no visible signs, although some may cause swelling in the area of the tumor that increases with activity. These tumors are often painful and require treatment.

This angiogram image shows a hemangioma deep in the thigh.

Bone hemangioma. The hemangiomas that occur in bones typically occur in the skull or spine and are most common in people who are 50 to 70 years of age. Capillary and cavernous types are the most common hemangiomas found in bone. They can grow on the surface or deeper into the center canal of a bone. Because they typically do not cause symptoms, these tumors are often found by chance when an x-ray image is taken for other purposes.

Internal organ hemangioma. Although uncommon, hemangiomas can develop in internal organs, most often the liver and intestines. Like hemangiomas found in bone, hemangiomas in internal organs are often found by chance during tests for other purposes. Unless they are causing symptoms, these hemangiomas do not require any treatment.

Vascular Malformations

Hemangiomas are often confused with vascular malformations, which are clusters of blood vessels that develop in arteries, veins, capillaries, or lymphatic vessels. Common types of vascular malformations include arteriovenous malformations (AVMs) and vascular ectasias.

Vascular malformations occur during fetal development. Although present at birth, some types of vascular malformation may not cause symptoms until adulthood.

Vascular malformations differ from infantile hemangioma in that they slowly grow along with the child and become more apparent with age. Because they do not shrink or resolve on their own, many types of vascular malformation in children require treatment.

Cause

Different types of hemangioma are associated with different causes, although exactly why hemangiomas develop is not well understood. For example, infantile hemangiomas are caused by errors in the development of the vascular system that occur during fetal development, but in many cases, the event that caused the error cannot be identified. Some hemangiomas develop after an injury, but whether an injury actually can cause a hemangioma has not been proven. Some hemangiomas develop with pregnancy and go away afterward. Some hemangiomas are associated with genetic abnormalities (for example, cavernous hemangiomas in von Hippel-Lindau disease).

There has been no proven connection between the development of hemangiomas and any particular occupation or exposure to chemicals or radiation. In addition, no known food, medication, or activity during pregnancy is known to cause a hemangioma in an infant.

Symptoms

Hemangiomas are usually painless, red to blue colored lesions on the skin, lips, or inside the mouth. They are often soft to the touch. Most often they are flush with the skin or slightly elevated, but sometimes they grow from a stalk. Superficial lesions may bleed or turn into sores, particularly if bumped or injured.

Deep hemangiomas in muscle may cause pain, as well as swelling around the hemangioma that increases with activity.

Hemangiomas in bones may cause pain and enlargement of the bone.

Doctor Examination

Hemangiomas can be confused with other vascular malformations. Because treatment may vary considerably depending on whether the lesion is a hemangioma or other type of malformation, a thorough doctor's examination is recommended.

Medical History and Physical Examination

Before a physical examination, your doctor will talk with you about your general health and current condition — or that of your child's, if you are a parent or family member. He or she will want to get a good history of the lesion, particularly how long the mass has been there and whether it has changed at all. Your doctor will want to know what symptoms — such as pain — are associated with the lesion, and when the symptoms began.

During the physical examination, your doctor will inspect and palpate any mass, noting exactly where it is located, what it feels like, and perhaps any surrounding changes in the skin.

Tests

Although doctors can often diagnose hemangiomas based on medical history and physical examination alone, imaging tests can be helpful.

X-rays and computed tomography (CT) scans. Although these tests create better pictures of dense structures like bone, plain x-rays and CT scans may show a cavernous hemangioma if it has calcifications. These calcifications are called phleboliths.

Magnetic resonance imaging (MRI) scans. These scans can create clear images of soft structures like a hemangioma. Hemangiomas in an MRI scan are often described as a "bag of worms."

Angiogram. In this test, dye is injected into the surrounding blood stream making the hemangioma show up in an x-ray image.

This MRI image of a patient's foot clearly shows the hemangioma (arrow).

Biopsy. It may be difficult to distinguish hemangiomas from other tumors, and a biopsy is sometimes necessary to confirm a diagnosis of hemangioma. In a biopsy, a tissue sample of the tumor is taken and examined under a microscope. Looking at the tissue under a microscope may be the best way to tell if the tumor is indeed a hemangioma and what sub-type it is.

During the biopsy, your doctor may give you a local anesthetic to numb the area and take a sample using a needle. Biopsies can also be performed as a small operation.

Blood tests. If there are multiple tumors or your symptoms are concerning for a specific disease pattern, your doctor may recommend blood tests for genetic analysis.

Differential Diagnosis

The imaging and tissue tests help your doctor differentiate hemangioma from other types of vascular malformations and soft-tissue tumors.

It is very important in planning treatment to differentiate hemangioma from more aggressive, cancerous vascular tumors like angiosarcoma.

Treatment

Treatment varies slightly by hemangioma subtype.

Nonsurgical Treatment

Observation. Although a hemangioma may not require any treatment, it is important to visit your doctor regularly to monitor any changes in the tumor.

Anti-inflammatory medication. If a tumor is growing near vital structures, such as the nose, lips, or eyelids, you doctor may recommend steroid medication. Steroids are often used to slow down the growth of the tumor. The drugs may be injected directly into the hemangioma, or given orally (in pill form).

Compression. Intermittent pneumatic compression is a treatment that uses inflatable sleeves or leggings to apply pressure to the tumor. It can be useful to decrease the swelling associated with a hemangioma. It will not, however, make the hemangioma go away.

Embolization. In this procedure, the blood supply to the tumor is closed off. This is a minimally invasive procedure where small particles are injected into the blood vessels to block them off. Sclerotherapy is a similar procedure where chemical agents are used to close off the vessels. These procedures can be very helpful in shrinking the tumor and decreasing pain. Often, however, the tumor will regrow its blood supply over time after these procedures. Embolization is also sometimes used prior to surgery to reduce the risk of heavy blood loss.

Surgical Treatment

Surgery may be recommended with a cavernous hemangioma if the lesion is destroying the healthy tissues surrounding it. In some cases, a hemangioma can cause painful symptoms severe enough to consider surgical treatment.

Procedure. The procedure to surgically remove a hemangioma is called an excision. General anesthesia is used to put you to sleep, then your doctor will make an incision in your skin and cut the tumor out.

Recovery. You will have a few stitches that your doctor will remove within a few weeks. Your doctor will wrap the area with a tight, compressive bandage and provide you with specific instructions about activity restrictions to guide your recovery.

Complications. The most common complication of surgery to remove a hemangioma is hemorrhage (blood loss). In addition, hemangiomas have a high tendency to come back after surgery, depending upon the type and location of the tumor.

Research

There is currently a great deal of research attempting to learn more about unregulated vascular proliferation, including hemangiomas. The development of medication directed at halting the development of blood vessels (anti-angiogenic) is an exciting area of research for many types of tumors.

Last reviewed: July 2012
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website.
Copyright 2012 American Academy of Orthopaedic Surgeons
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