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Infantile Hemangioma

Hemangiomas of the skin are common in infants — hence, people will call them "stork bites." They are sometimes present at birth, but most typically appear within the first weeks or months of life. Girls are affected slightly more often than boys.

Most infant hemangiomas are capillary hemangiomas, although cavernous and compound types do occur. 

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 or regression).

• Most infantile hemangiomas will completely regress (shrink) on their own and require no treatment. The timeframe for rapid growth and then involution varies greatly, but most infantile hemangiomas have finished involution by the time the child reaches puberty.
• However, some hemangiomas can cause problems with vital functions like breathing, eating, and seeing, and therefore require some form of treatment. 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.

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 (shrink) during a baby's first year (called rapidly involuting congenital hemangioma), or
• 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.

This angiogram image shows a hemangioma deep in the thigh.

Intramuscular hemangioma. Hemangiomas in muscle tissue can develop at any age, but they 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 and pain that increase with activity. These tumors are often painful and require treatment.

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 incidentally (by chance) when an X-ray or MRI image is obtained for another purpose.

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 another purpose. Unless they are causing symptoms, these hemangiomas do not require any treatment.

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. To get a good understanding of the lesion and its history, the doctor may ask:

• How long the mass or lesion has been present
• Whether/how the mass or lesion has changed — including any changes in size — over time
• Whether other symptoms — such as swelling and pain — are associated with the lesion, when those symptoms began, and which activities make the symptoms better or worse

During the physical examination, the doctor will inspect and palpate (feel) 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 computerized tomography (CT) scans. Although plain X-rays and CT scans are better for creating pictures of dense structures like bone, these imaging tests may show a cavernous hemangioma if it has calcifications (areas that have become hard, like stone; in fact, these calcifications are called phleboliths, which means "stone in the blood vessel" in Greek).

X-ray shows the small calcifications (phleboliths) inside the blood vessels of a cavernous hemangioma.

Reproduced from Johnson TR, Steinbach LS (eds): Essentials of Musculoskeletal Imaging. Rosemont IL. American Academy of Orthopaedic Surgeons, 2004, p. 155.

Magnetic resonance imaging (MRI) scans. MRI scans can create clear images of soft structures like a hemangioma. Hemangiomas in an MRI scan are often described as a "bag of worms" due to the way the blood vessels pack around one another.

This MRI scan shows a hemangioma in the sole of the patient's foot.

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

Biopsy. At times, it may be difficult to tell hemangiomas apart from other tumors, and a biopsy may be needed to confirm a diagnosis of hemangioma. In a biopsy, a tissue sample is taken from the tumor 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, if so, which subtype 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 with a small incision.

Blood tests. If there are multiple tumors or if 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 tell hemangioma apart from other types of vascular malformations and soft-tissue tumors.

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

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.

Beta blocker medication. Beta blockers are a medication that may be recommended depending on the type and size of a hemangioma. For certain types, such as superficial and infantile hemangiomas, beta blockers (a pill medication) may be given with the goal of slowing the lesion’s growth.

Anti-inflammatory medication. If a hemangioma is growing near vital structures, such as the nose, lips, or eyelids, your 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 (by mouth).

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

Embolization or sclerotherapy. In these procedures, the blood supply to the tumor is closed off. 

• Embolization 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 before surgery to reduce the risk of heavy blood loss.

Laser treatment. For some patients, lasers can be helpful in removing a tumor, preparing a tumor for other treatments, or decreasing pain and other unwanted symptoms. Depending on the size of the tumor and its location, multiple laser treatments may be needed. Laser treatment is typically reserved for hemangiomas involving the skin.

Surgical Treatment

Surgery may be recommended for 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. After general anesthesia is used to put you to sleep, your doctor will make an incision in your skin and cut the tumor out.

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

Complications. The most common complications of surgery to remove a hemangioma are blood loss and local recurrence (the tumor grows back).