(Radiology. 2001;218:841-847.)
© RSNA, 2001
Hemangiomas of the Fingers: MR Imaging Evaluation1
Nicolas H. Theumann, MD,
Jacques Bittoun, MD, PhD,
Sophie Goettmann, MD,
Dominique Le Viet, MD,
Alain Chevrot, MD and
Jean-Luc Drapé, MD, PhD
1 From the Department of Radiology B, CHU Cochin, AP-HP-Université Paris V, 27 rue du Fg Saint-Jacques, 75014 Paris, France (N.H.T., A.C., J.L.D.); Department of Radiology, CHUV, Lausanne, Switzerland (N.H.T.); Centre inter Etablissement de Resonance Magnetique, Hôpital de Bicêtre, AP-HP-Université Paris XI, France (J.B., J.L.D.); Department of Dermatology, CHU Bichat, Université Paris IX, France (S.G.); and Institut de la Main, Paris, France (D.L.V.). Received April 13, 2000; revision requested June 6; revision received August 14; accepted September 6. Address correspondence to J.L.D. (e-mail: jean-luc.drape@cch.ap-hop-paris.fr).
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ABSTRACT
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PURPOSE: To report the magnetic resonance (MR) imaging features of finger hemangiomas.
MATERIALS AND METHODS: Sixteen patients clinically suspected of having hemangioma of the finger underwent 1.5-T MR imaging with a customized local gradient coil. The location, size, margins, signal intensity, and enhancement patterns of the lesions were noted. In accordance with the literature on MR imaging of deep hemangiomas, the authors’ findings could be divided into those with typical features—that is, high signal intensity at T1- and T2-weighted imaging, lobulated appearance, strong enhancement, and heterogeneous pattern with flow void artifacts—and those with atypical features. The reference standard was surgery (n = 12) or clinical outcome (n = 4).
RESULTS: One posttraumatic hematoma was excluded. Most lesions were in the fingertip (n = 10), with involvement of the nail bed and/or the pulp (n = 5). Hemangiomas were classified as typical in ten cases and atypical in five. The mean size of typical lesions was larger than that of atypical lesions. The unique imaging features of atypical hemangiomas included a masslike appearance, which was either homogeneous with diffuse enhancement—suggestive of hypervascularity (n = 2)—or heterogeneous with poor enhancement (n = 3).
CONCLUSION: MR imaging characteristics of finger hemangiomas can be classified as typical or atypical. Knowledge of both patterns can be helpful in the distinction of soft-tissue abnormalities at this location.
Index terms: Angioma, soft tissues, 43.3141 • Fingers and toes, abnormalities, 43.3141 • Fingers and toes, neoplasms, 43.3141 • Hand, MR, 43.121411, 43.121412, 43.121416, 43.12142, 43.12143
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INTRODUCTION
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Hemangiomas are one of the most common soft-tissue tumors. They are estimated to comprise 7% of all benign tumors and have a predilection for the deep soft tissues (1). Magnetic resonance (MR) imaging has become the technique of choice for identification and characterization of soft-tissue masses (2–8). The MR imaging features of hemangiomas are well known: They have infiltrative margins and an overgrowth of fatty tissue, which has high signal intensity at T1-weighted imaging (9). Vascular components produce heterogeneous signal intensity with a serpentine-like pattern, extremely high signal intensity at T2-weighted imaging, and flow void artifacts. The finger location of hemangiomas is not uncommon (10) and is isolated (localized type) in most cases, or it may be included in angiomatosis with involvement of large segments of the body such as an entire extremity.
The small size of finger hemangiomas may explain the lack of studies on their MR imaging patterns in the literature. Furthermore, whether finger hemangiomas have the same MR imaging patterns as deep muscular hemangiomas has not been determined. The purpose of this retrospective study was to assess the high-spatial-resolution MR imaging findings of 15 finger hemangiomas and compare these findings with the MR imaging features of deep hemangiomas.
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MATERIALS AND METHODS
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Patients
Sixteen consecutive patients (10 female, six male; mean age, 43 years; age range, 15–69 years) who were clinically suspected of having hemangioma of the finger were examined with MR imaging. Each patient gave informed consent after approval was obtained from the Centre inter Etablissement de Resonance Magnetique institutional review board. Eleven lesions were on the tip of the second or third finger. Four of the 16 patients had a history of trauma (Table 1). The clinical symptoms were progressive with time. The duration of symptoms was 2 months to 23 years. The lesion appeared nine times as a focal blue-red discoloration and was beneath the lunula seven times. The patients had painful swelling episodes in nine cases. Three patients were explored postoperatively for clinical recurrence (postoperative range, 2–5 years). In one case, the histopathologic finding was a posttraumatic hematoma, and this misleading case was excluded from the study series.
Imaging
Anteroposterior and lateral radiographs of the involved finger were obtained in all patients. All MR imaging examinations were performed with a 1.5-T unit (Signa; GE Medical Systems, Milwaukee, Wis). A high-spatial-resolution module dedicated for skin imaging was used. A surface gradient coil was connected in place of the anteroposterior gradient coil of the system to increase the gradient strengths. This gradient coil was a one-sided pair of saddle-shaped coils. The maximum gradient strength was obtained perpendicularly to the finger pad and yielded 4.2 G/cm with a current intensity of 11 A. A voxel size of 117 x 234 x 700–3,000 µm3 was used with a 3-cm field of view, a 256 x 128 acquisition matrix, and a 16-KHz receiver bandwidth. A surface radio-frequency coil with a 1.5-cm radius was placed at the center of the gradient coil. The more technical specifications have been previously described (11,12). We altered the calibration of the gradients so that all spatial parameters reported by the machine were five times greater than the actual distances.
The patients underwent imaging while in the prone or decubitus position, with the arm extended above the head. The involved aspect of the finger was placed against the radio-frequency coil. Transverse intermediate- and T2-weighted spin-echo images (repetition time msec/echo time msec, 2,000/20–24, 72–80) were first acquired with one excitation (acquisition time, 5 minutes 12 seconds). In one case, transverse T2-weighted fast spin-echo images (4,000.0/138.4) were obtained with four excitations (acquisition time, 3 minutes 52 seconds). Transverse and sagittal T1-weighted spin-echo sequences (500–600/20–24) were performed before and after injection of 0.1 mmol of gadoterate meglumine (Dotarem; Ander Guerbet, Roissy, France) per kilogram of body weight with one excitation (acquisition time, 1 minute 18 seconds). The section thickness was 3 mm, with a 1-mm intersection gap. Three-dimensional gradient-recalled-echo acquisition in the steady state (GRASS; GE Medical Systems) imaging (50/12, 40° flip angle), which involved the acquisition of 28 transverse or sagittal 0.7–1.0-mm-thick contiguous sections, was performed in 11 patients. The acquisition time with one excitation was 6 minutes 50 seconds. MR angiography was performed with three-dimensional time-of-flight sequences (6.8/1.7; inversion time, 23.0 msec) and maximum intensity projection reformatting in one patient.
Image Interpretation and Data Analysis
On the radiographs of the fingers, an enlargement and/or calcifications of the soft tissues, as well as bone erosion or a periosteal reaction of the phalanx, were noted. The MR images were interpreted retrospectively and separately by two experienced musculoskeletal radiologists (N.H.T., J.L.D.) in a blinded manner, and final characteristics were decided by means of consensus. The location of the hemangioma—that is, the nail bed and/ or pulp or dorsal or palmar aspect of the finger—was noted. The largest size of each tumor, in millimeters, was calculated on the transverse and sagittal MR images by using an electronic caliper. The margins of the tumor were noted and designated as well defined or ill defined (ie, infiltrative lesion). The presence of bone erosion was evaluated on the MR images.
The homogeneity or heterogeneity of the signal intensity was noted. The predominant tumor signal intensity at T1- and T2-weighted imaging was recorded as hypointense, isointense, slightly high, or strongly high compared with the signal intensity of the dermis. Enhancement after injection of gadoterate meglumine was described as none, poor, or strong, and homogeneous or heterogeneous (ie, central or peripheral). Furthermore, the contents of hemangiomas were characterized as vascular (saccular or serpentine, fluid-fluid levels) or solid. The flow void artifacts visualized with the different sequences were separated into three categories—none, positive, and positive+ —which indicated, respectively, the absence, minimal appearance, or marked appearance of artifacts.
The similarity of the MR imaging findings of the finger hemangiomas to the MR imaging features of deep hemangiomas was quantified with a score of 0–10. The lower the score, the more atypical the finger hemangioma. Each of the following criteria was registered as one point: ill-defined margin, heterogeneity, fatty tissue (ie, high signal intensity at T1-weighted imaging), and strongly high signal intensity at T2-weighted imaging. The other more important criteria of strong enhancement, vascular content (ie, fluid-fluid levels), and presence of obvious flow void artifacts were registered as two points (7,9,13,14). The hemangioma was considered to be atypical when the total score was equal to or less than five points.
Histopathologic Findings
Twelve patients were operated on. The histopathologic findings were capillary hemangioma in two cases, cavernous hemangioma in three cases, hemangioendothelioma in one case, and five nonspecific hemangiomas.
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RESULTS
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Radiography
We found one clear-cut bone erosion of the lateral aspect of a distal phalanx, no periosteal abnormality, and four masses of the soft tissue. Two phleboliths were noted in the soft tissue of the dorsal side of a proximal phalanx.
MR Imaging
Location.—Most hemangiomas were located in the fingertip, and 10 lesions were in the nail bed (Table 2). In one case, the hemangioma was superficial and limited to the epithelial layer. In five cases, the lesions extended toward the pulp and invaded the rima ungualum, with displacement of the lateral interosseous ligament (ie, Flint ligament) (Fig 1). The lesions were located less commonly in the palmar or dorsal aspects of the finger (n = 5) (Fig 2).
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Figure 1. Case 1. Transverse intermediate-weighted spin-echo MR image (2,000/24) depicts hemangioma of the right third finger. The multilobulated lesion invades a thickened nail bed (arrowheads). The tumor extends to the pulp through an enlarged rima ungualum (*). The lateral interosseous ligament (arrow) is laterally displaced.
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Figure 2. Case 4. Hemangioma of the left third finger. Sagittal contrast material-enhanced T1-weighted spin-echo MR image (600/24) shows round vascular spaces with heterogeneous signal intensity (arrows) in the palmar aspect of the proximal phalanx.
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Imaging features.—In 10 of the 15 cases, the MR image features corresponded to the typical features of deep hemangiomas (score >5). In these 10 cases, the mean lesion size (± SD) was 9.1 mm ± 6. These lesions had saccular and/or serpentine vascular spaces. The margins were infiltrative in eight cases (Fig 3). The signal intensity was heterogeneous with flow void artifacts in six of 10 cases (Fig 4). We could observe the fluid-fluid levels in only one of these 10 cases (Fig 5). In all these cases, there was strong enhancement after injection of gadoterate meglumine (Fig 6). In five cases, there was peripheral enhancement (Fig 4). In one case, MR angiography depicted serpiginous feeding vessels in the nidus, ulnar dorsal collateral artery, and dorsal perforating arteries (Fig 7). However, we did not see fatty infiltration in any cases.
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Figure 3. Case 5. Capillary hemangioma of the right second finger. Transverse intermediate-weighted spin-echo MR image (2,000/72) obtained at the level of the metacarpophalangeal joint shows a high-signal-intensity infiltrative lesion (arrows) in the palmoulnar aspect of the digital canal.
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Figure 4a. Case 3. Hemangioendothelioma of the left second finger. (a) Transverse contrast-enhanced T1-weighted spin-echo MR image (600/24) shows a central flow void artifact (thick arrow) that is better depicted after injection of gadoterate meglumine. Note the maximal peripheral enhancement (arrowheads). Small serpentine vessels (thin arrow) also are enhancing in the nail bed. (b) Transverse contrast-enhanced three-dimensional gradient-recalled-echo MR image (50/12, 40° flip angle) shows the central flow void artifact (arrow) is larger than that in a.
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Figure 4b. Case 3. Hemangioendothelioma of the left second finger. (a) Transverse contrast-enhanced T1-weighted spin-echo MR image (600/24) shows a central flow void artifact (thick arrow) that is better depicted after injection of gadoterate meglumine. Note the maximal peripheral enhancement (arrowheads). Small serpentine vessels (thin arrow) also are enhancing in the nail bed. (b) Transverse contrast-enhanced three-dimensional gradient-recalled-echo MR image (50/12, 40° flip angle) shows the central flow void artifact (arrow) is larger than that in a.
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Figure 5. Case 4. Hemangioma of the right third finger. Transverse contrast-enhanced T1-weighted spin-echo MR image (600/24) shows numerous fluid-fluid levels (arrowheads) in large vascular spaces.
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Figure 6. Case 2. Hemangioma of the right third finger at the level of the proximal interphalangeal joint. Transverse contrast-enhanced three-dimensional gradient-recalled-echo MR image (50/12, 40° flip angle) shows the lesion in the dorsoulnar aspect of the joint. The hemangioma has strong enhancement and tiny flow void artifacts (arrowheads). The lesion is interposed between the median band of the extensor tendon (large arrows) and the ulnar collateral vessels (small arrow).
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Figure 7a. Case 10. Hemangioma of the right third finger. (a) Transverse T2-weighted fast spin-echo MR image (4,000/138.4 [effective]) shows a high-signal-intensity, well-limited lesion beneath the extensor tendon (short arrows) and dorsal interosseous extension (arrowheads). A prominent ulnar dorsal collateral artery (long arrow) is well depicted in the subcutaneous tissue. (b) Coronal MR angiogram (6.8/1.7, 40° flip angle) depicts the nidus (arrow) adjacent to the ulnar dorsal collateral artery (arrowheads). (c) Sagittal MR angiogram depicts serpiginous vessels in the nidus (arrowheads) and the feeding arteries (ie, prominent ulnar dorsal collateral artery [large arrow] and dorsal perforating arteries [small arrows]).
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Figure 7b. Case 10. Hemangioma of the right third finger. (a) Transverse T2-weighted fast spin-echo MR image (4,000/138.4 [effective]) shows a high-signal-intensity, well-limited lesion beneath the extensor tendon (short arrows) and dorsal interosseous extension (arrowheads). A prominent ulnar dorsal collateral artery (long arrow) is well depicted in the subcutaneous tissue. (b) Coronal MR angiogram (6.8/1.7, 40° flip angle) depicts the nidus (arrow) adjacent to the ulnar dorsal collateral artery (arrowheads). (c) Sagittal MR angiogram depicts serpiginous vessels in the nidus (arrowheads) and the feeding arteries (ie, prominent ulnar dorsal collateral artery [large arrow] and dorsal perforating arteries [small arrows]).
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Figure 7c. Case 10. Hemangioma of the right third finger. (a) Transverse T2-weighted fast spin-echo MR image (4,000/138.4 [effective]) shows a high-signal-intensity, well-limited lesion beneath the extensor tendon (short arrows) and dorsal interosseous extension (arrowheads). A prominent ulnar dorsal collateral artery (long arrow) is well depicted in the subcutaneous tissue. (b) Coronal MR angiogram (6.8/1.7, 40° flip angle) depicts the nidus (arrow) adjacent to the ulnar dorsal collateral artery (arrowheads). (c) Sagittal MR angiogram depicts serpiginous vessels in the nidus (arrowheads) and the feeding arteries (ie, prominent ulnar dorsal collateral artery [large arrow] and dorsal perforating arteries [small arrows]).
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In five (33%) of the 15 cases, the MR imaging features were atypical of deep soft-tissue hemangiomas (score 
5). In these cases, the mean lesion size was 6.2 mm ± 2. In two of these cases, the lesion manifested as a hypervascularized homogeneous solid mass similar to a glomus tumor or an angioleiomyoma. However, some subtle patterns pointed to the diagnosis of hemangioma: a superficial location in the epithelial layer (Fig 8), the lack of bone erosion compared with the large size of the lesion, and high signal intensity at T1-weighted imaging (Fig 9). In the other three cases, the lesions were ill-defined polylobulated masses that had slightly high signal intensity at T2-weighted imaging and poor enhancement after gadoterate meglumine injection. Furthermore, the gradient-recalled-echo images were very useful for depicting the small vessels inside the lesion (Fig 10).
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Figure 8. Case 11. Transverse nonenhanced (top) and contrast-enhanced (bottom) T1-weighted spin-echo MR images (500/20) of hemangioma of the right thumb. The highly vascularized superficial lesion (arrowheads) restricted to the epithelial layer of the ulnar side of the nail bed is better depicted on the contrast-enhanced image.
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Figure 9. Case 12. Transverse nonenhanced (top) and contrast-enhanced (bottom) T1-weighted spin-echo MR images (500/20) of hemangioma of the left second finger. The large lesion (arrowheads) is located in the nail bed and looks like a glomus tumor. However, there is no cortical defect, and the lesion has high signal intensity before contrast material injection; results of histopathologic analysis showed infiltrative fatty tissue. Note the strong enhancement after gadoterate meglumine injection (bottom).
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Figure 10a. Case 13. Hemangioma of the pulp of the right second finger. (a) On the transverse intermediate-weighted spin-echo MR image (2,000/80), the hemangioma (arrows) appears to have slightly high signal intensity, and its margins are ill defined. (b) The transverse contrast-enhanced three-dimensional gradient-recalled-echo MR image (50/12, 40° flip angle) more accurately depicts the margins of the lesion (arrowheads) and highlights the flow artifacts of small vessels (arrow). Surgical findings confirmed the diagnosis.
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Figure 10b. Case 13. Hemangioma of the pulp of the right second finger. (a) On the transverse intermediate-weighted spin-echo MR image (2,000/80), the hemangioma (arrows) appears to have slightly high signal intensity, and its margins are ill defined. (b) The transverse contrast-enhanced three-dimensional gradient-recalled-echo MR image (50/12, 40° flip angle) more accurately depicts the margins of the lesion (arrowheads) and highlights the flow artifacts of small vessels (arrow). Surgical findings confirmed the diagnosis.
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Differential diagnosis.—The excluded posttraumatic hematoma could not be distinguished from a hemangioma. The clinical history—that is, focal blue-red discoloration, increasing lesion size, and painful swelling episodes—was suggestive of a hemangioma. There was an 11-mm sharply defined saccular lesion in the palmar aspect of the third fingertip. The mass was close to the collateral vessels and had a low-signal-intensity core at all sequences and peripheral enhancement after contrast material injection (Fig 11).
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Figure 11. Posttraumatic hematoma of the right second finger. Transverse intermediate-weighted spin-echo MR image (2,000/72) shows a circular lesion (arrows) in the palmar aspect of the radial collateral vessels (arrowheads). A low-signal-intensity central core with a high-signal-intensity peripheral rim was seen. Results of histopathologic analysis showed an organized hematoma, although the lesion had numerous swelling episodes for 8 months.
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DISCUSSION
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Radiographs alone usually are inadequate in depicting hemangiomas of the finger. In our series, phleboliths and bone erosion were infrequent. This poor sensitivity could have been secondary to the small size of the tumors. At radiography, deep soft-tissue hemangiomas can appear aggressively, with a reactive change in the adjacent bone tissue, and simulate malignant bone tumors (15,16). However, hemangiomas are benign and can be treated with more conservative therapy. High-spatial-resolution real-time ultrasonography and Doppler imaging may depict superficial hemangiomas as small as 3 mm in diameter (17–20).
MR images provide accurate views of finger hemangiomas on the condition of high spatial resolution—about 150–200 µm. The diagnosis may be based on the enhancement of small vessels. The improvement in phased-array coils and increased strength of the gradient coils allow efficient MR imaging. The usefulness of MR angiography for the detection of deep soft-tissue hemangiomas has been demonstrated (21). In the finger, this technique has been described for imaging glomus tumors only (22). MR angiography of the fingers is associated with difficult technical problems, especially where spatial resolution is concerned. A gradient radio-frequency array is useful for obtaining angiograms of the collateral digital vessels (23). Determining the exact location of periungual hemangiomas is essential for avoiding nail dystrophy after surgery. The lateral approach allows exposure and excision of the tumor situated in the dorsal aspect of the finger once the nail plate has been removed (24).
Although fine-needle aspirates of normal tissue fragments are indicative of benignity, they may also be due to unrepresentative material from the tumor. Hemangiomas are composed of abnormal vascular elements with angioblastic proliferation and regression. Although some vascular tumors (eg, juvenile hemangiomas) regress altogether, most persist if they are untreated but have limited growth potential. Thus, MR imaging is important for correct preoperative diagnosis because of the characteristic findings.
Hemangiomas usually contain adipose or other nonvascular tissue (25). Several authors (5,14,26), in describing the internal structure of this neoplasm, have reported lacelike serpiginous fatty-fibrous intratumoral septa and a lobulated tumor appearance. Heterogeneous high signal intensity at T1- and T2-weighted imaging may be produced by reactive fatty tissue around the neoplastic vessels or by vessels filled with blood (9,13).
In the current study, two-thirds (10 of 15) of the finger hemangiomas had features that were typical of deep hemangiomas. However, no infiltrate fatty tissue could be depicted, perhaps because of the small size of the lesions. The usefulness of contrast material injection has been debated, because the nonenhanced features of hemangioma are already evocative in the typical cases (7). In our series, fewer than half the patients had peripheral enhancement (at MR imaging) similar to that seen in hepatic hemangiomas (27,28). Hemangioendothelioma may be more aggressive, and the usefulness of carcinologic resection has been debated (29). The MR imaging features of hemangioendothelioma are not distinct from those of other typical hemangiomas (30).
The five remaining cases were considered to have atypical MR imaging features. On one hand, two of these hemangiomas appeared as hypervascularized homogeneous solid masses with sharp margins. These lesions were located in the nail bed and were similar to a glomus tumor or an angioleiomyoma (31,32). However, some subtle patterns pointed to the diagnosis of hemangioma: The superficial location in the epithelial layer is not common in glomus tumors. The lack of bone erosion of the dorsal cortex of the distal phalanx also is unusual given the large size of the hemangioma in the nail bed. In one of these cases, the hemangioma had high signal intensity at T1-weighted imaging compared with the signal intensity of the nail bed dermis. This homogeneous high signal intensity was due to a fatty infiltration of the stroma and may have been assimilated into the round hemangiomas of the vertebral bodies. Homogeneous signal intensity of hemangiomas, even of deep hemangiomas, has been reported when the lesion is smaller than 2 cm (7).
On the other hand, three atypical hemangiomas were ill-defined saccular masses with atypical poor enhancement. They also had unusual, slightly high signal intensity at T2-weighted imaging. Histopathologic analysis results showed diffuse fibrous tissue infiltrating the stroma. Furthermore, the gradient-recalled-echo images were very useful for depicting the small vessels inside the lesion. Flow artifacts are magnified with gradient-recalled-echo sequences. The slow blood flow could be detected in fingers with three-dimensional gradient-recalled-echo imaging and a local gradient coil (23).
A posttraumatic hematoma may be misleading on MR images and histologic sections. However, the clinical history, demonstrating repeated painful swelling episodes, may be helpful. A hematoma appears to be well defined on MR images and usually has low signal intensity at T2-weighted imaging owing to methemoglobin deposits. Areas of T1-weighted high signal intensity are less common on delayed images. Gadoterate meglumine injection may produce peripheral enhancement. The detection of small vessels in a bleeding hemangioma is difficult. Histologic studies can hardly enable differentiation of an organized hematoma from a hemorrhagic hemangioma (33). A digital varix also is similar to hemangioma and is composed of dilated vascular spaces with thin-walled channels characterized by partial thrombosis and organization. Its pathogenesis is possibly an obstruction of the venous outflow in the superficial veins of the digital volar surface (34).
In conclusion, the results of this retrospective study, despite its small number of patients, demonstrate that high-spatial-resolution MR imaging enables an accurate diagnosis of finger hemangiomas. However, one-third of cases may be difficult to diagnose because of the lack of the classic patterns of deep muscular hemangiomas. Some lesions may mimic glomus tumors. Gradient-recalled-echo images are recommended for depicting small abnormal vessels.
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ACKNOWLEDGMENTS
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The authors thank Christine Chung, MD, for assistance in the preparation of the manuscript.
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FOOTNOTES
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Author contributions: Guarantors of integrity of entire study, J.L.D., A.C.; study concepts and design, J.L.D.; definition of intellectual content, J.L.D.; literature research, N.H.T.; clinical studies, S.G., D.L.V., N.H.T.; data acquisition, J.B., N.H.T.; data analysis, J.L.D., N.H.T.; manuscript preparation, J.L.D.; manuscript editing, N.H.T.; manuscript review, J.L.D.; manuscript final version approval, J.L.D.
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ABSTRACT
INTRODUCTION
