An adult hemangioma is a benign tumor characterized by an abnormal overgrowth of blood vessels. Unlike infantile hemangiomas, which usually regress spontaneously, adult hemangiomas are often acquired later in life or are lesions that persisted from childhood. These vascular lesions can be small, superficial growths like cherry angiomas, or deeper, complex masses known as cavernous hemangiomas that affect soft tissue, muscle, or internal organs like the liver and spine. While many are harmless, intervention is sought when the lesion causes pain, functional impairment, or significant cosmetic distress. Treatment is necessary to manage complications such as bleeding, ulceration, or compression of surrounding vital structures.
Deciding Whether to Treat or Monitor
The initial approach to an adult hemangioma often involves a period of monitoring, as many lesions remain stable and asymptomatic over time. Clinicians primarily move toward active intervention when the hemangioma’s behavior or location presents a risk to the patient’s health or function. For example, a hemangioma in a location that could impair vision, breathing, or spinal cord function is a strong indicator for treatment.
The size and growth rate are significant factors in the decision-making process, particularly for internal masses like liver hemangiomas. A lesion showing rapid enlargement or exceeding a certain size, often cited as over 5 centimeters for hepatic hemangiomas, increases the risk of complications like rupture or mass effect on adjacent organs. Symptoms such as chronic pain or signs of consumptive coagulopathy, known as Kasabach-Merritt syndrome, also necessitate prompt therapeutic action. When the diagnosis remains uncertain, especially if a malignancy cannot be definitively ruled out through imaging, treatment may be pursued to obtain a tissue sample or remove the mass.
Non-Surgical and Targeted Therapies
For many adult hemangiomas, treatment begins with minimally invasive or targeted methods designed to shrink the lesion without surgical removal.
Sclerotherapy
Sclerotherapy is a common localized procedure where a sclerosing agent is injected directly into the hemangioma to cause inflammation, scarring, and eventual obliteration of the abnormal blood vessels. Agents such as sodium tetradecyl sulfate or pure ethanol are used to induce this chemical destruction of the vascular endothelium. This technique is often favored for smaller, localized, or deep lesions where surgery is challenging.
Laser Therapy
Laser therapy offers a targeted approach, primarily used for superficial or cutaneous hemangiomas, such as cherry angiomas, or to treat the residual discoloration and ulceration of larger lesions. Pulsed dye lasers are effective in targeting the blood vessels to lighten the color and reduce the size of the vascular malformation on the skin surface. The heat energy from the laser causes selective damage to the hemoglobin in the vessels, leading to their collapse and subsequent fading.
Pharmacological Treatments
Pharmacological treatments, though more commonly associated with infantile cases, have demonstrated effectiveness in some adult hemangiomas, especially those causing functional compromise. The beta-blocker propranolol, which works by constricting blood vessels and inhibiting growth factors, has shown significant volume reduction in adult head and neck hemangiomas, sometimes achieving nearly complete resolution. For refractory or complex cases, particularly orbital hemangiomas, anti-angiogenic agents like bevacizumab may be used to target vascular endothelial growth factor (VEGF). This systemic therapy can reduce the tumor’s blood supply and promote regression in lesions unresponsive to other treatments.
Surgical Removal and Interventional Radiology
Surgical Excision
Surgical excision remains a definitive treatment option, particularly for well-defined, localized hemangiomas that can be completely removed without excessive functional or cosmetic deficit. This approach is often reserved for lesions that are unresponsive to non-surgical methods or those causing significant mass effect. Due to the highly vascular nature of hemangiomas, surgical planning is meticulous, focusing on minimizing intraoperative blood loss. Removal of deep lesions, such as those embedded in muscle or near nerves, requires careful dissection to preserve surrounding healthy tissue and may necessitate subsequent reconstructive procedures.
Interventional Radiology
Interventional radiology techniques, which involve catheter-based procedures, play a considerable role in managing large or deeply situated hemangiomas. Transarterial embolization (TAE) involves navigating a catheter into the feeding artery of the hemangioma and injecting embolic materials, like particles or coils, to block the blood flow. This technique is frequently used as a pre-operative step for giant hemangiomas, such as those in the liver, where it significantly reduces the size and vascularity of the lesion, making subsequent surgical removal safer and decreasing the risk of hemorrhage.
Direct embolization is also used as a stand-alone therapy for lesions where surgery is too risky or for internal hemangiomas causing symptoms. For giant hepatic hemangiomas, TAE can lead to a substantial decrease in tumor size and an improvement in symptoms. Other ablative interventional techniques, such as radiofrequency ablation, are used for smaller internal lesions, generating heat to destroy the hemangioma tissue.