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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 233-235

Blueberry look-alike masson's hemangioma over the thigh


Department of Dermatology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India

Date of Submission04-Jun-2020
Date of Decision26-Sep-2020
Date of Acceptance23-Nov-2020
Date of Web Publication26-Aug-2021

Correspondence Address:
A S Savitha
Department of Dermatology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru - 560 090, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_78_20

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  Abstract 


Masson's hemangioma (MH), also known as intravascular papillary endothelial hyperplasia, is a rare benign vascular tumor. Histopathology helps to confirm the diagnosis, wherein a papillary proliferation of thin-walled capillaries is almost always associated with thrombus formation in the lumen of a vessel. We report the case of a 48-year-old female with a purple-colored swelling over the right thigh that was diagnosed as MH with the help of histopathological examination. Dermoscopy was also done, and the findings were reported.

Keywords: Intravascular papillary endothelial hyperplasia, Masson's hemangioma, rainbow phenomenon in dermoscopy


How to cite this article:
Rai Y, Savitha A S, Nagesh T S, Prasannan S, Manjunath S, Reddy TD. Blueberry look-alike masson's hemangioma over the thigh. Clin Dermatol Rev 2021;5:233-5

How to cite this URL:
Rai Y, Savitha A S, Nagesh T S, Prasannan S, Manjunath S, Reddy TD. Blueberry look-alike masson's hemangioma over the thigh. Clin Dermatol Rev [serial online] 2021 [cited 2021 Dec 1];5:233-5. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/233/324575




  Introduction Top


Masson's hemangioma (MH) is a rare, benign vascular lesion that accounts for approximately 2% of all vascular tumors of the skin and subcutaneous tissue.[1] The condition was first described by Pierre Masson in 1923 in an ulcerated haemorrhoidal vein. It is also been reported to occur intracranially, thyroid gland, breast, neck, external jugular vein, tongue, oral cavity and rarely urethra.[1],[2] It mimics many conditions, so its diagnosis is usually not possible without the aid of histopathological examination.


  Case Report Top


A 48-year-old female patient presented to the dermatology outpatient department with the complaints of purple-colored spherical swelling over the right thigh noticed 4 months back [Figure 1], which resembled blueberry. The swelling was initially small which gradually increased in size. It was associated with pain. There was no history of any trauma prior to the onset of lesion. There were no episodes of bleeding from the lesion. The patient did not have any other systemic complaints and no comorbidities. Local examination revealed a spherical, smooth swelling of size 1 cm × 1 cm over the anterior aspect of the middle of the right thigh. On palpation, the swelling was soft to firm in consistency with well-defined margins and had a smooth surface, with the center showing central umbilication with a dark, soft mass. The swelling was freely mobile and mildly tender. General physical examination and systemic examination were found to be normal.
Figure 1: Clinical photograph showing purple-colored solitary swelling over the right thigh, resembling blueberry

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Dermoscopy [Figure 2] was done which showed blue-black clods, gray-white structureless areas, hemorrhage at the center with a dusky red background, and grayish veil. A multicolored dermoscopic feature, rainbow phenomenon, was also observed in the lesion through polarized light dermoscopy.
Figure 2: Dermoscopic picture of the swelling showing blueblack clods, graywhite structureless areas, and hemorrhage at the center with dusky red background and grayish veil and rainbow phenomenon

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The lesion was excised under local anesthesia and sent for histopathological examination. Histopathological examination revealed hyperkeratotic stratified squamous epithelium, areas of haemorrhage below the epithelium [Figure 3]a, hyalinized papillae was lined by plump endothelium with thin walled ectatic blood vessel filled with blood and papillary projections was seen [Figure 3]b with fibrin thrombi [Figure 3]c.
Figure 3: (a) Histology showing hyperkeratotic stratified squamous epithelium and areas of hemorrhage (H and E, ×10). (b) Histopathology showing plump endothelium and ectatic blood vessel and papillary projections (H and E, ×40). (c) Histopathology showing fibrin thrombi (H and E, ×40)

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Based on the history, clinical findings, dermoscopy, and histopathological examination of the excisional biopsy, a final diagnosis of Masson's hemangioma (MH) was made. As we have done complete excision of the growth, there was no chance of recurrence of the lesion.


  Discussion Top


MH was first described in 1923 by Pierre Masson. This was present within the lumen of inflamed hemorrhoidal veins in a 68-year-old male and he believed that the lesion would have caused obliteration of the vessel lumen, leading to subsequent degeneration and necrosis.[1] He named the lesion “vegetant intravascular hemangioendothelioma.” From the time of its initial description, it has been referred to by various eponyms, including Masson's tumor, Masson's hemangioma, Masson's intravascular and hemangioendothelioma, intravascular papillary endothelial hyperplasia (IPEH), or reactive papillary endothelial hyperplasia.[2] A more descriptive term which is more frequently used in the English literature, “IPEH,” was coined by Clearkin and Enzinger in 1976.[3] MH, a benign condition, originates from an organizing vascular thrombosis with reactive endothelial proliferation and mainly occurs in extraneural tissues, especially in the skin and soft tissue.[4] This condition is also reported to occur intracranially, in the thyroid gland, head and neck, breast, oral cavity, trunk and extremities. It can also occur in intra-abdominal organs such as liver, though rare.[5]

The pathogenesis of MH is unclear. Several investigators have described that this reactive process could be related to the antecedent history of trauma of endothelium and consequently formed thrombus. However, only 14% of the 314 cases in the reviewed literature were related to trauma.[6]

Hashimoto et al. in 1983 described three distinct types of MH as “pure,” “mixed,” and “extravascular.”[7] Primary or pure MH forms, within a dilated vascular space, most commonly arise from the subcutaneous tissue with a preference for extremities. Secondary or mixed or reactive MH is the most common and is predominately found in the musculature. It originates within preexisting vascular malformations such as varix, lymphangioma, or cavernous hemangioma. Tertiary MH is the rarest form within hematomas, and is extravascular.[7]

Clinically, MH resembles other types of subcutaneous tumors such as angiomas, angiolipomas, vascular malformation, cyst, and others. Histologically, its main differential diagnosis is with angiosarcoma, Histologically, its main differential diagnosis is with angiosarcoma, which can be distinguished by the absence of necrosis, cellular atypical and mitotic figures.[1]

MH is more common in women and exhibits peaks of prevalence between the fourth and sixth decades of life.[8] Masson's tumor affects the skin and subcutis of the head-and-neck region (23%), lower extremities (17%), and fingers (16%).[7]

The microscopic picture of MH is pathognomonic, showing endothelial proliferation within the vessel, multiple papillary projections, and fibrin thrombus within the vessel with no evidence of necrosis.[5] The treatment is surgical excision with complete resection.[7]

Recently, MH has been successfully treated by a beta-adrenergic antagonist nebivolol.[9]

There are several case reports of MH which has been diagnosed with the help of histopathology. On extensive research, dermascopic features of MH is not found. This article presents the dermoscopy features of MH, which adds as a supplement in the diagnosis of this rare entity. The dermoscopy features of MH described here include rainbow phenomenon which is observed in the lesion through polarized light dermoscopy, based on a series of physical phenomena such as diffraction, as the polarized light beam passes through the different skin layers until reaching the dermis. It has been described in skin lesions with abundant vascularization. The “rainbow” pattern is a relatively new dermoscopic term that describes a bluish-reddish coloration together with various colors of the rainbow, observable mainly through polarized light dermoscopy.[10] On dermascopy, blue-black clods may represent intravascular thrombosis, greyish white structureless areas shows acanthosis, haemorrahage or ruptured vessels present in the centre, dusky pink background represents vascular proliferation also greyish veil representing acanthosis, present throughout the lesion.

The prognosis of MH is excellent with no evidence of local invasion or metastasis. MH may recur if the lesion is incompletely excised.[3] We have done complete surgical excision of the growth.


  Conclusion Top


MH is a rare benign vascular tumor. The diagnosis is possible mainly by histopathology. However, the above-described dermoscopic features might help in the diagnosis. Complete excision is the treatment with excellent prognosis.

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 Top

1.
Malhotra M, Bhatia C, Kaur U, Bhardwaj S, Singh S. Masson's haemangioma an unusual neck swelling. Ann Clin Case Rep 2019;4:1654-5.  Back to cited text no. 1
    
2.
Kumar A, Surowiec S, Nigwekar P, Illig KA. Masson's intravascular hemangioma masquerading as effort thrombosis. J Vasc Surg 2004;40:812-4.  Back to cited text no. 2
    
3.
Sarode GS, Sarode SC. Extra-vascular type of oral intravascular papillary endothelial hyperplasia (Masson's tumor) of lower lip: A case report and review of the literature. Indian J Dent Res 2015;26:101-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Patil KA, Noda S, Auten M, Fekete R. Masson's hemangioma: A very rare cause of spinal cord compression. Neurol India 2013;61:89-90.  Back to cited text no. 4
    
5.
Sarda A, Nachiappan M. Masson's haemangioma presenting as a fibrolipoma. J Clin Diagn Res 2016;10:PD07-8.  Back to cited text no. 5
    
6.
Han Y, Yun S, Choi IH. Intravascular papillary endothelial hyperplasia occurring in the foot: A case report and review of literature. Medicine (Baltimore) 2019;98:28-30.  Back to cited text no. 6
    
7.
Mirmohammadsadeghi H, Mashhadiabbas F, Latifi F. Huge central intravascular papillary endothelial hyperplasia of the mandible: A case report and review of the literature. J Korean Assoc Oral Maxillofac Surg 2019;45:180-5.  Back to cited text no. 7
    
8.
Vicensoto Moreira Milhan N, Cavassini Torquato L, Costa V, Carvalho De Marco A, Rodarte Carvalho Y, Lia Anbinde A. A mixed form of intravascular papillary endothelial hyperplasia in an uncommon location: Case and literature review. Dermatol Online J 2018;24:8.  Back to cited text no. 8
    
9.
Prey S, Haberstroh G, Vergier B, Taïeb A, Wassef M, Ezzedine K, et al. Successful treatment of intravascular papillary endothelial hyperplasia (IPEH) by the beta-adrenergic antagonist nebivolol. Br J Dermatol 2012;166:1147-9.  Back to cited text no. 9
    
10.
Draghici C, Vajaitu C, Solomon I, Voiculescu VM, Popa MI, Lupu M. The dermoscopic rainbow pattern – A review of the literature. Acta Dermatovenerol Croat 2019;27:111-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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