Journal of Postgraduate Medicine
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IMAGES IN PATHOLOGY
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Year : 2000  |  Volume : 46  |  Issue : 2  |  Page : 132-3  

Images in pathology: verrucous haemangioma.

AB Rupani, CV Madiwale, P Vaideeswar 
 Department of Pathology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India

Correspondence Address:
A B Rupani
Department of Pathology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
India




How to cite this article:
Rupani A B, Madiwale C V, Vaideeswar P. Images in pathology: verrucous haemangioma. J Postgrad Med 2000;46:132-3


How to cite this URL:
Rupani A B, Madiwale C V, Vaideeswar P. Images in pathology: verrucous haemangioma. J Postgrad Med [serial online] 2000 [cited 2019 Jul 21 ];46:132-3
Available from: http://www.jpgmonline.com/text.asp?2000/46/2/132/294


Full Text

A 16-year-old male complained of a swelling on skin of volar aspect of the forearm, present since early childhood. At the age of eight years, the swelling had been excised, however, recurrence was noted within a few months. There was occasional pain and bleeding from the lesion. At the time of current presentation, patient gave the history that the swelling used to diminish on elevation of the arm. Physical examination revealed a soft, compressible 16 x 8 cm elevated skin lesion with a papillary keratotic surface with focal ulceration and haemorrhage. Smaller, discrete satellite nodules with a similar appearance were noted in the vicinity. A venogram was performed and the findings suggested a venous malformation. Complete excision of the lesion with skin grafting was performed. At surgery, it was found that the malformation enveloped the radial artery and extended along the flexor tendons.

Gross examination of skin resection revealed that the areas beneath the papillary keratotic surface had a spongy appearance due to presence of multiple, thin walled spaces [Figure:1]. Microscopy revealed papillomatosis and hyperkeratosis of epidermis with few purulent crusts on the surface. The papillary dermis showed multiple, thin walled, dilated blood filled spaces [Figure:2]. Similar spaces were present in the lower dermis and subcutaneous tissue. There was pseudoepitheliomatous hyperplasia of the epidermis and the vascular spaces present between the elongated rete pegs appeared as though they were enclosed within the epidermis. A diagnosis of verrucous haemangioma was made.


  ::   DiscussionTop


Verrucous haemangioma is a rare vascular malformation seen as a capillary or cavernous haemangioma involving the dermis and subcutaneous tissue[1]. Diagnosis of verrucous haemangioma is seldom made on clinical examination. The lesion is generally noted at birth or in early childhood and is often located on the lower extremities[2]. The early lesions are bluish red in colour, secondary infection is a frequent complication and this results in reactive papillomatosis and hyperkeratosis and thus the older lesions acquire a verrucous or warty surface[1]. This warty surface and frequent dark, discoloured appearance due to haemorrhage may prompt a diagnosis of verruca, angiokeratoma, seborrhoeic keratosis or even malignant melanoma[1],[3]. Spread by formation of satellite nodules as seen here, is quite characteristic.

The histologic appearance closely resembles an angiokeratoma as both lesions show vascular spaces just beneath a papillomatosis and hyperkeratotic epidermis[3]. However, in contrast to angiokeratoma, the vascular spaces in verrucous haemangioma also involve the lower dermis and subcutaneous tissues and therefore the lesion may recur if inadequately excised[1],[2]. In fact, verrucous haemangiomas are true vascular malformations, unlike angiokeratomas which represent telangiectasias secondary to injury[1],[3].

Identification is essential to avoid clinical and histologic misdiagnosis and to ensure an adequate surgical excision to prevent recurrences.

References

1 Imperial R, Helwig EB. Verrucous hemangioma – A clinico-pathologic study of 21 cases. Arch Derm 1967; 96:247-253.
2Calonje E, Wilson-Jones E. Tumours like conditions of blood vessels and lymphatics. In: Elder D editor. Lever’s histopathology of the skin, 8th ed. Philadelphia: Lippincott-Raven; 1997. pp 889-932.
3Imperial R, Helwig EB. Angio-keratoma. Arch Derm 1967; 95:166-175.

 
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