A 24-year-old young man presented with a history of three swellings on the right lower
limb for the last 4 years. Multiple patches of reddish-purple discoloration had been
noticed by his parents in infancy over the sites of present-day swellings. These patches
persisted and remained static with respect to size till the age of 20 years, when
they started growing to become large solid swellings. The swelling on the dorsum of
the foot was the first to appear, followed by another on the mid-anterolateral leg
and finally one on the anterior knee region ([Fig. 1a, b]). The main complaints of the patient were pain, ulceration, aesthetic deformity,
and inability to wear his shoe.
Fig. 1 (a,b) Swellings on the right knee, mid-anterolateral leg, and dorsum of the foot with
few sites of ulceration.
On local examination, the swelling on the dorsum of the foot extended onto the dorsum
of the medial four toes distally and proximally almost up to the ankle and measured
13 cm × 8 cm × 3 cm. Medially, it reached up to the sole skin and laterally spared
a small strip of skin on the fifth ray. It was hard in consistency with no mobility
over the underlying structures. The overlying skin was reddish-purple in color and
adherent firmly to the swelling, with ulcerations at places. There was another one
on the mid-anterolateral leg (12 cm × 9 cm × 3 cm) and one on the anterior knee (11 cm × 8 cm × 1 cm).
They were well defined, with hard consistency and a few areas of ulceration on the
surface. These were freely mobile over the underlying muscles and nonpulsatile on
palpation.
Hematological investigations were within normal limits. Ultrasonography, computed
tomography (CT) angiography, and magnetic resonance imaging (MRI) could not differentiate
between vascular lesion and soft-tissue tumor ([Fig. 2]). An excision biopsy of all the three tumor masses was done under regional anesthesia.
There were excellent planes of dissection between the lesions and the underlying muscle
fascia/paratenon ([Fig. 3a]). The surgically created raw areas were covered with intermediate-thickness split
skin grafts ([Fig. 3b]). All the lesions showed features of hemangioma on histopathology without any evidence
of malignant change.
Fig. 2 (a,b) Magnetic resonance imaging (MRI) cross-section at the level of the mid-leg and distal
foot. MRI showed lobulated soft-tissue mass lesions in the subcutaneous plane, iso-
to hyperintense to muscle on T1-weighted imaging (T1WI) and heterogeneously hyperintense
on T2/short tau inversion recovery (STIR) images, appearing multilobulated with T2
hypointense septa. Few T1 hype-intense foci were seen, likely hemorrhagic foci. Heterogenous
enhancement was noted on postcontrast images, suggestive of sarcomatous changes in
a long-standing soft-tissue tumor. (c) Computed tomography (CT) angiography showing well-defined, near homogenous, minimally
enhancing soft-tissue lesion on the mid-right leg with a few feeders from the anterior
tibial artery.
Fig. 3 (a) Intraoperative image with the surgically created raw areas. (b) Three months postoperative photograph showing well-taken-up grafts.
The spectrum of features of hemangioma may range from simple macular telangiectasias
to bosselated soft to firm swellings.[1] When involving the superficial skin, they may show reddish hue, while bluish hue
is seen when deeper skin and subcutaneous tissues are involved.[1] Only around 15% of all infantile hemangiomas occur on the extremities, while the
maximum occur in the head and neck region (60%).[2]
[3] Presentation in the adult age group as swellings that are unusually hard in consistency,
thus masquerading as soft-tissue tumor, as in our case, is unusual.
Involution, seen clinically as centrifugally spreading pallor and compressibility,
is achieved at the rate of 10% per year. The usual residual changes described are
atrophic scarring, lax skin, telangiectasia, yellowish discoloration of skin, etc.,
which persist in almost half of the patients.[4]
[5] In the present case, there was a deviation from the typical natural history of a
hemangioma. Instead of involution, the hemangioma stayed passive for a very long period
of nearly 20 years followed by growth in all the three dimensions.
