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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 2  |  Page : 257-258
Synovial hemangioma: A rare benign synovial lesion


Department of Pathology, VMMC and Safdarjung Hospital, New Delhi, India

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   Abstract 

We report an unusual case of a 10-year-old female with complaints of pain and swelling of the right knee for the last 4 years along with the limitation of movement for last 1 year. Repeated fine needle aspirations yielded blood and a provisional diagnosis of hemarthrosis was suggested. Coagulation profile subsequently carried out was found to be within normal limits. Arthroscopic biopsy was performed and tissue was sent for histopathological examination. A diagnosis of synovial hemangioma was made. Subtotal synovectomy was performed and the lesion was completely excised. The patient is completely asymptomatic and shows no signs of recurrence at 1 year.

Keywords: Knee, synovial hemangioma

How to cite this article:
Rajni, Khanna G, Gupta A, Gupta V. Synovial hemangioma: A rare benign synovial lesion. Indian J Pathol Microbiol 2008;51:257-8

How to cite this URL:
Rajni, Khanna G, Gupta A, Gupta V. Synovial hemangioma: A rare benign synovial lesion. Indian J Pathol Microbiol [serial online] 2008 [cited 2014 Apr 17];51:257-8. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/257/41676



   Introduction Top


Synovial hemangioma is a rare benign tumor of joint cavities. It may be a cause of pain and recurrent joint swelling in children and young adults. This lesion has been described anatomically as synovial, juxta-articular and intermediate. It may be pedunculated or diffuse. [1] Histopathologically, it has three types: capillary, cavernous, or mixed. In general, the presentation is insidious with a painful swelling of knee mostly unaccompanied with any history of trauma. [2] Often, several years lapse between onset of symptoms and treatment. These days, various modalities aid in the diagnosis like closed system venography, red blood cell scan, arthroscopy and MRI. Among these, MRI is most useful which helps in diagnosing as well as delineating the extent of lesion. But the final diagnosis is made on histopathology. [3]


   Case History Top


A 10-year-old female child presented to the orthopedic out patient department of Safdarjung hospital with complaints of pain and swelling of the right knee for the last 4 years along with limitation of movement for past 1 year. In spite of repeated questioning, no history of trauma could be elicited. On examination, a poorly defined, soft, compressible swelling was noticed on the medial side of the right knee. A plain radiograph revealed a soft tissue swelling with no bony abnormality. Repeated FNACs yielded altered blood. A provisional diagnosis of hemarthrosis was offered. Coagulation profile subsequently carried out was found to be within normal limits. An arthroscopic biopsy was carried out and a histopathological diagnosis of synovial hemangioma was suggested. An MRI performed prior to excision showed that the lesion was confined to synovium. These findings were confirmed pre-operatively and sub-total synovectomy was carried out removing the whole of soft tissue mass. The diagnosis of synovial hemangioma was re-confirmed on histopathology.

Pathological findings

Grossly, the specimen was a discrete soft tissue mass approximately 7 cm 4 cm 2 cm in size, heavily pigmented, somewhat brownish in color showing exuberant papillary fronds [Figure 1]. The hematoxylin and eosin stained sections showed an admixture of dilated vascular (cavernous) spaces (both thick and thin walled) and capillary-sized vessels [Figure 2]. Cavernous spaces dominated the lesion. Hemosiderin deposits were noted mainly along the synovial lining. Few scattered hemosiderin laden macrophages were also seen [Figure 3]. No lymphoid follicles, stromal giant cells, or any morphologic features suggestive of aggressive behavior were noted.


   Discussion Top


Synovial hemangiomas are rare causes of recurrent, non-specific joint complaints and take place most often in the knee joint. Till now, fewer than 200 cases have been reported in the world published reports. [4] By definition, a synovial hemangioma is "a benign vascular lesion arising from any structure lined by synovium including the intra-articular region, bursal spaces and tendon sheaths." [5] Some authors prefer to label hemangiomas arising from tendon sheaths as hemangiomas of tendon sheaths and not synovial hemangiomas as they are not actually confined by a synovial structure. Also to be excluded from the group of true synovial hemangiomas are soft tissue lesions that involve in addition to synovial structures, other regions, e.g., intramedullary compartment of bone, skeletal muscle, or subcutis. [5]

Synovial hemangiomas mostly present as a non-traumatic joint swelling combined with recurrent hemorrhagic effusions in early childhood. The symptoms usually persist for several years before the time of diagnosis. In most cases, a spongy compressible mass can be palpated over the joint, which decreases in size with elevation of the extremity. [2] Plain films of the joint may show non-specific changes including capsular thickening, vague soft tissue density and rarely bony erosion. No bony changes were evident in our case. The clinical examination and plain radiographs do not prove to be of much help in reaching a diagnosis of synovial hemangioma. The preferred diagnostic modality is MRI, which not only diagnoses but also delineates the lesion. But none of these modalities is confirmatory and the final diagnosis is made only on histopathology. [3] The origin of synovial hemangiomas continues to be an enigma. Whether they merely represent late stages of post-traumatic lesion or are they true neoplastic vascular proliferations; is not yet clear.

The clinical/radiologic differentials of synovial hemangioma include pigmented villonodular synovitis (PVNS), non-specific synovitis and lipoma arborescens. [5] From a pathologic standpoint, the differentials of this entity include PVNS, non-specific synovitis, organizing hemorrhage and angiomatosis. [5] Reactive and hyperplastic lesions (such as synovitis) accentuate the normal patterns of native vasculature. Reactive vessels are sometimes surrounded by a peri-vascular myxoid change, a finding not seen in true synovial hemangiomas. The most significant histologic differential, in terms of prognosis, is PVNS, a lesion which has a significant risk of recurrence. Traditionally, PVNS was considered to be a reactive lesion but recent observations (histologic, cytogenetic and flowcytometric) support a neoplastic origin. The deep stroma in PVNS is filled with a sheet like proliferation of histiocytes (with or without cytoplasmic deposits of hemosiderin) and multinucleated giant cells, a pattern not found in synovial hemangioma. [5] Hemosiderin deposits may be prominent in both hemophilic (coagulopathy related) and post-traumatic hemosiderosis, both of which were excluded in our case, based on clinical history and coagulation parameters. While scattered dilated spaces may be found in an organizing hemorrhage, the finding of large, cavernous, thin-walled spaces is interpreted as evidence of a hemangioma. Accurate and adequate pre-operative assessment with MRI and arthroscopy, aids in the appropriate classification of the lesion and guides definitive management. Management of a case of synovial hemangioma depends on the anatomical distribution of the lesion. Arthroscopic excision is carried out, if the lesion is pedunculated and well-circumscribed. Diffuse lesions are difficult to excise arthroscopically, as in our case; and for such cases, open wide excision is recommended. [3] Inspite of its rarity, synovial hemangioma had to be considered as a differential diagnosis in young patients presenting with recurrent painful swelling of the knee; which alone can lead to early diagnosis and proper management of the case.

 
   References Top

1.DePalma AF, Manler GG. Hemangioma of synovial membrane. Clin Orthop Relat Res 1964;32:93-9.  Back to cited text no. 1    
2.Enzinger FM, Weiss SW. Benign tumors and tumor-like lesions of blood vessels. In : Soft Tissue Tumors. 2 nd ed. St Louis: MO, Mosby; 1988. p. 489-53  Back to cited text no. 2    
3.Rogalski R, Hensinger R, Loder R. Vascular abnormalities of the extremities: Clinical findings and management. J Pediatr Orthop 1993;13:9-14  Back to cited text no. 3  [PUBMED]  
4.Price NJ, Cundy PJ. Synovial Hemangioma of knee. J Pediatr Orthop 1997;17:74-7.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Kenneth D, Vinh TN, Sweet DE. Synovial hemangioma: A report of 20 cases with differential diagnostic considerations. Hum Pathol 1993;24:737-45.  Back to cited text no. 5    

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Correspondence Address:
Geetika Khanna
House No. 88, Sector 37, Noida, Uttar Pradesh - 201303
India
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DOI: 10.4103/0377-4929.41676

PMID: 18603700

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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    Abstract
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