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Journal of Stomatology Oral and Maxillofacial Surgery
Volume 120, n° 2
pages 89-90 (avril 2019)
Doi : 10.1016/j.jormas.2018.11.011
Received : 8 August 2018 ; 

Intramuscuar hemangiomas are venous malformations

G. Colletti , A. Dionisio, C. Liberale, M. Cucurullo, M. Dessy
 University of Milan, San Paolo Hospital, Department of Maxillo-Facial Surgery, Via A. DiRudinì, 8, 20100, Milan, Italy 

Corresponding author.
To the Editor

Rudolph Virchow was an outstanding scientist. Among other things, he first used the microscope to classify vascular anomalies. He coined the terms Capillary, Cavernous and Racemous Angiomas. The force of Virchow teachings in medical science are somewhat similar to those that Aristotle had in Philosophy.

The senior author, not a long ago, had to hold a lecture on “bony hemangiomas” in an international meeting (and bony hemangiomas substantially do not exist [1]).

Virchow terms still permeate even updated pathology textbooks and WHO meanders.

However, Mulliken and Glowacki more than 35 years ago were able to demonstrate that angiomas, or hemangiomas, are tumors, and all the rest should be called malformations. Since 1992, there is a vibrant scientific community, the ISSVA, that reunites experts in the field from all over the world. ISSVA has gifted us with a classification [2] that divides tumors (hemangiomas and others) from vascular malformations (capillary, lymphatic, venous, arteriovenous, combined, complex and syndromic ones).

Herein lies the scope of this letter: to try to use the ISSVA classification to readdress the beautiful case that Andrade and coworkers have presented (j.jormas.2018.05.008).

They describe a young patient suffering from an intramuscular hemangioma.

According to the most updated literature we believe that this should be renamed an “Intramuscular Venous Malformation of the Masseter”.

We have previously published some strikingly similar cases [3] and have tried to shed light in general on the field of venous malformations of the head and neck [4]. The features presented in this case are very typical of an intramuscular venous malformation (VM): an indolent mass lying within the fascia of a muscle (the temporalis, the pterygoids and other muscles can harbor it) that appears either compressible (most of the times) or firm-elastic (rare but possible) and that become more apparent during dependence or muscular contraction: the wattle sign reported by the authors (I thank them for this definition that I will adopt from now on). In some cases, on palpation, one can feel some small, very firm nodules that are usually phleboliths. The presence of a phlebolith is what unmask the mass as being a VM. Phleboliths are the result of a Local Intravascular Coagulation (LIC) that takes place because flow, inside a VM, is stagnating at times. These are the periods when the patient feels pain and the VM becomes swollen. If the intravascular thrombus cannot be entirely taken away by inflammation, our body reacts by containing, calcifying it. Hence, the phlebolith (something similar to the Tubercular Calcifications).

MRI images provided by the authors also give a clue for diagnosis. A VM is isointense in T1 and hyperintense in T2. Advanced dynamic MRI imaging with ADC and TRICKS may add to the diagnosis in difficult areas such as those within the orbit (Colletti et al. Vascular Malformations of the orbit, Accepted Paper, JCMFS, 2018. j.jcms.2018.09.009).

So, we made a diagnosis. How to treat then? Sclerotherapy is the mainstay. However it is not totally risk free [5].In the case of a masseteric VM, however, we will surely try to sclerose it first, since the results are so outstanding and radical (in limited forms, such as the one presented in this paper), that we believe this should be the way to go. Surgery has a definite role when VMs do not respond to sclero, when there are remnants or when sclero itself is contraindicated [6].

Overall, we ask the Authors to help us spreading the word that the term “Cavernous Hemangioma” is so wrong and misleading (because it implies tumor pathology) that it should be totally abandoned, at least in our beautiful niche of Maxillo-Facial Surgeons [7].

Disclosure of interest

The authors declare that they have no competing interest.


Colletti G, Frigerio A, Giovanditto F, Biglioli F, Chiapasco M, Grimmer JF Surgical treatment of vascular malformations of the facial bones J Oral Maxillofac Surg 2014 ;  72 (7) : 132610.1016/j.joms.2014.02.012[e1-18].
Wassef M, Blei F, Adams D, Alomari A, Baselga E, Berenstein A, and al. ISSVA Board and Scientific Committee Vascular anomalies classification: recommendations from the international society for the study of vascular anomalies Pediatrics 2015 ;  136 (1) : e203-e21410.1542/peds.2014-3673[Epub 2015 Jun 8. Review].
Colletti G, Valassina D, Bertossi D, Melchiorre F, Vercellio G, Brusati R Contemporary management of vascular malformations J Oral Maxillofac Surg 2014 ;  72 (3) : 510-52810.1016/j.joms.2013.08.008 [cross-ref]
Colletti G, Ierardi AM Understanding venous malformations of the head and neck: a comprehensive insight Med Oncol 2017 ;  34 (3) : 4210.1007/s12032-017-0896-3
Colletti G, Deganello A, Bardazzi A, Mattassi R, Dalmonte P, Gazzabin L, Stillo F Complications after treatment of head and neck venous malformations with sodium tetradecyl sulfate foam J Craniofac Surg 2017 ;  28 (4) : 388-392
Colletti G, Saibene AM, Pessina F, Duvina M, Allevi F, Felisati G, and al. Shift in the orbit: immediate endoscopic reconstruction after transnasal orbital tumors resection J Craniofac Surg 2017 ;  28 (8) : 2027-2029 [cross-ref]
Colletti G, Deganello A Cavernous hemangioma: a term to be canceled Eur Arch Otorhinolaryngol 2017 ;  274 (4) : 2069-207010.1007/s00405-016-4324-7 [cross-ref]

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