Case Report

Intraluminal Pyogenic Granuloma of the Basilic Vein Color Duplex Sonographic Manifestations Eduard Ghersin, MD, Samy Nitecki, MD, Olga R. Brook, MD, Amos Ofer, MD, Joseph K. Kaftori, MD, Aaron Hoffman, MD, Diana Gaitini, MD

P

yogenic granuloma (PG) is a common benign tumor that occurs mainly on cutaneous and mucosal surfaces.1 Intravascular occurrence is extremely uncommon.2 Here we describe a PG of the basilic vein diagnosed preoperatively on the basis of color Doppler sonography.

Case Report Abbreviations PG, pyogenic granuloma

Received September 15, 2003, from the Departments of Diagnostic Imaging (E.G., O.R.B., A.O., J.K.K., D.G.) and Vascular Surgery (S.N., A.H.), Rambam Medical Center, Haifa, Israel. Revision requested October 16, 2003. Revised manuscript accepted for publication October 22, 2003. Address correspondence and reprint requests to Eduard Ghersin, MD, Department of Diagnostic Radiology, Rambam Medical Center, PO Box 9602, Haifa 31096, Israel. E-mail: [email protected].

A 21-year-old man was referred to a vascular surgeon because of a 2-month history of a painless firm swelling at the medial aspect of his right elbow. The patient denied any previous trauma, infection, or needle insertions. On physical examination, a firm tubular mass measuring 4 × 1 cm was palpated. The overlying skin appeared normal. Because of clinically suspected superficial thrombophlebitis of the right basilic vein, sonography was performed with an HDI 5000 sonographic scanner (Philips Medical Systems, Bothell, WA) with a broadband frequency linear array transducer (L12-5, 38 mm). On gray scale sonography, an echogenic intraluminal thrombus measuring 3.8 × 0.5 cm was shown in the right basilic vein (Figure 1A). The thrombus had rounded edges and was uncompressible. Also noted were internal tiny anechoic tubular structures that on color Doppler sonography showed internal blood flow in diverse directions (Figure 1B). On a spectral display, internal arterial flow of low resistance and venous flow were demonstrated (Figure 1C). The external walls of the affected basilic vein and the surrounding perivascular soft tissues appeared normal on sonographic examination. On the basis of these findings, a tentative preoperative diagnosis of an intravenous tumor of benign behavior was made.

© 2004 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 23:443–445, 2004 • 0278-4297/04/$3.50

Intraluminal Pyogenic Granuloma of the Basilic Vein

Figure 1. A, Longitudinal gray scale sonogram of the right basilic vein with the use of a standoff pad showing a well-defined echogenic thrombus with rounded edges (arrows). Note the internal tiny anechoic tubular structures (dotted arrow). B, Longitudinal color Doppler image of the thrombus showing internal blood flow in diverse directions (dotted arrow). C, Spectral display of this blood flow showing arterial flow of low resistance as well as venous flow.

The patient underwent wide surgical excision of the affected basilic vein. At surgery, the surrounding soft tissues appeared normal on gross inspection. On gross pathologic evaluation, the lesion consisted of a soft tissue tumor attached to the intimal layer of the basilic vein. Histologically, the tumor displayed characteristic features of intravascular PG.

Discussion Pyogenic granuloma is a common, benign, rapidly growing vascular proliferation that affects any cutaneous or mucous membrane surfaces.1 Because of its characteristic histopathologic appearance, consisting of abundant capillaries growing in sparsely cellular, edematous, collagenous stroma, which may contain inflammatory cells, many authors prefer the name lobular capillary hemangioma.1,3 Rarely, these benign lesions may occur intravenously, usually affecting veins of the neck and upper extremities2–4 and occasionally veins of the ocular adnexa.5 Histologically, intravenous PG appears as a single polypoid mass that is attached to the luminal surface of the vein wall through a fibrovascular stalk2,3 or a broad base.5 The sonographic manifestations of intravenous PG, as shown in this case, are a well-demarcated echogenic intravenous thrombus, which on color Doppler sonography shows internal low-resistance arterial flow and the absence of extravascular extension with preservation of venous wall and surrounding soft tissue integrity. On the basis of these findings, we made a preoperative diagnosis of a basilic vein tumor with benign sonographic characteristics. The major differential diagnosis of primary venous tumors includes malignant neoplasms such as hemangioendothelioma, leiomyosarcoma, and primary malignant lymphoma6,7 and a variety of benign entities, including PG and an organized thrombus.2 In malignant tumors, we would anticipate marked involvement of venous walls and the surrounding soft tissues, as described by Rulli et al.6 The absence of extravenous extension and the preservation of venous wall integrity enabled us to practically exclude the possibility of a malignant venous tumor. The appearance of arterial flow of low resistance inside the venous thrombus excluded the possibility of an organized blunt thrombus. On the basis of these deductions, a tentative preoperative diagnosis of a benign venous tumor was made. 444

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Ghersin et al

This report is unique because it describes the sonographic features of intravenous PG. Recognition of these characteristic sonographic findings may help radiologists postulate a preoperative diagnosis of PG, avoiding unnecessary additional workup and aggressive surgical approaches.

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Rulli F, Neri A, Bigotti G, Tartaglione R, Cefaro GA, Farinon AM. Primary malignant lymphoma of the saphenous vein. J Vasc Surg 2002; 35:168–171.

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Saglik Y, Icli F, Uluoglu O, Isiklar ZU. Leiomyosarcoma of the great saphenous vein. Int Orthop 1992; 16: 185–187.

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