Management of an elevated soft-tissue lesion with diagnosis of capillary hemangioma

Rahman Nazeri; Marzieh Ghaiour

doi:10.4103/srmjrds.srmjrds_61_17

CASE REPORT

Year : 2018 | Volume : 9 | Issue : 1 | Page : 48-51

Management of an elevated soft-tissue lesion with diagnosis of capillary hemangioma

Rahman Nazeri, Marzieh Ghaiour
Department of Pediatric Dentistry, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication

16-Mar-2018

Correspondence Address:
Dr. Marzieh Ghaiour
Department of Pediatric Dentistry and Research Committee, School of Dentistry, Isfahan University of Medical Sciences, Isfahan
Iran

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/srmjrds.srmjrds_61_17

Abstract

Capillary hemangiomas are considered one of the rare benign oral tumors. Hemangioma of oral cavity is rare; accordingly, the present study aims to report a rare case of hemangioma that it is clinical sign representing mucocele and irritation fibroma, but the histologic results obtained from excisional biopsy led to the diagnosis of capillary hemangioma happening in the lower lip, in which the benign endothelial cell neoplasms are typically absent at birth but have a drastic development in childhood years with a natural involution in the later years of human life. In contrast to other human vascular malformations, related clinical reports have rarely mentioned its occurrence in the lower lip.

Keywords: Capillary hemangioma, swelling, vascular malformations

How to cite this article:
Nazeri R, Ghaiour M. Management of an elevated soft-tissue lesion with diagnosis of capillary hemangioma. SRM J Res Dent Sci 2018;9:48-51

How to cite this URL:
Nazeri R, Ghaiour M. Management of an elevated soft-tissue lesion with diagnosis of capillary hemangioma. SRM J Res Dent Sci [serial online] 2018 [cited 2023 May 30];9:48-51. Available from: https://www.srmjrds.in/text.asp?2018/9/1/48/227765

Introduction

Hemangioma is a benign tumor on the skin or mucosa that is caused by excessive blood vessel growth.^[1],[2],[3] Although this tumor is the most common soft-tissue tumor in the head and neck area, it rarely appears in the oral cavity.^[4] The lesion can be in various forms such as skin, mucous, intramuscular, or intraosseous.^[5],[6] In cases where the lesion is superficial, it is very easy to diagnose it. However, diagnosis of deeper lesion would be more difficult.^[7],[8]

The origin and pathogenesis of hemangioma are still a matter of great controversy.^[9] It is generally agreed that the lesion consists of incomplete and abundant blood vessels with fast-growing and hyperplastic endothelial cells occurring more often in women, Caucasian races, and people with low birth weights.^[10] Histologically, based on the size of the arterial vessels, the hemangiomas are divided into three classes, namely, capillary, cavernous, and mixed.^{[11],[12],[13]} Clinically, hemangioma is a soft, smooth or lobulated mass, sessile, or pedunculate, without pain and in sizes ranging from a few millimeters to a few centimeters, whose color varies, depending on the depth of the lesion, from pink to red and violet, and when pressed, the lesion is blanching.^[12],[14] Bleeding occurs spontaneously or reactively.^[12] Oral hemangiomas often appear on the gum.^[12] The lesion originates from an interdental papilla and spreads to adjacent teeth.^[15]

Most patients with hemangiomas do not require special treatment because the lesion will be fine spontaneously and requires only follow-up and conservative considerations.^[16] According to a study by Ronchese,^[17] 50% of hemangiomas recover until the age of 5, 70% before 7, and 90% until the age of 9. Only 10%–20% of cases of hemangiomas need special treatment for various reasons such as the size of the lesion, its location, and its interference with the individual's appearance and function.^{[10],[18],[19]} In the absence of treatment and prolonged growth of the lesion, complications such as ulcers, large masses, deformity, functional impairment, bleeding, and apparent changes may occur.^[20],[21]

Different treatment methods have been proposed for hemangioma including corticosteroid injections, intramuscular fibrosis agent infusion, interferon-alpha, radiation, electrocoagulation, cryosurgery, laser, embolization, and surgery.^{[22],[23],[24]} However, the definitive treatment can be achieved using excisional biopsy surgery.^[25],[26]

Surface lesions are easily removed, but deeper lesions require extensive surgery with the risk of area deformation and bleeding.^[5] Hemangioma prognosis is generally excellent, and the tendency to recurrence or malignancy is quite low.^[4],[27] Since 40%–60% of hemangiomas occur in the head and neck area,^[20] It is important for dentists to be aware of how to manage these lesions. Therefore, the purpose of this study was to present a case of oral hemangioma and its treatment.

Case Report

The patient, a 4-year-old girl, complained of an elevated lesion on the lips that was created 2–3 years ago. This lesion started to grow gradually, with minor discomfort during eating and without any conceivable pain until the case referred to the Pediatric Department of the Faculty of Dentistry in Isfahan University of Medical Sciences.

Social and medical history

In the initial examination of the patient, it was found out that her socioeconomic status was low; however, there was no medical history, drug use, or allergies, and the patient was vaccinated according to a regular schedule.

Dental history

In examining the dental history of the patient, it was revealed that she was referred to the dentist regularly, and her last visit was 3 months ago for dental restoration. The oral health was poor and tooth decay was observed, deciduous teeth eruption was normal, and no history of trauma was found.

Extraoral examination

The patient was in normal developmental condition and had no problems or any asymmetries.

Intraoral examination

In the intraoral examination, on the lining mucosa of the lower lip, a pedunculated firm soft-tissue nodule with no traumatic lesions and pain with a specific margin, and a flat surface of 5 mm in diameter with red-blue color, hand blanched was found, [Figure 1]. Periapical radiography was prepared from the area, and there was no indication of bone resorption. Lamina dura and bone trabecula were healthy and normal. Tooth decay was observed in five deciduous teeth.

Figure 1: Intraoral clinical view of soft-tissue lesion

Click here to view

Differential diagnosis

The location and nature of the lesion were similar to irritation lesions and benign tumors, so the differential diagnosis comprised mucocele, irritation fibroma, and tumor lesions such as pyogenic granuloma.

Management

Under local anesthesia, excisional biopsy of the lesion with a healthy margin was performed. The base of lesion tightly closed by a string to minimize blood supply, then, the base of the lesion was cutoff, and curettage was done. Mild bleeding from the area was controlled by a brief pressure of sterilized gas. The lesion was placed in 10% formalin and sent to histopathology laboratory. The surgical area was sutured and the patient was given the necessary recommendations after the surgery. After a week, the suture was removed and the lesion was examined at regular intervals.

Histopathology report

In the histopathologic view, the stratified squamous epithelium was seen in the oral mucosa; in the connective tissue below, there were abundant capillary canals with thin walls and proliferation of endothelial cells. Scattered lymphocytes and plasma cells were also seen [Figure 2].

Figure 2: Histopathologic view from the excisional biopsy

Click here to view

Diagnosis

Based on the existing clinical signs, history, and histology, a definitive diagnosis of capillary hemangioma was introduced.

Discussion

Clinically, differential diagnosis of hemangioma is mucocele, pyogenic granuloma, irritation fibroma, and Kaposi's sarcoma.^{[23],[24],[28]} In the present case, considering the location of the lesion and its appearance, the diagnosis was directed toward irritation lesions such as irritation fibroma, mucocele, and pyogenic granuloma, and the slow growth of the tumor within 2–3 years indicates its benignity.

The occurrence of hemangioma in the lining mucosa of the lips is rare; in similar studies, only Yoshikawa et al.^[28] reported a sample of pedunculated cavernous hemangioma with clinical sign of irritation fibroma, and Sun et al.^[29] reported two cases of epithelioid hemangiomas on the lining mucosa of the lip.

The reason for this lesion is unclear. Some see it as a developmental anomaly or hamartoma ^[30] while others consider angiogenesis as the cause of hemangioma. According to more recent theory, the increase of angiogenesis-stimulating factors such as fibroblast growth factor and vascular endothelial growth factor and reduction of angiogenesis inhibitors such as gamma interferon, tumor necrosis factor-β, and transforming growth factor-β lead to hemangioma.^[31]

In the present case, the treatment was performed by an excisional biopsy, which is the selective treatment of capillary hemangioma.^[5],[32] Surgical treatment may cause complications such as bleeding or recurrence.^[5],[32] In the present case, there was little bleeding during surgery that was relieved by a brief gas pressure and the patient was evaluated at regular intervals and there was no indication of recurrence until 1 year after surgery.

Dentists should be aware of the possibility of hemangioma bleeding of head and neck both in the evolution phase and in the regression phase during the clinical intervention that may threaten the life of the patients.^[33] The dentist should avoid any sudden moves of the patient and the touch of the lesion and if necessary, anesthetizing the nerve block in the most remote area of the lesion.^[16]

Conclusion

Because hemangioma is often diagnosed by dentists in the head and neck region, it is important for dentists to be aware of the characteristics of such lesions. As such, they should assess the clinical behavior of these lesions and observe the necessary considerations. Capillary hemangioma is may be problematic due to disruption of systemic health and sometimes esthetic in these conditions; surgery should be performed with caution and bleeding should be monitored before and after surgical operations. Although the clinical diagnosis of the lesion was similar irritation lesions, the dentists should be aware of the possibility of bleeding and the clinical intervention that may threaten the life of the patients for any lesion of the lip and mouth.

Acknowledgment

The authors want to thanks Dr. Neda Kargahi, Associate Professor of Oral and Maxillofacial Pathology, Department of Oral and Maxillofacial Pathology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran, and Department of Oral and Maxillofacial Pathology of Isfahan University of Medical Sciences, Isfahan, Iran, and Torabinejad Dental Research Center of Isfahan University of medical sciences, Isfahan, Iran.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Edgerton MT. The treatment of hemangiomas: With special reference to the role of steroid therapy. Ann Surg 1976;183:517-32. [PUBMED]
2.	Kräling BM, Razon MJ, Boon LM, Zurakowski D, Seachord C, Darveau RP, et al. E-selectin is present in proliferating endothelial cells in human hemangiomas. Am J Pathol 1996;148:1181-91.
3.	Odabasi AO, Metin KK, Mutlu C, Başak S, Erpek G. Intramuscular hemangioma of the masseter muscle. Eur Arch Otorhinolaryngol 1999;256:366-9.
4.	Kocer U, Ozdemir R, Tiftikcioglu YO, Karaaslan O. Soft tissue hemangioma formation within a previously excised intraosseous hemangioma site. J Craniofac Surg 2004;15:82-3.
5.	Açikgöz A, Sakallioglu U, Ozdamar S, Uysal A. Rare benign tumours of oral cavity – Capillary haemangioma of palatal mucosa: A case report. Int J Paediatr Dent 2000;10:161-5.
6.	Van Doorne L, De Maeseneer M, Stricker C, Vanrensbergen R, Stricker M. Diagnosis and treatment of vascular lesions of the lip. Br J Oral Maxillofac Surg 2002;40:497-503.
7.	Enzinger FM, Weiss SW, editors. Benign tumors and tumorlike lesions of blood vessels. In: Soft Tissue Tumors. 3^rd ed. St. Louis, Mo, USA: Mosby; 1995. p. 579-626.
8.	Kim DH, Hwang M, Kang YK, Kim IJ, Park YK. Intramuscular hemangioma mimicking myofascial pain syndrome: A case report. J Korean Med Sci 2007;22:580-2.
9.	Torer B, Gulcan H, Kilicdag H, Derbent M. PHACES syndrome with small, late-onset hemangiomas. Eur J Pediatr 2007;166:1293-5.
10.	Hemangioma Investigator Group, Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, et al. Prospective study of infantile hemangiomas: Demographic, prenatal, and perinatal characteristics. J Pediatr 2007;150:291-4.
11.	Tröbs RB, Mader E, Friedrich T, Bennek J. Oral tumors and tumor-like lesions in infants and children. Pediatr Surg Int 2003;19:639-45.
12.	Yoon RK, Chussid S, Sinnarajah N. Characteristics of a pediatric patient with a capillary hemangioma of the palatal mucosa: A case report. Pediatr Dent 2007;29:239-42.
13.	Mueller BU, Mulliken JB. The infant with a vascular tumor. Semin Perinatol 1999;23:332-40.
14.	Hand JL, Frieden IJ. Vascular birthmarks of infancy: Resolving nosologic confusion. Am J Med Genet 2002;108:257-64.
15.	Onesti GM, Mazzocchi M, Mezzana P, Scuderi N. Different types of embolization before surgical excision of haemangiomas of the face. Acta Chir Plast 2003;45:55-60.
16.	Santin GC, Guimarães KS, de Oliveira SS, da Silva RA, Nelson-Filho P, Palma-Dibb RG, et al. Consequences of facial hemangioma with regard to dental treatment. Contemp Clin Dent 2017;8:185-7. [PUBMED] [Full text]
17.	Ronchese F. The spontaneous involution of cutaneous vascular tumors. Am J Surg 1953;86:376-86.
18.	Qiam F, Khan M, Ud Din Q. Mucosal venous hemangiomas of the oral cavity – An analysis of 43 cases and literature review. JKCD 2011;2:1-5.
19.	Pope E, Krafchik BR, Macarthur C, Stempak D, Stephens D, Weinstein M, et al. Oral versus high-dose pulse corticosteroids for problematic infantile hemangiomas: A randomized, controlled trial. Pediatrics 2007;119:e1239-47.
20.	Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, et al. Prospective study of infantile hemangiomas: Clinical characteristics predicting complications and treatment. Pediatrics 2006;118:882-7.
21.	Pransky SM, Canto C. Management of subglottic hemangioma. Curr Opin Otolaryngol Head Neck Surg 2004;12:509-12.
22.	Burstein FD, Simms C, Cohen SR, Williams JK, Paschal M. Intralesional laser therapy of extensive hemangiomas in 100 consecutive pediatric patients. Ann Plast Surg 2000;44:188-94.
23.	Deans RM, Harris GJ, Kivlin JD. Surgical dissection of capillary hemangiomas. An alternative to intralesional corticosteroids. Arch Ophthalmol 1992;110:1743-7.
24.	Childers EL, Furlong MA, Fanburg-Smith JC. Hemangioma of the salivary gland: A study of ten cases of a rarely biopsied/excised lesion. Ann Diagn Pathol 2002;6:339-44.
25.	Buckmiller LM, Richter GT, Suen JY. Diagnosis and management of hemangiomas and vascular malformations of the head and neck. Oral Dis 2010;16:405-18.
26.	Bharti V, Singh J. Capillary hemangioma of palatal mucosa. J Indian Soc Periodontol 2012;16:475-8. [PUBMED] [Full text]
27.	Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. 6^th ed. Philadelphia: WB Saunders Co.; 2009. p. 143.
28.	Yoshikawa F, Nishiyama T, Sakuda M. Pedunculated cavernous hemangioma. A case report. Oral Surg Oral Med Oral Pathol 1993;75:688-9.
29.	Sun ZJ, Zhang L, Zhang WF, Alsharif MJ, Chen XM, Zhao YF, et al. Epithelioid hemangioma in the oral mucosa: A clinicopathological study of seven cases and review of the literature. Oral Oncol 2006;42:441-7.
30.	Chang J, Most D, Bresnick S, Mehrara B, Steinbrech DS, Reinisch J, et al. Proliferative hemangiomas: Analysis of cytokine gene expression and angiogenesis. Plast Reconstr Surg 1999;103:1-9.
31.	Chang MW. Updated classification of hemangiomas and other vascular anomalies. Lymphat Res Biol 2003;1:259-65.
32.	Miri SM, Habibi Z, Hashemi M, Meybodi AT, Tabatabai SA. Capillary hemangioma of cauda equina: A case report. Cases J 2009;2:80.
33.	Ethunandan M, Mellor TK. Haemangiomas and vascular malformations of the maxillofacial region – a review. Br J Oral Maxillofac Surg 2006;44:263-72.