INTRODUCTION
Hemangiomas are the most benign tumors of the infancy and occur in about 10% of term infants.Hemangioma can be present at birth,they usually arise shortly after birth and grow rapidly during the first year of life,with slowing of growth in the next 5 year and involution by 10~15 year of the age［1］.The large forms of infantile cavernous hemangiomas are visually displeasing,frequently have accelerated growth,and may cause significant functional disturbances and existential complications.Several non-controversial indications that demand treatment include hemangiomas affecting vision or producing serious permanent disfigurement or other problematic symptoms that depend on the anatomic location［2］.When lesional vascular channels are considerably enlarged,the term cavernous hemangioma has traditionally been applied.This differs from capillary hemangioma in that it is less well circumscribed,is larger and is usually deeper in submucosal tissues.Sluggish blood flow may result in organized or dystrophically calcified thrombi within dilated vessels.The vessels may be arranged in a haphazard or a somewhat lobular pattern and there may be areas with fibrosis of the background stroma［3］.Here we report a case of cavernous hemangioma in the buccal mucosa.
CASE REPORT
A 7-year-old female child was examined in pediatric department at KHS hospital,Sevagram.The patient presented with swelling on the right side of cheek since last 3 year.Initially it was small in size but now gradually increasing since last 6 months.Facial asymmetry was present because of swelling.Physical examination revealed a large deep hemangioma in the buccal mucosathat measured 15 cm×15 cm (Figure 1) without affecting the nearby structure.Dental caries was present with normal dental development.Laboratory investigation,the complete blood count and routine blood chemistry were within normal ranges,and no lesions in the mandible or tooth were found by X-ray.Intralesional steroid was given but there was no improvement,so patient was referred to interventional radiologist for laser therapy.
Figure 1 Proliferating lobulated cavernous hemangioma in the buccal mucosa
DISCUSSION
Hemangiomas are the most common tumors of infancy［4］.Traditionally,this term has been applied to benign tumors of vascular tissues and vascular malformations.Hemangiomas are classified as capillary,cavernous,and mixed lesions.The incidence in newborns is 1%~3%,and this increases to 10% by the age of 1 year［5］. Finn,et al.［5］,in a large series,found that 60% of hemangiomas occurred on the head and the neck,25% on the trunk,and 15% on the extremities.Whereas 80% of patients have a single hemangioma,others have multifocal ones［6］.Seventy percent of hemangiomas initially appear in the first several weeks of life.Rapid growth during the neonatal period is the historical hallmark of hemangiomas［7］.It is known that hemangiomas of infancy occur more frequently among female infants (male / female ratio is 1∶3)［2］ and are most commonly located on the head and neck (< 60% of cases)［7,8］.Hemangiomas are composed of proliferating,plump endothelial cells.Early in proliferation,the cells are in disarray,but,with time,they form vascular spaces and channels replete with blood cells.These benign-appearing endothelial cells produce limited basement membrane structures.Takahashi,et al.hypothesized that during the third trimester of fetal development,immature endothelial cells coexist with immature pericytes which maintain their proliferative capacity for a limited period during postnatal life［9］.Yoshikawa F,et al.［10］ reported a rare case of pedunculated hemangioma of the oral mucosa.Clinically,it was diagnosed as a fibroma induced by irritation,but histologic examination followed to excisional biopsy demonstrated that it was a cavernous hemangioma.
The earliest sign of a hemangioma is blanching of the involved skin.This may be followed by fine telangiectasias and then a red or crimson macule.Sixty percent of cutaneous hemangiomas occur on the head and neck,25% on the trunk,and 15% on the extremities.Hemangiomas also can occur in extra cutaneous sites including the liver,gastrointestinal tract,larynx,central nervous system,pancreas,gall bladder,thymus,spleen,lymph nodes,lung,urinary bladder,and adrenal glands.If the hemangioma is located in the subcutaneous tissue,the overlying skin may be completely normal.Color varies with the depth from the surface and can be bright red or crimson (superficial dermis),purple,blue,or flesh-colored with predominant involvement of the deeper tissues.Most hemangiomas reach a maximum size of 0.5~5 cm,but they can range from the size of a pinhead to greater than 20 cm in diameter［5,11］.
Small and uncomplicated hemangiomas in children can be managed conservatively with observation and follow-up alone.Complicated lesions and those involving eyelids,ears,tongue,or lip require active management.Superficial ulcerated lesions can be managed with laser treatment.If the lesion is less than 2.5 cm diameter,sclerotherapy,intralesional steroid,or bleomycin injections are recommended.Systemic treatment is needed for a lesion larger than 2.5 cm［12］ and also for complications such as cardiac failure and coagulopathy.Corticosteroids and interferon form the first line of treatment.Vincristine and bleomycin are considered for problematic hemangiomas in infants,which fail to respond to steroids.Surgery is indicated in small,well localized lesions of the eyelid,lip,and neck or other parts of the body ［13］.Laser surgery is beneficial in treating both proliferating and residual vessels from hemangiomas.The flash lamp-pumped pulsed dye laser has become the most widely employed laser for selective ablation of vascular tissue in childhood［14］.