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Table of Contents 
Year : 2015  |  Volume : 60  |  Issue : 5  |  Page : 525
Usefulness of MRI in delineation of dermal and subcutaneous verrucous hemangioma

1 Department of Radiology, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, India
2 Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, India

Date of Web Publication4-Sep-2015

Correspondence Address:
K Nagarajan
Assistant Professor of Radio-Diagnosis, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Orissa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.164453

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Magnetic resonance imaging (MRI) has established itself as diagnostic modality of choice of soft tissue and musculoskeletal lesions but dermatological lesions have been diagnosed mainly by clinical examination. We present MRI features of dermal and subcutaneous verrucous hemangioma involving the dorsum of foot in a 20-year-old male and its usefulness in differentiating it from angiokeratoma with similar clinical features.

Keywords: Angiokeratoma, magnetic resonance imaging, soft tissue magnetic resonance imaging, verrucous hemangioma

How to cite this article:
Nagarajan K, Banushree C S. Usefulness of MRI in delineation of dermal and subcutaneous verrucous hemangioma. Indian J Dermatol 2015;60:525

How to cite this URL:
Nagarajan K, Banushree C S. Usefulness of MRI in delineation of dermal and subcutaneous verrucous hemangioma. Indian J Dermatol [serial online] 2015 [cited 2021 Jul 23];60:525. Available from: https://www.e-ijd.org/text.asp?2015/60/5/525/164453

What was known?
Verrucous hemangioma can mimic angiokeratoma in superficial biopsy. MRI can delineate soft-tissue lesions exquisitely.

   Introduction Top

Verrucous hemangiomas are rare angiomatous nevi that are present at birth and grow into adulthood. [1],[2] They usually involve the dermis with extension into subcutaneous plane and deserve deep excision to avoid recurrence. [3],[4] Magnetic resonance imaging (MRI) has been used in soft tissue and musculoskeletal lesions: both benign and malignant, not just for diagnosis, but also to delineate and characterize the extent and plan the treatment. [5],[6],[7] Recent reviews of superficial soft-tissue tumors including lesions involving the skin and its appendages and subcutaneous plane using ultrasonography or MRI have shown the usefulness of these modalities in evaluating and assessing these lesions. [8] Herein, we present a case of verrucous hemangioma involving the epidermis, dermis and subcutaneous plane thereby differentiating it from similar appearing 'angiokeratoma'.

   Case Report Top

Twenty-year-old male presented with hyperpigmented hyperkeratotic plaque with warty papules on the medial dorsum of foot over the first metatarsal. The lesion showed brownish red papules with purple margins. The patient had another hyperpigmented macular lesion on the plantar aspect of medial foot that was considered as evolving or satellite lesion [Figure 1]. Clinical diagnosis was that of angiokeratoma. The patient was referred for MRI to look for deeper extent of the lesion. On MRI, linear plaque-like heterogenous T1 isointense/T2-STIR hyperintense lesion was noted on the medial dorsum of foot involving the subcutaneous plane with dermal warty surface, suggestive of a lesion with dermal and subcutaneous components, looking similar to hemangioma. The deeper part of the lesion is seen extending upto the extensor hallucis longus/brevis tendons. No bony involvement or signal changes noted in the first metatarsal bone. The MRI sections also showed the plantar lesion involving dermal and subcutaneous planes without any deeper extension into plantar fascia [Figure 2] and [Figure 3].
Figure 1: (a) and (b) Clinical photograph of the right foot showing larger dorsal and satellite ventral hyperkeratotic lesions medially

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Figure 2: (a-c) MRI (T2-weighted with fat suppression) of right foot sagittal (a), coronal (b and c) planes showing heterogeneous hyperintense lesions involving the dermal, epidermal, and subcutaneous planes with strands inside, extending upto the extensor tendons dorsally

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Figure 3: (a) and (b) MRI sections (T1 & T2 weighted) in coronal plane showing the lesions to be isointense in T1 and hyperintense in T2-weighted images

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Deeper biopsy from the larger lesion on the medial dorsum of foot showed verrucous hyperplasia of the epidermis with hyperkeratosis, acanthosis, and irregular papillomatosis. Papillary dermis showed markedly dilated vessels partially enclosed by elongated rete ridges with similar foci of dilated vessels in deep dermis and subcutaneous tissue [Figure 4]. The histopathological diagnosis was that of verrucous hemangioma.
Figure 4: Histopathological (H and E) section from the lesion (magnification ×10) showing hyperkeratosis, acanthosis, and dilated vessels within papillary dermis partially enclosed by elongated rete ridges (arrows) and similar vessels also in deeper dermis

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   Discussion Top

Verrucous hemangiomas clinically resemble angiokeratomas, which are capillary telangiectasia involving only the papillary dermis and suspected to originate due to local trauma. Angiokeratomas respond to local ablation by cryotherapy, laser, or electrocautery. Verrucous hemangiomas need wide excision, although combined approach of laser or ultrasound therapy with surgical excision is now being more used. [9],[10],[11] Though verrucous hemangiomas have been reported long back in dermatological literature, [2] they are easily confused with angiokeratoma differing only in their deeper extent and only deep tissue biopsy can resolve the two. [12] However, MRI with its excellent delineation of superficial soft tissue can be used to delineate the extent of the plane of the lesion and differentiate both of them. If the biopsy does not include sufficient deeper tissue, it may lead to wrong diagnosis of superficial angiokeratoma. [12]

MRI has been used in superficial epidermal/dermal lesions like neurofibromas, hemangiomas, myxomas, granular cell tumor, giant-cell tumor of soft tissue, granuloma annulare, nodular fasciitis apart from lesions arising from skin appendages like infundibular/epidermal inclusion (known as sebaceous) cysts, pilomatricoma, merkel cell carcinoma, eccrine and apocrine-gland tumors. [5],[6],[7] Very few cases of MRI features of purely cutaneous (epidermal/dermal) lesions have been reported. Chung et al.,[13] reported one case of angiokeratoma in their comparison of imaging features of 164 benign and 102 malignant soft tissue lesions in an attempt to differentiate the two groups using MR features of size, depth and MR signal heterogeneity. Garrido Rios et al.,[14] reported a 38-year-old woman with right thigh lesion initially suspected as angiokeratoma and subsequent MRI showed the deeper subcutaneous extent confirming it to be verrucous hemangioma. Similar cases have been reported without the use of imaging in their evaluation and differentiation. [12] The differential diagnosis in our country should also include tuberculosis verrucousa cutis. However, long clinical history, absence of any associated ulceration, normal chest radiograph and above all histopathology have helped to differentiate it from tuberculosis verrucosa cutis.

Recent reports have attempted to delineate the origin of these lesions - whether vascular anomalies or tumors. [15],[16] Tennant et al.,[16] compared similarly appearing localized hyperkeratotic lesions clinically diagnosed as angiokeratomas, verrucous hemangiomas and capillary-venous/lymphatic malformations. They found the following features: thick vascular walls, multi-lamellated basement membrane, relatively uniform channel size, GLUT immunopositivity, and low MIB-1 reactivity in verrucous hemangiomas. These features resemble infantile hemangiomas in their involutive phase.

In our case as well, the initial clinical diagnosis and even a superficial biopsy were that of angiokeratoma, but subsequent MRI done before planning surgery revealed the deeper extent of the lesion and led to revision of diagnosis. MRI with its fine soft tissue pathology delineation and non-invasive advantage can help in such dermatological conditions to enable proper diagnosis before planning appropriate definitive treatment.

   References Top

Halter K. Verrucous hemangioma with osteoporosis. Dermatol Z 1937;75:275-9.  Back to cited text no. 1
Imperial R, Helwig B. Verrucous hemangioma. A clinicopathologic study of 21 cases. Arch Dermatol 1967;96:247-53.  Back to cited text no. 2
Chang JK, Tsang WY, Calonje E, Fletcher CD. Verrucous hemangioma. A distinctive but neglected variant of cutaneous hemangioma. Int J Surg Pathol 1995;2:171-6.  Back to cited text no. 3
Rossi A, Bozzi M, Barra E. Verrucous hemangioma and angiokeratoma circumscriptum: Clinical and histologic differential characteristics. J Dermatol Surg Oncol 1989;15:88-91.  Back to cited text no. 4
Laffan EE, Ngan BY, Navarro OM. Pediatric soft-tissue tumors and pseudotumors: MR imaging features with pathologic correlation: Part 2. Tumors of fibroblastic/myo-fibroblastic, so-called fibrohistiocytic, muscular, lymphomatous, neurogenic, hair matrix, and uncertain origin. Radiographics 2009;29:e36.  Back to cited text no. 5
Blacksin MF, Ha DH, Hameed M, Aisner S. Superficial soft-tissue masses of the extremities. Radiographics 2006;26:1289-304.  Back to cited text no. 6
Beaman FD, Kransdorf MJ, Andrews TR, Murphey MD, Arcara LK, Keeling JH. Superficial soft-tissue masses: Analysis, diagnosis, and differential considerations. Radiographics 2007;27:509-23.  Back to cited text no. 7
Jin W, Kim GY, Park SY, Chun YS, Rhyu KH, Park JS, et al. The spectrum of vascularized superficial soft-tissue tumors on sonography with a histopathologic correlation: Part 2, malignant tumors and their look-alikes. AJR Am J Roentgenol 2010;195:446-53.  Back to cited text no. 8
Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: A combined approach. Dermatol Surg 2002;28:913-9.  Back to cited text no. 9
Maejima H, Katsuoka K, Sakai N, Uchinuma E. Verrucous hemangioma successfully treated using 13-MHz ultrasonography. Eur J Dermatol 2008;18:597.  Back to cited text no. 10
Achar A, Biswas SK, Maity AK, Naskar B. Verrucous hemangioma treated by electrocautery. Indian J Dermatol 2009;54:51-2.  Back to cited text no. 11
  Medknow Journal  
Pavithra S, Mallya H, Kini H, Pai GS. Verrucous hemangioma or angiokeratoma? A missed diagnosis. Indian J Dermatol 2011;56:599-600.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
Chung WJ, Chung HW, Shin MJ, Lee SH, Lee MH, Lee JS, et al. MRI to differentiate benign from malignant soft-tissue tumours of the extremities: A simplified systematic imaging approach using depth, size and heterogeneity of signal intensity. Br J Radiol 2012;85:e831-6.  Back to cited text no. 13
Garrido-Ríos AA, Sánchez-Velicia L, Marino-Harrison JM, Torrero-Antón MV, Miranda-Romero A. A histopathologic and imaging study of verrucous hemangioma. Actas Dermosifiliogr 2008;99:723-6.  Back to cited text no. 14
Brown A, Warren S, Losken HW, Morrell DS. Verrucous lymphovascular malformation versus verrucous hemangioma: Controversial nomenclature. Cutis 2008;81:390-6.  Back to cited text no. 15
Tennant LB, Mulliken JB, Perez-Atayde AR, Kozakewich HP. Verrucous hemangioma revisited. Pediatr Dermatol 2006;23:208-15.  Back to cited text no. 16

What is new?
MRI can delineate the dermal and subcutaneous plane of the lesions and guide biopsy for histopathological diagnosis.


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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