May 28, 2020
A 41-year-old woman during early postpartum with a 1-week history of intermittent episodes of epistaxis
Lobular Capillary Hemangioma
- Background:
- Lobular capillary hemangioma, classically known as “pyogenic granuloma,” is the most common type of hemangioma in the sinonasal region (generally arising from the nasal septum). It is composed of capillary-sized vessels lined with flattened epithelial cells separated by a collagen stroma.
- It usually occurs between the third and fifth decades of life.
- Its etiopathogenesis is not clearly known, although this entity is commonly found in middle-aged women, specifically in pregnant women and women on oral contraceptive treatment, and shows a strong association with trauma and hormonal influences on its development.
- Clinical Presentation:
- Symptoms may include epistaxis and nasal obstruction.
- Key Diagnostic Features:
- CT: Well-circumscribed mass with prominent enhancement, surrounded by a hypodense peripheral rim. Bone remodeling and erosion are rarely identified as the tumors become larger than 2 cm.
- MRI: Heterogeneous hyperintensity with a hypointense peripheral rim on T2-weighted imaging and hypointensity on T1-weighted imaging with marked contrast enhancement and a nonenhancing, thin peripheral ring. Signal voids within the mass are often identified. Dynamic contrast-enhanced study may show a washout pattern (in about 75% of capillary hemangiomas).
- Differential Diagnoses:
- Angioleiomyoma: 1:2 (male:female). The inferior nasal turbinate, nasal septum, and nasal vestibule are the most common locations. CT shows an isodense and expansile mass. On MRI, it demonstrates heterogeneous hyperintensity on T2WI and isointensity on T1WI with remarkable contrast enhancement, which indicates its hypervascular nature. A cystic appearance is sometimes identified.
- Respiratory epithelial adenomatoid hamartoma (REAH): 7:1 (male:female). Usually located in the anterior half of the olfactory cleft (enlargement without bone destruction) and posterior nasal septum. MR imaging shows well-delineated tissue filling on T2WI and homogeneous contrast enhancement.
- Pleomorphic adenoma: Third to sixth decades of life, with slight female predilection. It usually arises from nasal septal submucosa without destruction of surrounding tissue. A multilobulated appearance is one of the key findings. Adjacent bony erosion and intratumoral calcifications may be seen in CT. It is iso- to hyperintense on T2WI and hypointense on T1WI with heterogeneous curvilinear contrast enhancement. Nonenhancing parts representing cystic areas within the tumor can also be seen (9–40%).
- Organized hematoma: Variable state of hematoma surrounded by an organized fibrous capsule, usually placed in the maxillary sinus. CT shows a heterogeneous hypo- to hyperdense mass with bone expansion (destruction is rare) and patchy contrast enhancement. The central portion shows variable signal intensity in MRI depending on the stage, with heterogeneous enhancement. The fibrous capsule is hypointense on T2WI and iso- to hypointense on T1WI. Rim enhancement may be seen if neovascularization occurs within the fibrous capsule.
- Sinonasal angiomatous polyp (SAP): 4–5% of all sinonasal polyps. Extension to choana and nasopharynx may be seen. CT shows an isoattenuating, expansile soft-tissue mass which causes bulge or destruction of the bony wall, with well-defined margins. It shows heterogeneous isointensity with interspersed slight hyperintensity on T1WI and a hypointense internal septum and peripheral rim (highly specific). Postcontrast MRI demonstrates characteristic areas of heterogeneous marked enhancement with unenhanced hypointense rims and septa.
- A typical polyp is unlikely, usually associated with mucosal thickening and often originating from the maxillary sinus. CT shows an oval, hypondense mass that may be hyperdense due to increased protein content. MRI shows hypo- to hyperintensity on T2WI and isointensity on T1WI with peripheral contrast enhancement, useful for the differential.
- Treatment:
- Preoperative embolization to decrease bleeding prior to surgical resection
- When association with pregnancy is present, it may regress spontaneously following childbirth. Postpartum lesions that do not regress completely may require surgery.
