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CASE REPORT  
Year : 2018  |  Volume : 61  |  Issue : 4  |  Page : 604-606
Synovial hemangiomas of wrist and ankle joint: A report of two rare cases


1 Department of Pathology, Maulana Azad Medical College, New Delhi, India
2 Department of Surgery, Maulana Azad Medical College, New Delhi, India

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Date of Web Publication10-Oct-2018
 

   Abstract 


Synovial hemangioma is a rare, benign, vascular tumor of synovium leading to joint pain and swelling. The most common site is the knee joint, but rare cases involving other sites have also been reported. We report two rare cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint. Histopathology is the gold standard for diagnosis of these cases. Early treatment is warranted to prevent the risk of permanent joint damage.

Keywords: Ankle, histopathology, joint, synovial hemangioma, wrist

How to cite this article:
Saxena P, Agarwal R, Nain G, Khurana N, Lal P, Tudu SK. Synovial hemangiomas of wrist and ankle joint: A report of two rare cases. Indian J Pathol Microbiol 2018;61:604-6

How to cite this URL:
Saxena P, Agarwal R, Nain G, Khurana N, Lal P, Tudu SK. Synovial hemangiomas of wrist and ankle joint: A report of two rare cases. Indian J Pathol Microbiol [serial online] 2018 [cited 2018 Dec 15];61:604-6. Available from: http://www.ijpmonline.org/text.asp?2018/61/4/604/242998





   Introduction Top


Synovial hemangioma is a rare benign tumor of vascular origin arising from synovium-lined tissues. It has anatomically been divided into three types: synovial, juxta-articular, and intraarticular. The most common joint involved is the knee joint followed by the elbow joint. Involvement of the wrist joint and ankle joint has rarely been reported. Histopathologically, they are of three types: capillary, venous, and mixed.[1] The patient may present with pain, swelling, and compressive symptoms.

We present two cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint.


   Case Reports Top


Case 1

A 55-year-old male visited the outpatient department with complaints of swelling over the right lateral malleolus for 1 month, progressively increasing in size. The swelling was not associated with pain, and no history of trauma could be elicited. On examination, a 5 cm × 5 cm spherical, nontender swelling was palpable. It was cystic in consistency. A plain radiograph showed a soft-tissue swelling [Figure 1]. No bony involvement was noted. Repeated fine-needle aspiration cytology (FNAC) yielded hemorrhagic aspirate only. The lesion was surgically excised, and a provisional diagnosis of synovial cyst was suggested.
Figure 1: (a) X-ray showing no bony deformity (arrow shows soft-tissue swelling); (b) Case 1: Photomicrograph showing hemangioma with synovium from ankle joint (dotted arrow – hemangioma, solid arrow – synovium from the ankle joint); (c) Case 2: Photomicrograph showing thin-walled capillaries with synovium from the wrist joint; (d) Proliferating thin-walled capillary channels in high power (×40)

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Histopathological findings

Gross examination – the biopsy was received as multiple soft-tissue fragments measuring together 4 cm × 4 cm × 3 cm. No definite cystic structure was identified.

Microscopic examination – multiple hematoxylin and eosin (H and E)-stained sections examined showed synovium-lined tissue fragments with underlying tissue showing diffuse as well as lobular proliferation of capillary channels [Figure 1]. No synovial hyperplasia or inflammation was noted. No atypia or mitosis of endothelial cells was noted.

Histopathological diagnosis of synovial hemangioma was given.

Case 2

A 17-year-old female visited the outpatient department with complaints of swelling and pain over the volar aspect of the left wrist joint for the past 1 month. The swelling was progressively increasing in size. There was no history of trauma, tingling, or numbness. On examination, a soft, cystic swelling of size 3 cm × 2 cm was present. Overlying skin was free. Repeated FNAC yielded blood only. The patient underwent surgical excision of the lesion. A provisional diagnosis of bursal cyst was given.

Histopathological findings

Gross examination – a single gray-white to tan soft-tissue mass measuring 3 cm × 2 cm × 1.5 cm was received. No cystic structure was identified.

Microscopic examination – multiple H and E-stained sections showed benign, lobular proliferation of endothelium-lined capillary channels [Figure 1]. No inflammation, atypia, or mitosis was noted.

A diagnosis of synovial hemangioma was given on histopathology.

Both the patients are under follow-up in the outpatient department and are doing well.


   Discussion Top


Synovial hemangiomas are rare causes of joint swelling and pain. Around 250 cases have been reported to date majority of which involve knee joint.[2] Synovial hemangiomas may arise not only from the intraarticular region but also from the bursae or tendon sheaths.[3] Those arising from the ankle or the wrist joint are exceedingly rare.

Only one case of synovial hemangioma of the wrist joint has been previously described in the literature.[4] Three more cases of wrist joint swelling and pain have been described which were finally diagnosed as hemangioma of the flexor tendon sheath.[5],[6],[7] All the three cases had pain along with features of carpal tunnel syndrome.

We found only two cases of ankle joint hemangioma reported in the literature.[1],[8] Diagnosis in most of these cases is delayed due to nonspecific signs and symptoms. Swelling is the most common presentation followed by pain which may not be present in all cases. Clinically, the differential diagnoses may include synovial osteochondromatosis, pigmented villonodular synovitis (PVNS), juxta-articular myxoma, synovial sarcoma, and lipoma arborescens.[3]

X-ray shows a soft-tissue density with no bony involvement. Bony erosion may rarely be seen in late cases.[4] Magnetic resonance imaging is a better modality for assessing these lesions.[9]

The gold standard for diagnosis is histopathology. The histopathological differential diagnoses include PVNS, nonspecific synovitis, and organizing hemorrhage. It is important to distinguish synovial hemangiomas from PVNS as PVNS is known for its local aggressiveness and recurrence. Cases with PVNS show multinucleated giant cells along with sheets of histiocytes (with or without hemosiderin). Nonspecific synovitis shows reactive vessels occasionally surrounded by perivascular myxoid change while organizing hemorrhage shows scattered, dilated blood vessels with hemorrhage and fibrinous exudation and fibrosis.[10] Our cases had none of the above features. The most prominent features in both of our cases were presence of thin-walled capillaries in a lobular configuration without any fibrosis or inflammation of the intervening stroma.

Arthroscopic excision is the treatment of choice in cases of well-circumscribed, discreet lesions while open wide excision should be carried out in patients with diffuse lesions.[10]

Although rare, synovial hemangioma should always be kept as a differential diagnosis, in cases of joint pain and swelling. Prompt diagnosis and management is necessary to prevent any risk of subsequent arthropathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Oumakhir S, Ghfir M, El Ktaibi A, Albouzidi A, Sedrati O. Synovial hemangioma of the ankle. Foot (Edinb) 2010;20:42-3.  Back to cited text no. 1
    
2.
Lopez-Oliva CL, Wang EH, Cañal JP. Synovial haemangioma of the knee: An under recognised condition. Int Orthop 2015;39:2037-40.  Back to cited text no. 2
    
3.
Devaney K, 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. 3
    
4.
Greenspan A, Azouz EM, Matthews J 2nd, Décarie JC. Synovial hemangioma: Imaging features in eight histologically proven cases, review of the literature, and differential diagnosis. Skeletal Radiol 1995;24:583-90.  Back to cited text no. 4
    
5.
Kim JY, Sung JH, Lee S. A haemangioma of the flexor tendon sheath causing carpal tunnel syndrome. J Hand Surg Eur Vol 2010;35:73-4.  Back to cited text no. 5
    
6.
George R, Lee K. Synovial angioma of the FDP flexor sheath: A Rare cause of carpal tunnel syndrome. Open Orthop J 2013;7:72-4.  Back to cited text no. 6
    
7.
Chow LT, Ho PC, Kumta SM. Papillary endothelial hyperplasia within synovial haemangioma of the flexor tendon sheath of the wrist. APMIS 2004;112:314-8.  Back to cited text no. 7
    
8.
Mahata M, Gayen R, Dasgupta S, Ghosh S, Dasgupta J, Sarka R. Synovial hemangioma of the ankle joint: A rare and unusual encounter. Int J Biomed Res 2015;6:726-8.  Back to cited text no. 8
    
9.
Narváez JA, Narváez J, Aguilera C, De Lama E, Portabella F. MR imaging of synovial tumors and tumor-like lesions. Eur Radiol 2001;11:2549-60.  Back to cited text no. 9
    
10.
Rajni, Khanna G, Gupta A, Gupta V. Synovial hemangioma: A rare benign synovial lesion. Indian J Pathol Microbiol 2008;51:257-8.  Back to cited text no. 10
    

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Correspondence Address:
Radhika Agarwal
Room No. 62, Pathology Block, MAMC, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_603_17

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