The Clinical Classification And Pathological Study Of Upper Limb Cavernous Hemangiomas

Objective: Taking a observation of the the clinical and pathologicalfeatures of upper limb cavernous hemangioma,and then a classification ofupper limb cavernous hemangioma was made according to its clinicalfeatures and laboratory examinations.To explore the relation between clinicalclassification and pathological features and its clinical significance inoperation.Method: From September2010to February2013,clinical andpathological date of56cases of upper limb cavernous hemangioma werecollected and comparatively analysed.The upper limb cavernoushemangioma were treated with different surgical approaches after dividinginto three different subtypes according to their clinical characteristics andauxiliary examination(Color Doppler ultrasound and MRI).32cases in TypeⅠ(Superficial type),the tumour were soft,compressible and shallower inposition with limited range,the skin of whose surface were bluish violet andamaranth.There was generally no bone changes showed by X-rayexamination on tumour. Ultrasound examination showed a honeycomb ortortuous tubular structure with clear boundary.This type was treated withsimple excision by surgery.18cases in TypeⅡ(Relatively focal type),thetumor was located in the subcutaneous deep tissue with relatively limitedrange.And it was irregular or soft and lumpy,which sometimes involved themuscles, nerves and other soft tissue around it. X-ray examination showedimage of tumefaction of soft tissue,half of the cases could be seen multiplephleboliths and calcified.There were gridding echo inside the tumour and arelatively clear boundary showed by the Ultrasound examination.MRIshowed a round or irregular masses.The tumour which had an envelope and aclear boundary could be removal along the envelop.The normal tissue such as the nerves and blood vessels could be separate from the tumour under themicroscope when they were invaded by the tumour around them. Thetumour was removed pecie by piece with a transfixion combined withelectrocoagulation for its vessels when it invaded the tendonsheath,peritendon tissues and muscle.6cases in Type Ⅲ(Relatively focaltype)The tumours were tufted with a wide range.Except involving some axialveins of the fingers,hand and the foream,the nerves,muscles,bone and itsnutrient vessels were often invaded by the tumour. X-ray examinationshowed punctiform calcification and moth-eaten alterations when invadingthe bone. The Ultrasound examination showed the boundary of the tumourwere unclear and there were honeycomb like echo inside the tumour. ColorDoppler flow imaging (CDFI) showed a small amount continous low flowvein blood flow signals.The MRI showed the tumour were diffuse with atortuous cord-like structure,the vessel invaded by the tumour could also bedemonstrated using the enhanced scan. For this type,the tumour was treatedby combining sclerotherapy and surgical resection with the malformedvasculars ligaturing fully.Sometimes the muscles and the nerves affectedwere also removed,and then a functional reconstitution was maded at thesecond stage.At last,the pathological features of each type was observedunder the microscope after operation.The surgical treatment were assessedby four levels:cure,effective,efficient,recurrence.Results:56patients were followed up for18-30months after operationwith an average of20months.The pathological structure of upper limbcavernous hemangioma generally manifested three types:fiber-vein, celluarsinus and mixed. A lot of substance and a small amount of fibrousconnective tissue could be noticed under the microscope in fiber-veintype.The malformed vein or dilated sinusoid with irregular shape and cavitygap between them made up of the substance. Adjacent sinusoids composedby the endothelial cell layer and the smooth muscle cell layer communicatedwith each other,which formed a channel structure.There were some intervalscomposed by fibrous connective tissue of different densities between sinusoid and cavity gap,with some collagen fibers, fat cells and smoothmuscle cells in them.Some cases could be observed phleboliths under themicroscope. The celluar sinus types mainly constituted by a large number ofdilated sinusoid with thin wall and large cavity,which formed a honeycombstructure.The sinusoid wall composed by single-deck discontinousendothelial cells,lacking of smooth muscle cells.The connective tissue wasrare the collagen fibers were sparse between adjacent sinusoid wall.Therewere some irregular gaps between the sinusoids,with a large number of redblood cells in them.The mixed type possessed two of the components infiber-vein type and celluar sinus types.The malformed vein and the dilatedsinusoid were mixed with each other,with a disordered arrangement.The fiber-vein type dominated in Type Ⅰunder microscope. The tumourswere disappeared in14patients without any complications afteroperation,and were nearly disappeared in11patients with skin above whichwas generally normal.The tumour in5cases became significantly small and2cases recurred.The overall efficiency was93.7%and the recurrence ratewas6.25%.There were celluar sinu types and mixed type in Type Ⅱundermicroscope.4cases were disappeared,5cases were nearly disappeared,6cases became significantly small and3cases recurred after operation.Thesuffered fingers or limbs became smaller at varying degrees after operationin12cases,feeling in some part became insensitive in2cases and the fingerflexion was limited in1cases. The overall efficiency was83.3%and therecurrence rate was16.7%. The celluar sinus type dominated in TypeⅢunder microscope.1cases were nearly disappeared,3cases becamesignificantly smaller with some deformation on suffered limb.The localfeeling was disappeared in1cases,with finger flexor dysfunction. Theoverall efficiency was66.7%and the recurrence rate was33.3%.Conclusion:The clinical characteristic of upper limb cavernoushemangioma is closely related to its pathological features. Different clinicaltypes have different clinical and pathological features.It is important to makea classification on upper limb cavernous hemangioma according to its clinical characteristic and pathological features,which has a very importantrole in chosing the operation indication.There are significant effect and lowrecurrence rate using different surgical approaches according to clinicalclassification.