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Special Feature
February 16, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(2):191-192. doi:10.1001/archsurg.2008.582-b

Answer: Rectus Abdominis Intramuscular Hemangioma

The patient underwent an exploratory laparotomy, radical resection of the left abdominal wall mass, and reconstruction of the abdominal defect with a large acellular dermal inset and Marlex mesh (Figure 2). Hemangiomas, the most common tumor of infancy, occur often in the head and neck region, although 25% are found in the trunk. Giant intramuscular hemangiomas are progressively enlarging benign tumors, characterized by variable appearance. They are congenital malformations that may be present at birth and become significant only in adulthood. Intramuscular hemangiomas occur in patients of all ages but are most common in young adults, with 90% occurring before the age of 30.1They may act as infiltrating lesions, leading to the misdiagnosis of angiosarcoma. Hemangiomas are distinguished from angiosarcomas by the lack of pleomorphism or significant endothelial multilayering and by the lack of irregular, ramifying, anastomosing thin-walled channels. In addition to blood vessels infiltrating the spaces between muscle fibers, there is frequently an abundance of adipose tissue.2

Figure 2. 
Radical resection of a rectus abdominis intramuscular hemangioma with the feeding vessels ligated.

Radical resection of a rectus abdominis intramuscular hemangioma with the feeding vessels ligated.

The first sizable analysis of intramuscular hemangiomas, a review of 89 cases, was performed by Allen and Enzinger3in 1972. Although rare, intramuscular hemangiomas are of interest clinically because of their ability to mimic aggressive tumors, and because they may cause pain, cosmetic disfigurement, and compressive symptoms. Pain can be a symptom of enlarging hemangiomas or those with spontaneous thrombosis. Intramuscular hemangiomas are defined pathologically as vascular spaces of variable size lined with endothelial cells and separated by fibrous septa localized within the skeletal muscle. These tumors never metastasize; however, they are associated with a 20% local recurrence rate, which is thought to be related to inadequate primary surgical excision.2,4

Radical resection remains the most effective treatment for giant intramuscular hemangiomas and often results in permanent cure. Giant intramuscular hemangiomas are challenging to the surgeon in that they have a tendency to recur if they are not completely resected and if their feeding and draining vessels are not identified and divided. We recommend performing one-stage radical en block resection of these tumors at first diagnosis with abdominal wall reconstruction.

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Correspondence:Emad Kandil, MD, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, Box SL-22, New Orleans, LA 70112 (ekandil@tulane.edu).

Accepted for Publication:May 29, 2007.

Author Contributions:Study concept and design:Kandil, Campbell, and Tufaro. Acquisition of data: Kandil, Campbell, and Tufaro. Analysis and interpretation of data:Campbell and Tufaro. Drafting of the manuscript:Kandil and Tufaro. Critical revision of the manuscript for important intellectual content: Campbell and Tufaro. Administrative, technical, and material support: Kandil, Campbell, and Tufaro. Study supervision:Tufaro.

Financial Disclosure:None reported.

Stimpson  N Infiltrating angiolipomata of skeletal muscle.  Br J Surg 1971;58 (6) 464- 466PubMedGoogle ScholarCrossref
McGee  JIPWright  NADick  MSlack  MPE Oxford Textbook of Pathology. Vol 2a. New York, NY Oxford University Press1992;
Allen  PWEnzinger  FM Hemangioma of skeletal muscle: an analysis of 89 cases.  Cancer 1972;29 (1) 8- 22PubMedGoogle ScholarCrossref
Quinn  PSSieunarine  KLawrence-Brown  MTan  P Intramuscular haemangiomas: hookwire localization prior to surgical excision: report of four cases.  ANZ J Surg 2001;71 (1) 62- 66PubMedGoogle ScholarCrossref