Subcutaneous Lobular Capillary Hemangioma Mimicking Brachial Plexus Neurofibroma : Journal of Spinal Surgery

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Case Report

Subcutaneous Lobular Capillary Hemangioma Mimicking Brachial Plexus Neurofibroma

Reddy, D. Abhilash; Bansal, Tungish; Gurjar, Hitesh; Borkar, Sachin

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Journal of Spinal Surgery 10(1):p 36-39, Jan–Mar 2023. | DOI: 10.4103/joss.joss_33_22
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To describe the case of subcutaneous lobular capillary hemangioma (LCH) mimicking brachial plexus neurofibroma. Pyogenic granuloma or LCHs is benign vascular lesions affecting the superficial dermis or mucous membranes. Subcutaneous forms have been very rarely reported. We present the rare case of a 22-year-old female presented with a 5-year history of firm gradually progressive left supraclavicular swelling. The patient had an iatrogenic long thoracic nerve palsy from an exploration and partial excision 3 years back in another hospital and had developed axillary and suprascapular nerve palsy for the last 2 years. Imaging was suggestive of a large contrast-enhancing supraclavicular lesion involving the brachial plexus. The lesion was explored and total excision was achieved under neuromonitoring without any new deficits. The histopathological examination revealed a diagnosis of a LCH. Subcutaneous LCH involving the brachial plexus is a rare entity. Surgical excision assisted by neuromonitoring provides good outcomes. Subcutaneous LCH is a rare diagnosis but can mimic a neurofibroma of the brachial plexus and should be kept as a differential diagnosis.


Lobular capillary hemangiomas (LCH) are the benign tumors of vascular origin, commonly affecting the mucous membranes and the superficial skin. They are characterized by rapid growth and friable surface and often profuse bleeding. Other uncommon and rare variants include LCH gravidum, intravenous LCH, LCH with satellite lesions, and subcutaneous LCH. Subcutaneous LCH form is rare with very few case repots. Subcutaneous LCH lacks the characteristic surface properties and present as deeper nodules, making it difficult to diagnose clinically. We present the case of a 22-year-old female presenting with a subcutaneous LCH in the supraclavicular region, mimicking a brachial plexus neurofibroma.


A 22-year-old female presented to us with a left supraclavicular mass first noticed 5 years back. The lesion gradually progressed in size and was not associated with pain. She had undergone exploration and partial resection of the lesion at another hospital 3 years back with surgery being abandoned. Immediately, after the surgery, she developed winging of left scapula suggesting an iatrogenic injury to the left long thoracic nerve. No biopsy report from the previous surgery was available. The residual swelling had gradually progressed over time.

On examination, the patient had a 5 cm × 5 cm × 4 cm swelling in the left supraclavicular region in the subcutaneous plane. It had a smooth surface, firm consistency, distinct margins and was non tender to touch. Neurological examination revealed weakness in shoulder abduction with a power of 3/5, shoulder rotation-3/5 and elbow flexion-4/5. A sensory loss of around 30%–40% was also noticed in the left upper lateral arm. Further examination also revealed a medial winging of scapula on the same side.

Imaging revealed 56 mm × 42 mm × 49 mm lobulated lesion in the left supraclavicular region with multiple flow voids involving the brachial plexus and vascularization from left subclavian artery. The lesion was isointense on T1, hyperintense on short-tau inversion recovery, and T2 imaging [Figure 1] and enhancing on contrast imaging. Nerve conduction studies were suggestive of a left suprascapular and axillary neuropathy with ongoing denervation and evidence of chronic reinnervation.

Figure 1:
MRI images of the lesion (a) Coronal T1 section (b) Axial T1 section (c) Coronal T2 section (d) Axial STIR section. STIR = Short tau inversion recovery, MRI = Magnetic resonance imaging

A surgical excision was planned. The patient was placed in the supine position with neck rotated to the right side. A 4 channel NIM (nerve integrity monitor, Medtronic Memphis, TN, USA) was planned to be used and appropriate electrodes were placed in appropriate shoulder, arm and forearm muscles. A longitudinal incision along the base of the neck was planned at the site of the previous incision and subplatysmal dissection was carried out to visualize the tumor. Tumor was encapsulated, grayish white in color and firm in consistency. Although the capsule of the tumor was adhered at the surrounding tissue a plane could be made out by gradual careful dissection, extracapsular dissection was carried out and NIM probe used at each step to delineate functional neural tissue [Figure 2]. Careful dissection was carried out and functional nerves could be identified on the medial, lateral and inferior aspects the tumor which were delineated and preserved. A gross total excision was achieved. Integrity of brachial plexus branches reconfirmed using NIM probe. Hemostasis was achieved and closure was done in layers. Postoperatively, the patient had an uneventful postoperative hospital stay and had no new deficits.

Figure 2:
(a) Image showing the patient positioning for the case. (b) Image showing intraoperative image for the case showing a the tumor adhered to the axillary nerve (shown by forceps) on the lateral side. (c) Gross section and (d) Cut section of the tumor

Histopathological examination revealed well-circumscribed vascular lesion arranged in lobules, comprising of variable sized capillaries admixed with larger vessels. Hobnailing of endothelial nuclei was absent. Endothelial cells were immunopositive for with CD-31, CD-34, D2-40. These features were in line with a diagnosis of LCH, adult type [Figure 3].

Figure 3:
Histopathological and IHC images (a) Hematoxylin and Eosin stain show well circumscribed vascular lesion arranged in lobules, comprising of variable sized capillaries admixed with larger vessels. IHC images showing endothelial cells were immunopositive for with (b) CD-31 (c) CD-34 and (d) D2-40. IHC = Immunohistochemistry


LCH or pyogenic granuloma is a benign pathology that is made up of capillary clusters set up in a lobular architecture with fibrous bands separating the lobules.[1] LCH is most commonly seen in children and young adults with mucosal and dermal forms being most common.[2] Some of the other forms include intravenous, satellitosis, LCH gravidum, and subcutaneous forms. Subcutaneous form is very rare, forming <5% of all cases of LCH.[3] A few case reports have reported subcutaneous LCH to occur at face, neck, abdominal wall, and extremities.[4–6] However, to the best of our knowledge, we report the first case of a subcutaneous LCH involving the brachial plexus.

The mucosal and dermal forms of LCH are often raised, friable lesions that bleed easily on touch. However, subcutaneous forms lack these characteristics and present as deep nodules with no characteristic appearance, making clinical diagnosis very challenging.[3] The lesion in the present case was isointense on T1, hyperintense on T2, and homogenously enhancing on contrast. A schwannoma which is a more common lesion at this location with similar radiological findings was kept as the presumptive diagnosis in this case. It can be extremely difficult to radiologically differentiate between the two.

Surgical excision is the mainstay of treatment in these cases. The lesion is often well encapsulated and can be removed in toto. Operating around the brachial plexus can be challenging with high rates (16%–50%) of postoperative functional deficits being reported.[7,8] Intraoperative neuromonitoring is now widely across surgical specialties in surgeries around the nerves.[9,10] The technique facilitates identification of the nerve, minimizing trauma to the nerve during dissection, and final confirmation of neural integrity at the end of surgery. Neuromonitoring has been shown to beneficial and improve the safety of resection in case of brachial plexus tumors.[11] In the present case, a safe resection preserving the brachial plexus branches was facilitated by the use of neuromonitoring.

Localized recurrence and satellite lesions have been reported have been reported with dermal and mucosal forms of LCH. Recurrence rates as high as 16% have been reported, mostly attributed to incomplete excision.[12] However, none of the few reports of subcutaneous LCH have noted any recurrence after excision. In the present case, a partial excision had been done previously with residual lesion left being which gradually progressed over time. No adjunctive radiotherapy or chemotherapy is needed for these benign lesions.[4–6]


Subcutaneous LCH involving the brachial plexus is a rare entity. It can mimic a brachial plexus schwannoma which is more common and should be kept as a differential diagnosis. Surgical excision assisted by neuromonitoring provides good outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1. Fortna RR, Junkins-Hopkins JM. A case of lobular capillary hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. Am J Dermatopathol 2007;29:408–11.
2. Lin RL, Janniger CK. Pyogenic granuloma. Cutis 2004;74:229–33.
3. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma):A clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8:267–76.
4. Lee N, Isenstein A, Zedek D, Morrell DS. A case of childhood subcutaneous pyogenic granuloma (lobular capillary hemangioma). Clin Pediatr (Phila) 2012;51:88–90.
5. Cooper PH, Mills SE. Subcutaneous granuloma pyogenicum. Lobular capillary hemangioma. Arch Dermatol 1982;118:30–3.
6. Saadeh C, Ulualp SO, Rakheja D. Subcutaneous lobular capillary hemangioma presenting as a facial mass. Case Rep Otolaryngol 2018;2018:5973619 doi:10.1155/2018/5973619.
7. Ganju A, Roosen N, Kline DG, Tiel RL. Outcomes in a consecutive series of 111 surgically treated plexal tumors:A review of the experience at the Louisiana State University Health Sciences Center. J Neurosurg 2001;95:51–60.
8. Kehoe NJ, Reid RP, Semple JC. Solitary benign peripheral-nerve tumours. Review of 32 years'experience. J Bone Joint Surg Br 1995;77:497–500.
9. Hu J, Fleck TR, Xu J, Hsu JV, Xu HX. Contemporary changes with the use of facial nerve monitoring in chronic ear surgery. Otolaryngol Head Neck Surg 2014;151:473–7.
10. Schneider R, Randolph GW, Barczynski M, Dionigi G, Wu CW, Chiang FY, et al. Continuous intraoperative neural monitoring of the recurrent nerves in thyroid surgery:A quantum leap in technology. Gland Surg 2016;5:607–16.
11. Jung IH, Yoon KW, Kim YJ, Lee SK. Analysis according to characteristics of 18 cases of brachial plexus tumors:A review of surgical treatment experience. J Korean Neurosurg Soc 2018;61:625–32.
12. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma:A review. J Oral Sci 2006;48:167–75.

Lobular capillary hemangioma; neurofibroma; pyogenic granuloma; supraclavicular

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