Usefulness of MRI in Delineation of Dermal and Subcutaneous Verrucous Hemangioma.

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.

What was known?

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

Introduction

Verrucous hemangiomas are rare angiomatous nevi that are present at birth and grow into adulthood.[12] They usually involve the dermis with extension into subcutaneous plane and deserve deep excision to avoid recurrence.[34] 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.[567] 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

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 [Figures 2 and 3].

Figure 1

(a) and (b) Clinical photograph of the right foot showing larger dorsal and satellite ventral hyperkeratotic lesions medially

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

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

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

Discussion

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.[91011] 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.[567] 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.[1516] 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.

What is new?

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