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Thursday, 13 June 2013

CASE REPORT AND LITERATUR REVIEW BY HERRY SETYA YUDHA UTAMA SURGEON : HAEMANGIOMA


CASE REPORT 

Patient Identity :
1.     Name: Mr.I 
2.     Age: 33 years old 
3.     Gender: Male 
4.     Religion: Islam 
5.     Address: Gempol
6.     Medical Record : 046748 
7.     Date of entry: 06 May 2013 
8.     Check-out date: 10 May 2013 
Anamnesis (Autoanamnesa) 
- The main complaint: There is a lump in the right arm
- Additional Complaints: - 
- Disease History :
Patients came to surgery Arjawinangun Hospital with a bump on a complaint right arm were admitted since a few weeks ago .The lump more and more enlarged, and no pain. The lump settled, and can be driven. Denied a history of trauma. 
Previously History of Disease: - 
Other Disease History: 
a. Diabetes Mellitus (-)           d. 
Heart Disease (-) 
b. Hypertension (-)                 e. Lung Disease (-) 
c. Asthma (-)                           f. Liver disease (-) 
Family history of disease 
In no patient families who suffer from such diseases.




PHYSICAL EXAMINATION

General Status:
General condition         : Good Looks 
Awareness                    : Compos mentis 
Vital Signs                    :
BP       : 110/80 mmHg 
P          : 80 x / min 
RR       : 20 x / min 
T         : 36.2 ° C 
Weight : + / - 58 kg 

Head:
Form                            : Normocephal 
Hair                             : Black, not easy to pull. 

Eyes 
Lid                               : edema - / - 
Conjunctiva                 : anemis - / - 
Sclera                           : jaundice - / - 
Arcus senilis                 : - / - 
Pupil                            : Round, isokor 
Light reflex                  : + / + 
Cataracts                      : - / - 

Ear 
Shape                           : Symmetrical 
Liang                           : Field 
Mucosa                                    : Not hyperemia 
Cerumen                      : No 
Membrane Timpani     : intact
Nose 
Shape                           : Symmetrical 
Septal deviation                       : No 
Secretions                    : No 
Concha                                    : Not hyperemia 

Mouth 
Lips                             : lip mucosa moist, not cyanosis 
Tongue                                    : Not Dirty 
Tonsils                         : T1-T1 calm 
Pharyngeal mucosa      : Not hyperemia
Neck 
LND                            : no enlargement
Thyroid gland             : no enlargement
JVP                             : not examined 

Thoracic
1. Lungs
Inspection                   : respiratory movement of both hemithorax symmetric 
Palpation                     : vocal and tactile fremitus right = left 
Percussion                   : Sonor all lung fields 
Auscultation               : breath sounds vesikler, rh - / -, wh - / - 
2. Heart
Inspection                   : Ictus cordis is not visible 
Palpation                     : Ictus cordis palpable between the ribs on the left midclavicular line
  V 
Percussion                   : Limit the heart within normal limits 
Auscultation               : I-II heart sound pure, murmur (-), gallop (-) 

Abdomen
Inspection                   : Flat, symmetrical 
Palpation                     : Supple, tenderness (-), off pain (-) 
Percussion                   : across the field abdomen Tymphani 
Auscultation               : Bowel (+) within normal limits 

Extremity
- Top
Akral                           : Warm
Cyanosis                     : Not cyanosis
Perfusion                     : Good
- Bottom
Akral                           : Warm
Cyanosis                     : Not cyanosis
Perfusion                     : Good

Local Status
Region                         : Brachialis dextra
Inspection                   : looks a lump
Palpation                     : palpable lumps, mobile, and there is no tenderness

Examination Support
Laboratory (CBC): -
Radiology (Photo Thorax): -

Different Diagnosis
1. Hemangioma
2. Soft Tissue Tumors: lipoma 

Diagnosis
Hemangioma

Management
Operative



Prognosis
Quo ad Vitam:  dubia ad bonam
Quo ad Functionam: dubia ad bonam
Quo ad sanationam: dubia ad bonam











                        








HEMANGIOMA
1.     Definition, Etiology, and Pathophysiology 

Hemangioma is a benign tumor of blood vessels that proliferate cells vascular endothelium followed by continuous involution led to disorder is the result of anomalous development of the vascular plexus. Hemangiomas are common in infants of 1.1% to 2.6% and the children are 10% to 12%. These lesions are more common in females than males with a ratio of 3:1. Hemangioma lesions are not present at birth. 
They manifest in the first month of life, suggesting a rapid proliferation phase 
and an perfect slowly towards involusion. Lesions,
Until now hemangioma etiology remains unclear, there are many hypotheses that expressed about the etiology of hemangiomas. However, the process of angiogenesis plays a role important. Cytokines, such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) has been shown to be associated with the process of angiogenesis. Increased levels of factor. The angiogenesis and or reduced levels of angiogenesis inhibitors such as gamma  interferon (Ύ-IF), tumor necrosis factor-beta (TNF-β) and transforming growth factor-beta  (TGF-β) is suspected to be the cause of hemangioma. There are several hypotheses put forward regarding the pathophysiology of hemangioma,of them stated that this process begins with a proliferation of cells endothelium is not regular and the travel time to be organized by forming lobe-shaped blood vessels with lumen containing blood cells Hypothesis of Takahashi stated that in the last trimester of pregnancy, in the immature fetal endothelium is formed along with the immature pericyte also 
have the ability to perform limited proliferation begins at the age of 8 months to 
The first 18 months after birth the life span at age thus formed 
hemangioma. 

                     

During the proliferative activity of endothelium occurs influx of a number of mast cells and tissue inhibitors of metalloproteinases (TIMP or tissue growth inhibitor). Proliferation endothelium return to normal after stopping proliferation or involution phase. Largely hemangioma will undergo spontaneous involution at the age of 5-7 years or until the age of 10-12 years.

          

2.      Classification and Clinical Features 

       Several classifications have been used to classify the various forms of  hemangiomas, but not entirely explained in detail. In 1982 Mulliken and Glowacki introduced a classification scheme based on physical examination hemangioma, nature clinic and provider of lesions. They divide the tumor vasoformatif into two categories, namely hemangiomas and malformations vascular. 
In general, the experts classified hemangiomas into three types: (1)  capillary hemangioma, which is composed of capillary hemangiomas in children (nevus vasculosus, strawberry nevus), pyogenic granuloma, and cherry-spot. (2) hemangioma cavernosum (3) mixed hemangioma. Vascular malformations further divided into arterial malformations, venous, capillary, and malformations limfatic.  Neville et al, classifies a hemangioma capillary hemangioma, hemangioma  juvenile, cavernous hemangioma and hemangioma arterivenosa. Capillary hemangioma is most often found, because the color is also called strawberry hemangiomas. 
Juvenile hemangioma is more often found in the parotid region, cavernous hemangioma generally larger in diameter and involve deeper structures. Hemangioma arterivenosa is a situation where there is an abnormal connection between the arteries and vena. A simple classification made by Watson and McCarty by 1308 type of tumor blood vessels are capillary hemangioma, hemangioma cavernous, hemangioma hipertrophic / angioblastic, recemose hemangioma, diffuse systemic hemangioma, hemangioma metastasis (spread), vinosus nevus or port-wine stain, and hemorrhagic telangiectasia hereditary. Lesions in almost all cases of hemangioma occurs when the newborn and increases in the first year. According to Watson and McCarthy report, 85% of 1308 lesions has been formed at the end of the first year infant age. The most commonly affected areas are the lesions head and neck which is about 56% of cases, while the rest can occur in six to seven skin surface tubuh.The clinical features vary according to the type hemangioma. Capillary hemangioma (Strawberry nevus) appears as patches of bright red, tense and lobular-shaped,demarcated, which can occur in various places on the body. Unlike the capillary hemangioma, hemangioma lesions in the corpora cavernosa not demarcated can be erythematous macular or nodes that are red to purple. When pressed deflated and will quickly swell again if released.
The clinical features of hemangiomas mixture is a combination of capillary types and species cavernosa. Tumor lesions in the form of soft, bluish red color on development can provide an overview keratotic and verukosa. Largely found in the lower extremities and usually unilateral.

              

3.     Oral Manifestations and Differential Diagnosis 

       Hemangiomas that occur in the soft tissues of the mouth with the same shape  hemangioma of the skin. Lesions are usually shaped lesions appear flat or  bulging of the mucosa, dark red or bluish red and not demarcated. 
Areas that are often affected are the lips, tongue, buccal mucosa, and palate. Hemangioma tumor often followed by trauma and infection continues ulcerated and the second. In the oral cavity, bones and muscles can also be affected by the hemangioma, as mucosa and skin. Intraosseous hemangioma incidence varies the 0,5 - 1,0% of the entire intraosseous neoplasm. Facial bones most often affected are the mandible, maxilla,and nasal bones. Intraosseous lesions more often on the mandible than the maxilla ie 2:1. Intramuscular hemangioma in the oral cavity is most often the masseter muscle, with approximately 5% of the whole incident hemangioma intramuskular Determination diagnosis of hemangioma seen from patient history and clinical examination  appropriate. In clinical diagnosis of hemangioma is not difficult, especially on the typical lesions. The differential diagnosis of hemangioma is the other skin tumor that is limfangioma, higroma, lipoma, neurofibroma, congenital vascular malformations, venous stars, and hereditary Hemorrhagic telangiectasias (Osler-Weber-Rendu Syndrome) .
           
                         

4.     Treatment Hemangioma 
     
There are various types of hemangioma therapy with the advantages and disadvantages of each. In general, treatment of hemangiomas can be divided into conservative therapy (observation)  where naturally hemangioma lesions will undergo changes in the months first, then reaches a maximum and then a large spontaneous regression occurs around age 12 months. Regression of lesions continue to hold until the age of five years. In addition to the treatment conservative, hemangioma lesions can also be done actively namely surgery, radiation, the use of corticosteroids, and, elektrokoagulasi.Treatment with surgery has evolved, some of which is excision, laser, cryo surgery, and sclerotherapy. Excision is rarely done because  hemangiomas tend to bleed. Excision is done by combination with  sclerotherapy to reduce bleeding. The use of lasers has been widely used to treat hemangiomas. There are several laser types such as: yellow light lasers, Nd: YAG laser, argon laser, laser Carbondioxide.

Using Argon laser surgery has been known to give better results Indications to do surgery are:
1. There is a sign - a sign of growing too fast, for example, in some weeks the lesions became 3-4 times larger. 
2. Hemangioma is large with thrombocytopenia.
3. No spontaneous regression, for example, did not occur diminution after 6-7 years.

Treatment with radiation in the year - last year was a lot left out because  irradiation resulted in less well in children - children whose bone growth is still active, complications of treatment in the form of malignancy that occurs in the long term, and cause fibrosis of the skin that is healthy to be difficult when we need an act.
Treatment with surgical cryo is cold applications using liquid nitrogen.
Whereas treatment with corticosteroids is done for this type of hemangioma strawberry, cavernosa, and mix. Corticosteroids used is prednisone, which
resulted in hemangioma held regression.

          




References
1.     R, Syamsuhidajat, Wim de Jong; Buku Ajar Ilmu Bedah : Jakarta EGC, 1997, hal 300
2.     Schwartz. Principles of Surgery. Ed. 7th. The McGraw-Hills Company, 1999
3.     Dunphy Englebert J, MD, Way W Lawrence, MD, Current Surgical Diagnosis & Treatment.
4.     Marchuk, DA, 2001, Pathogenesis of Hemangioma, Journal Clinical Investigations, volume 107,USA
5.     Stringel, G, 1980, Hemangiomas and Lymphangiomas, dalam Ashcraft, KW, Pediatric Surgery, edisi 3, W.B. Saunders Company, Philadelphia, New York
6.     www.nlm.nih.gov/medlineplus/ency/article
7.     www.webmd.com/skin-problems-and-treatments

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