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Hemangioma Versus Vascular Malformation: Presence of Nerve Bundle Is

a Diagnostic Clue for Vascular Malformation


Patrick A. Adegboyega, MD and Suimin Qiu, MD, PhD
From the Department of Pathology, University of Texas Medical Branch, Galveston
Reprints: Patrick A. Adegboyega, MD, Department of Pathology, University of Texas
Medical Branch, 2.190 John Sealy Annex, 301 University Blvd, Galveston, TX 77555-0588
(paadegbo@utmb.edu)

Abstract
Context.Arteriovenous vascular malformations and hemangiomas are benign
vascular lesions that are difficult to distinguish from one another clinically. Also,
they may be confused with each other at histopathology. Therefore, histochemical
stains for the presence of an artery are frequently used to distinguish between the
two.
Objective.Because it is clinically relevant to differentiate between arteriovenous
vascular malformations and hemangiomas, this study was carried out to explore
additional diagnostic clues that may help in the diagnosis and differentiation of
these lesions.
Design.A total of 167 cases of benign extracranial vascular lesions were retrieved
from the anatomic pathology file of our institution. These comprised 66 cases
diagnosed as arteriovenous vascular malformations and 101 cases previously
diagnosed as hemangiomas. The hematoxylin-eosinstained glass slides were
reviewed, Movat pentichrome histochemical stain was used to identify elastic
vessels (arteries/arterioles), and S100 immunostain was used to identify nerves
within these vascular lesions. For immunohistochemistry, the avidin-biotin
detection method was used.
Results.With Movat stain, the presence of thick-walled elastic arteries was
detected in 12 of the 101 cases previously diagnosed as hemangiomas, and these
cases were therefore reclassified as vascular malformations. Using the same
criterion, 2 of the 66 cases originally diagnosed as arteriovenous vascular
malformations were reclassified as hemangiomas because they lacked arterial
structures. Thus, with this strict criterion, we ended up with 91 cases of
hemangiomas and 76 cases of arteriovenous vascular malformations. Intralesional
nerves were identified in 91% (69/76) of cases of arteriovenous vascular
malformations, including all the 12 arteriovenous vascular malformations
previously diagnosed as hemangiomas. In contrast, no intralesional nerve was
detected in any of the 91 hemangiomas.

Conclusions.These results show that nerve bundles are consistently present in


vascular malformations and absent in hemangiomas and so can be used as a
diagnostic clue to differentiate between these lesions. Also, in addition to
describing a previously unreported component of vascular malformations, these
data further confirm the hamartomatous nature of these lesions.
Accepted: January 17, 2005;

Vascular lesions are very common, with vascular tumors constituting the most common
tumors in childhood.1 The diagnosis and treatment of these lesions involve several medical
subspecialties, including surgeons, radiologists, internists, and histopathologists. The
diagnosis and management of vascular lesions continue to present diagnostic and therapeutic
challenges to all. This is in part because of lack of agreement regarding the nosology and
classifications of the lesionsboth for diagnostic and therapeutic purposes.2 Many authors
use the term hemangioma to describe or qualify vascular malformations and a potpourri of
vascular anomalies, whereas others continue to use the term cavernous hemangioma for
venous malformation and port-wine stain for capillary malformation,3 venous malformation,
and arteriovenous malformations (AVMs),4 thus perpetuating the nosologic confusion and
the attendant problems. A simple 2-tier classification system proposed by Mulliken and
Glowacki5 in 1982, which was later modified and adopted by the International Society for
the Study of Vascular Anomalies,6 has helped simplify the clinical classification and
management of the lesions. However, the diagnosis and pathogenesis of these lesions
continue to challenge histopathologists, who are often called on to help with the definitive
diagnosis and classification of these lesions. The presence of arteries, arterioles, or both as an
integral part of the lesions (as shown by elastic tissue stains) is often used as a diagnostic
criterion for differentiating AVMs from hemangiomas.7 To further characterize the
histomorphologic differences between hemangioma and AVM, we used histochemical elastic
stains (Movat pentichrome stain) and S100 (an immunohistochemical stain for nerve and
nerve fibers) to study the various tissue components present in these lesions.

MATERIALS AND METHODS


The study materials were retrieved from the anatomic pathology file of our institution and
consisted of 167 consecutive cases of benign vascular lesions that were diagnosed during a
period of 8 years (19952002) in our division of surgical pathology. The material consisted of
101 cases originally diagnosed as hemangiomas (with exclusion of pyogenic granulomas) and
66 cases originally diagnosed as AVMs. To be included in the study, a lesion must have been
extracranial and must have had available hematoxylin-eosin (H&E) glass slides for review
and formalin-fixed, paraffin-embedded tissue blocks for further histochemical and
immunohistochemical studies. Cases in which the available tissue blocks did not contain
adequate lesion for both histochemical stain and immunohistochemistry were excluded. The
glass slides were reviewed to confirm the diagnosis and also to look for the presence of
intralesional nerves in these lesions. For definitive characterization and subcategorization of

the lesions as hemangiomas or AVMs, Movat pentichrome histochemical stain was used to
identify elastic lamina in the walls of the blood vessels (arteries/arterioles). All cases that
were previously diagnosed as hemangiomas but contained arteries, arterioles, or both (based
on findings with Movat stain) were reclassified as AVMs. In addition, cases that were
previously diagnosed as AVMs but were shown by Movat stain to lack blood vessels with
elastic lamina in their walls were reclassified as hemangiomas. In a preliminary
study,8intralesional nerves were reported to be present in vascular malformations and absent
in hemangiomas. Therefore, all confirmed cases of AVMs in which intralesional nerve was
not observed in H&E-stained tissue sections were subjected to immunohistochemical staining
with S100 antibody to evaluate the presence of nerves within those lesions. Also, all
hemangiomas that were equivocal for the presence of nerves in the H&E-stained tissue
sections were stained with S100. For that purpose, we used a polyclonal S100 antibody that is
known to react strongly with human S100A and S100B (Dako Corporation, Carpinteria,
Calif; working dilution 1:6000). Immunohistochemistry was done on representative 4-mthick sections of the paraffin-embedded tissue blocks using citrate buffer antigen retrieval and
established avidin-biotin detection method (Vector, Burlingame, Calif), as previously
described.9 The immunostained sections were evaluated with light microscopy for the
presence or absence of nerves within the vascular lesions.

RESULTS
Twelve of the 101 cases originally diagnosed as hemangiomas were reclassified as AVMs
based on the presence of thick-walled elastic arteries or arterioles as part of the lesion as
demonstrated by Movat stain (Figure 1, B through D). With the same stain, 2 of the 66 cases
previously diagnosed as AVMs were reclassified as hemangiomas. Following this
reclassification, therefore, we had 91 confirmed cases of hemangioma and 76 confirmed
cases of AVM.
Of the 91 confirmed cases of hemangioma, 79 were from skin and subcutaneous tissues, 5
from oral mucosa, 1 from maxillary sinus, 1 from vocal cord, 1 from vulva, 1 from liver, and
3 from bone. Fifty-three of the 76 cases of confirmed AVM were from the skin and
subcutaneous tissues, 5 from oral mucosa, 7 from gastrointestinal mucosa, 3 from the urinary
bladder, 7 from the endomyometrium and uterine adnexae, and 1 from the lung. All the
lesions studied were excisional resection specimens except the 1 from the lung, which was a
needle biopsy specimen.
In the H&E-stained tissue sections, intralesional nerve bundles were detected in none of the
cases of hemangioma. In contrast, intralesional nerve bundles were detected in 85% (65/76)
of the correctly categorized cases of AVM. Of the 12 AVMs previously diagnosed as
hemangiomas, 10 had intralesional nerves in H&E sections (Figure 1, A through C), and S100
showed intralesional nerves in the remaining 2 cases. The nerves ranged from small twigs
(Figure 1, A and D) to large nerve bundles (Figure 1, B and C). In the 11 cases of AVM in
which nerve bundles were not observed in the H&E- and Movat pentichrome stained
sections, S100 immunostain revealed intralesional nerve bundles in 4 (Figure 2). Therefore,
in all, intralesional nerves were seen in 91% (69/76) of cases of AVM. Cases of AVM in
which nerve bundles were not detected in any of the sections examined included 1 case from
the stomach, 2 myometrial, 1 paratubal, and 3 subcutaneous lesions (1 from the forearm and 2
from the leg). In the hemangioma group, there was also a good correlation between the

results of Movat stain and S100 immunostain; nerve bundles were not detected (with S100
immunostain) in any of the cases classified to be hemangioma using Movat stain.
Three of the vascular lesions we studied were intramuscular in location (1 in the tongue, 1 in
the upper chest wall, and 1 in the thigh). Two of the lesions were classified as AVMs based on
the presence of intralesional arteries/ arterioles as highlighted by Movat stain, and they both
contained intralesional nerves. The third intramuscular lesion (located in the pectoral muscle)
was classified a hemangioma because, as confirmed with Movat stain, it contained no arterial
vessel, and no intralesional nerve bundles were detected with S100 immunostaining of that
lesion.

COMMENT
Vascular lesions are very common and have been described as the oldest tumor because of
the discovery of intraosseous hemangiomas in dinosaur vertebrae.1 But to this day, they
continue to pose diagnostic and therapeutic challenges to clinicians and histopathologists
alike, with consequent and often protracted distress for the patients, who sometimes shuffle
from physician to physician seeking help.10 In this study, we show the presence of
intralesional nerve to be a helpful discriminator that can be of diagnostic utility for
histomorphologists for the correct classification and diagnosis of hemangiomas and AVMs.
Arteriovenous malformations are the result of errors in morphogenesis and are divided into
subtypes based on the constituent vessels: capillary, venous, arterial, lymphatic, and
combined forms. Hemangiomas, on the other hand, result from a derangement in
angiogenesis with exuberant proliferation of vascular elements due to imbalance between
angiogenic and angiostatic forces.3,11,12 Therefore, arteries and arterioles are not part of the
lesion. Arteriovenous malformations are a complex network of intercommunicating arterial
and venous structures.13 Hence, pathologists rely on elastic stains as ancillary tools for
making a definitive diagnosis of AVMs, because arteries and arterioles (with elastic lamina in
their walls) are an integral part of AVMs.7 The presence of intralesional nerve in AVM, as
reported in this study, provides an additional diagnostic criterion that is simple and reliable
and can be readily used to differentiate AVMs from hemangiomas, even in H&E-stained
tissue sections. Also, the presence of nerve in AVMs supports the theory that AVMs are
hamartomas, which by definition are mass lesions composed of an abnormal architectural
organization of tissues that are normally present at a particular site or organ.7
Only a handful of previous studies have focused on the presence or distribution of nerves in
benign vascular lesions. Rydh et al4reported absence of nerve bundles and paucity of nerve
fibers around the dilated vessels in 9 cases of port-wine stains (which they called venous
malformations) and concluded that loss of vascular tone due to absence of adequate nerve
supply may be responsible for the vascular ectasia that characterizes those lesions.
Considering the absence of nerve bundles in those lesions, we suggest they are better
classified as venous hemangiomas. Robinson et al14 studied the innervation of 6
intramuscular hemangiomas using S100 immunohistochemical stain. They reported the nerve
content of hemangiomas to be the same as that in normal tissue and that in surrounding
margins of the lesions. They also observed increased presence of nerves in the immediate (1
3 mm) vicinity of the intramuscular hemangiomas. Increased neuropeptides (substance P and
calcitonin generelated products) were found within the lesions, and the authors surmised
that these neuropeptides were responsible not only for creating the symptom of pain but also

for inducing growth of the lesions by stimulating proliferation of fibroblasts and endothelial
cells. The nerve bundles observed in that study and also previously reported in other benign
intramuscular vascular lesions15,16 were likely to be nerve bundles that are normally present
within the richly innervated skeletal muscles in which those hemangiomas are located. Jang
et al17 studied 15 hemangiomas (6 proliferating and 9 involuting) and 7 vascular
malformations of unspecified types and looked at nerve fiber (not nerve) contents of these
lesions. They reported an increased number of nerve fibers in proliferative hemangiomas
compared with their involuting counterparts and AVMs, and based on that, they hypothesized
that neuropeptides released by nerve fibers in proliferating hemangiomas may play some
angiogenic role in promoting the growth of hemangiomas. In our study, we found nerve
bundles to be present only in AVMs and not in hemangiomas, but small nerve fibers
(highlighted by S100 immunostain) were observed in both lesions. In agreement with the
finding reported by Jang et al,17 we noticed comparable presence of nerve fibers in the
hemangiomas and AVMs we studied, which may be because all the hemangiomas we studied
were past the proliferative phase (which usually occurs in infancy).
Additional fundamental differences between hemangiomas and AVMs include (1) the timing
of their clinical appearance, (2) their growth patterns, (3) the biologic behavior or growth
characteristics of their endothelial lining in cell culture, (4) the stromal cellular and
extracellular matrix compositions, and (5) the response of the lesions to pharmacotherapeutic
agents.
Hemangiomas appear very early in life, either at birth or within the first 2 weeks of
life.2,3,5 Arteriovenous malformations by definition are technically present at birth but may
not become noticeable until much later in life, with some coming to sight as late as during
puberty or even during the postpubertal period. The timing of the clinical appearance of
vascular malformation depends on the type of vessels involved.18 Capillary and lymphatic
malformations are usually evident at birth or within the first year of life, venous
malformations any time between birth and early adulthood, and arterial malformations and
AVMs often at puberty or during pregnancy because of the associated hormonal
changes.18,19 Hemangiomas grow with a rapid growth phase during the first year of life and
usually involute within the first decade of life.5,19 In contrast, AVMs grow proportionately
with the patient; do not involute; and may sometimes increase in size because of vascular
ectasia induced by conditions such as sepsis, trauma, puberty, and pregnancy.18 The
endothelial lining of hemangiomas (particularly in the proliferative phase) is plump, and
when cultured, they proliferate and form tubular structures reminiscent of vascular channels.
The endothelial cells that line AVMs are quiescent flat cells that neither proliferate nor
differentiate into vascular structures in vitro.19 Immunohistochemical studies have shown
that, unlike the extracellular matrix of vascular malformations or normal tissues, the
extracellular matrix of hemangiomas contains increased fibronectin, perlecan, and
laminin3,20,21; increased growth factors (basic fibroblast growth factor, insulin-like growth
factor, and vascular endothelial growth factor)20,2224; proteases (type IV collagenase and
urokinase); and adhesion molecule E selectin.25Also in line with their divergent growth
characteristics, hemangiomas (especially in the proliferative phase) respond to
corticosteroids, interferon 2, ionizing radiation, and laser photocoagulation,18,26,27 all of
which have no growth-inhibiting effects on AVMs.
Considering the differences in the pathobiology and natural history of these lesions, as well
as the therapeutic and prognostic implications of accurately distinguishing between
hemangiomas and AVMs, it is important that these lesions be correctly diagnosed. Not only

will AVMs that are misdiagnosed as hemangiomas and treated as such fail to respond to
medical treatment with pharmacologic agents, error in surgical management of such lesions
may also result in treatment failure and loss of angio-access for proper management of the
lesion in the future.28 We here show the presence of intralesional nerve to be a simple,
reliable, and cost-neutral diagnostic criterion for correctly distinguishing between
hemangiomas and AVMs.

Acknowledgments
Thanks to Mr Thomas Bednarek for his assistance with photography.

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Figure 1.Hematoxylin-eosinstained (A, B, C) and Movat


pentichrome stained (D) sections showing the presence of
intralesional nerves in arteriovenous malformations. The nerves
range from small twigs (A, D) to medium-sized and large nerve
bundles (B and C, respectively). Movat stain also shows the
presence of thick-walled arterial vessels with elastic lamina (D)
(original magnification 100)

Figure 2.S100 highlighting the presence of a small nerve


bundle in an arteriovenous vascular malformation (original
magnification 400). Note the presence of nerve fibers in the
upper right quadrant of this micrograph