Intramuscular Cavernous Hemangioma of the Latissimus Dorsi Muscle: A Rare Presentation of Chronic Musculoskeletal Pain – Case Report

Introduction

Intramuscular cavernous hemangiomas are rare, benign tumors of unknown pathogenesis. Comprising 0.8% of all hemangiomas [1–4], they pose a diagnostic challenge, partly due to the lack of specific clinical findings. They are most commonly described as affecting the extremities, with few reports involving the thorax [5,6]. A search of PubMed and Scopus (January 2, 2026; keywords “intramuscular AND cavernous hemangioma AND thorax”) identified 2 reported cases, excluding intercostal intramuscular lesions and lesions of the mediastinum [6,7]. Here, we report a case of intramuscular cavernous hemangioma of the latissimus dorsi muscle in a 53-year-old woman with a 2-year history of a painful, progressively enlarging swelling on the right lateral chest wall. The lesion was surgically resected, with a favorable postoperative outcome.

Case Report

A 53-year-old Chinese woman – previously healthy with no clinically significant comorbidities – presented with a mass on the right lateral chest wall that had caused intermittent discomfort and pain during physical activity. The discomfort was controlled with simple analgesics as needed. On examination, a soft, round mass measuring approximately 2×2 cm was palpated along the right mid-axillary line. The lesion was difficult to sufficiently delineate for clinical assessment because it was located deep within the latissimus dorsi muscle. Differential diagnoses included lipoma, hemangioma, and neurofibroma. Magnetic resonance imaging (MRI) demonstrated a lobulated, patchy enhancing lesion measuring 2.4×1.2×2.3 cm within the right latissimus dorsi muscle, abutting the underlying ribs (Figure 1).

Over the same 2-year period as her symptoms, the patient underwent follow-up with musculoskeletal ultrasonography every 3 to 6 months. Interval scans demonstrated progressive enlargement of the lesion to 2.9×0.8×3.0 cm. Figure 2 shows a representative examination from this follow-up period, demonstrating a lobulated hypoechoic lesion that measured 2.7×1.1×2.7 cm. She developed worsening symptoms, including increasing pain and numbness radiating down the right arm; escalating analgesic use was required. Therefore, a decision was made to proceed with surgical excision of the lesion.

We anticipated challenges in localizing the lesion under general anesthesia; therefore, the patient underwent ultrasound-guided preoperative lesion marking. Intraoperatively, a transverse incision was made over the lesion. However, the mass was not palpable after exposure of the latissimus dorsi muscle. An intraoperative ultrasound scan localized the lesion, but it remained impalpable during surgical dissection and exploration. Ultimately, the lesion was secured with an Allis clamp under ultrasound guidance, and a wide local excision was performed.

Histopathologic examination revealed brownish tissue measuring 2.0×1.0×0.5 cm after fixation, composed of lobulated channels of dilated blood vessels lined by flattened endothelial cells, with areas of smooth muscle within adipose tissue and striated muscle bundles (Figure 3). These findings were consistent with a cavernous hemangioma. Postoperatively, the patient remained well and asymptomatic; the wound healed uneventfully.

Discussion

Hemangiomas – localized, benign soft tissue tumors composed of blood-filled vessels – are often congenital [4] and many undergo spontaneous involution [5]. Proliferation later in life may result in pain secondary to local mass effect. The pathogenesis underlying this proliferation remains unclear; trauma, chronic liver disease, and hormonal changes have been proposed as contributing factors [1,6,8,9].

Hemangiomas comprise 7% of benign soft tissue tumors and can occur in any part of the body; clinical presentation varies according to location [10]. The prevalence is higher in women, with a male-to-female ratio of 1: 3 [11]. Histologic variants include arteriovenous, venous, capillary, pyogenic, cavernous, and mixed types [1,2,5,9,11,12]. Only 0.8% of hemangiomas are intramuscular [1–4,12], and 26% of these comprise the cavernous histologic variant [1]; thus, intramuscular cavernous hemangiomas are exceptionally rare.

Cavernous hemangiomas are hamartomatous lesions that arise from mesodermal remnants. They consist of large, dilated blood vessels and contain blood-filled spaces resulting from dilation and thickening of capillary loop walls [10]. These lesions are infiltrative, frequently involve deep structures, and do not spontaneously regress; therefore, they may cause local destruction via pressure on surrounding tissues [13]. Patients with intramuscular cavernous hemangiomas commonly present with a painful, enlarging mass [1,8,12,13]. Clinical assessments reveal a lesion that is often soft and mobile; it lacks the vascular signs characteristic of superficial hemangiomas, such as overlying skin discoloration, pulsation, or bruit [1,4].

Radiography is commonly used to aid in the evaluation and diagnosis of soft tissue tumors. Ultrasonography is noninvasive, nonionizing, relatively cost-effective, and widely available; therefore, it is generally the preferred initial imaging modality [3]. Hemangiomas appear hypoechoic on ultrasonography. In the presence of calcified thrombi, known as phleboliths (15–30% of cases), acoustic shadowing may be observed [1,6,8,9,12,13]. On contrast-enhanced computed tomography, a hemangioma appears as a heterogeneous, low-attenuation mass due to its vascular, fatty, and stromal components. Phleboliths may also be identified on contrast-enhanced computed tomography [5,9,10]. Although computed tomography may help to evaluate anatomic relationships, MRI is the gold standard for evaluation and characterization of soft tissue lesions. On T1-weighted imaging, hemangiomas are typically hypointense or isointense relative to muscle; on T2-weighted imaging, they appear hyperintense due to high fluid content [1,3,10,12]. In our patient, incidental hepatic hemangiomas were identified on MRI. The coexistence of intramuscular and hepatic hemangiomas may suggest syndromes such as von Hippel-Lindau disease or PHACE syndrome. Further genetic evaluation was not pursued in the present case because the patient did not exhibit additional systemic features (eg, cutaneous lesions, visual disturbances, headache, or imbalance). Moreover, such syndromes are more commonly diagnosed in childhood, rather than adulthood.

Histopathology is the gold standard for establishing the diagnosis and determining the grade of soft tissue tumors [3,14]. On histologic examination, hemangiomas are characteristically well-defined, unencapsulated lesions composed of endothelial-lined vascular channels separated by connective tissue stroma [1,2,5].

Management options include observation, medical therapy, or surgery. Medical treatments include intralesional corticosteroids (triamcinolone), immunomodulators (interferon), chemotherapy (vincristine), and beta-blockers (propranolol). Surgical options include excision, embolization, and laser therapy [9,11,14]. The feasibility of surgical intervention depends on patient factors (eg, demographics, comorbidities, cosmetic considerations), lesion characteristics (eg, growth rate, depth of invasion, potential for malignancy), and surgical expertise [1,14]. Surgical management is the most commonly utilized treatment modality, and complete excision with clear margins offers the most favorable outcomes [4,6,14].

Local recurrence of intramuscular hemangiomas occurs in around 18% to 20% of cases and is primarily associated with incomplete resection [1,5–8,14]. Recurrence rates vary among histologic variants; a rate of approximately 20% is reported for the cavernous subtype [1]. Malignant transformation of hemangiomas is rare [4,5,9,12,14].

Conclusions

As a general clinical consideration, a lesion with fluctuating consistency may suggest a vascular origin. Our case highlights the importance of considering intramuscular hemangioma in the differential diagnosis of patients who present with chronic musculoskeletal pain. MRI remains the imaging modality of choice for lesion characterization, although histopathologic analysis is often required to confirm the diagnosis. When conservative management fails, wide surgical excision can yield favorable outcomes. Surgeons may consider ultrasonography for preoperative and intraoperative lesion localization. Clinical and radiologic follow-up is recommended due to the risk of recurrence. Finally, given the potential association of hemangiomas with underlying syndromes, clinicians should perform a comprehensive systemic review and thorough physical examination, including assessment for cutaneous lesions and additional intramuscular hemangiomas. Imaging evaluation should be guided by the patient’s clinical presentation.