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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 10  |  Page : 809-811

Hemangioma of rib masquerading a malignancy


1 Lab Operations, SRL Ltd., Shimla, Himachal Pradesh, India
2 Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication24-Sep-2018

Correspondence Address:
Shailja Puri
SRL Ltd., Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.204847

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 > Abstract 


Hemangioma of bone is a rare bone tumor accounting for <1% of all osseous tumors. Hemangiomas are common in skull and vertebrae but uncommon in rib. Rib hemangiomas may increase in size over a period and may cause symptoms due to increasing size. Preoperative diagnosis is not always possible due to overlapping radiological features between benign and malignant lesions. Use of preoperative aspiration and biopsy has their own risks and benefit. Excision of rib in case of monostotic rib lesions is the treatment of choice due to low risk of recurrence and no reported postoperative complications. We report a case of rib hemangioma which mimicked a malignancy preoperatively.

Keywords: Hemangioma, monostotic rib lesion, rib


How to cite this article:
Puri S, Gupta N, Asotra S. Hemangioma of rib masquerading a malignancy. J Can Res Ther 2018;14, Suppl S3:809-11

How to cite this URL:
Puri S, Gupta N, Asotra S. Hemangioma of rib masquerading a malignancy. J Can Res Ther [serial online] 2018 [cited 2020 Jun 4];14:809-11. Available from: http://www.cancerjournal.net/text.asp?2018/14/10/809/204847




 > Introduction Top


Hemangiomas of the bone are rare benign vascular tumors and they account for <1% of all osseous tumors.[1] Common sites for hemangiomas are vertebral body and skull. The localization to the ribs is rare, with only sporadic case reports in literature.[2] It is reported that rib tumors represent 5.9% of the primary bone tumors and 89% of them are malignant.[3] Hemangioma of the rib is extremely rare and it should be considered in the differential diagnosis of rib tumors, especially in asymptomatic patients.[1] A case of a rib hemangioma is presented in which the preresection diagnosis was an aggressive tumor.


 > Case Report Top


A 63-year-old man presented with pain in the left chest wall and dyspnea for 1 year. X-ray chest showed a radiopaque shadow in the left mid and lower zone. Contrast-enhanced computed tomography (CT) showed a heterogeneous, expansile, osteolytic, eccentric bony outgrowth arising from 4th rib [Figure 1]a and [Figure 1]b. A possibility of chondrosarcoma was kept on the basis of age of patient and location of the tumor. The 4th rib was excised and sent for histopathological examination (HPE). Grossly, the rib measured 13 cm × 2 cm. Posterior surface of the rib showed an encapsulated, globular, and expansible growth measuring 6.5 cm × 5 cm × 2.5 cm [Figure 2]a. Cut surface showed cystic degeneration filled with hemorrhage. HPE showed variably sized dilated and congested thin-walled as well as thick-walled vascular spaces [Figure 2]b and [Figure 2]c. Bony trabeculae lined by conspicuous osteoblastic rimming (new bone formation) were present between the vascular spaces. The stroma was fibroblastic and was infiltrated by abundant pigment-laden macrophages and inflammatory cells. A diagnosis of hemangioma – 4th rib – was given.
Figure 1: (a and b) Computed tomography showing\heterogeneous, expansile, osteolytic, eccentric bony outgrowth arising from 4th rib

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Figure 2: (a) Grossly, posterior surface of the rib showed an encapsulated, globular, and expansible growth measuring 6.5 cm × 5.0 cm × 2.5 cm. (b and c) Histopathological examination showing variably sized, dilated, and congested, thin-walled as well as thick-walled vascular spaces with intervening bony trabeculae and fibroblastic stroma

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 > Discussion Top


Rib hemangioma is a rare bone tumor accounting for <1% of all bone tumors.[1] Most bone hemangiomas are encountered in skull and spine. Rib is a rare location for hemangioma. To our best knowledge, <50 cases of rib hemangioma have been reported in literature.[2] Rib tumors are mostly asymptomatic and detected incidentally on X-ray chest. Primary tumors of rib are uncommon accounting for only 6%–10% of primary bone tumors[3] and approximately half of them are malignant.[4]

Radiographically, bony hemangioma present as radiolucent and well-demarcated defects. It expands and thins the cortex in flat bones, but complete cortical disruption is not present,[5] produced by the formation of reactive spicula. Various terms have been used to describe bone hemangioma such as “sunburst appearance” for skull hemangioma, “corduroy-like appearance” for vertebra hemangioma, and “honeycomb appearance” for rib hemangioma.[5] These appearances are due to reactive spicula formation; however, radiological diagnosis for rib hemangiomas is never achieved before histological confirmation because of its rarity.

It has been suggested that when asymptomatic bone tumors show aggressive imaging features hemangioma should be considered; however, radiographic findings resembling both benign and malignant bony tumors have been described in rib hemangiomas. Chest CT scan can more clearly identify the size and the extent of cortical destruction. The differential diagnosis may include malignant rib tumors such as Ewing sarcoma, chondrosarcoma, and myeloma or benign rib tumors such as osteochondroma, fibrous dysplasia, eosinophilic granuloma, and aneurysmal bone cyst.[1]

Bone scans may show variable degree of uptake and are not specific; however, they are useful as all primary rib neoplasms can metastasize to bones or a second primary tumor may be discovered. Magnetic resonance imaging data are sparse and mostly derived from bony hemangiomas from other sites. Angiography findings of bony hemangiomas are nonspecific and can range from small pooling of contrast material to marked hypervascularity.[6]

The necessity and usefulness of preoperative biopsy are controversial. Some reports have stated that preoperative biopsy should be avoided due to risk of bleeding or seeding[7] while others have found this technique to be safe and useful for obtaining a definitive diagnosis. The biopsy has been limited by inhomogeneous and limited sample size which can be misleading.[6]

Aspiration cytology of the tumor showed mainly blood cells, suggesting a hematoma or hemangioma.[7]

Histopathologically, there are three types of hemangiomas - cavernous, venous, and capillary. Cavernous hemangiomas are the most common consisting of large, dilated vessels lined by a single layer of endothelial cells surrounded by a fibrous stroma layer while the capillary hemangiomas which are less common, show numerous tortuous small vascular channels lined with endothelium.

The possibility of rib hemangioma although rare has to be considered in cases of solitary tumors of the rib. It is not possible to diagnose whether the rib tumor is benign or malignant before resection; thus, a policy of excision of all monostotic tumors should be adopted.[6] Rib hemangiomas can increase in size over a period and lead to development of symptoms.[6] Excision of rib hemangiomas is a safe procedure with no reported complication after removal or recurrence. Excision of rib hemangioma is a definitive treatment as well as preventive measure to prevent enlargement of tumor and development of symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Okumura T, Asamura H, Kondo H, Matsuno Y, Tsuchiya R. Hemangioma of the rib: A case report. Jpn J Clin Oncol 2000;30:354-7.  Back to cited text no. 1
    
2.
Haro A, Nagashima A. A rare case report of rib hemangioma mimicking a malignant bone tumor or metastatic tumor. Int J Surg Case Rep 2015;16:141-5.  Back to cited text no. 2
    
3.
Sabanathan S, Salama FD, Morgan WE, Harvey JA. Primary chest wall tumors. Ann Thorac Surg 1985;39:4-15.  Back to cited text no. 3
    
4.
Kuo YT, Lin MB, Sheu RS, Liu GC, Chai CY, Chou SH. Imaging diagnosis of cavernous hemangioma of the rib – One case report and review of the literature. Gaoxiong Yi Xue Ke Xue Za Zhi 1994;10:469-73.  Back to cited text no. 4
    
5.
King RM, Pairolero PC, Trastek VF, Piehler JM, Payne WS, Bernatz PE. Primary chest wall tumors: Factors affecting survival. Ann Thorac Surg 1986;41:597-601.  Back to cited text no. 5
    
6.
Narayan P, Chakrabarthi S, Collins C, Anthony Morgan A. Rib haemangioma: A rarity and diagnostic dilemma. Indian J Thorac Cardiovasc Surg 2008;24:212-4.  Back to cited text no. 6
    
7.
Abrão FC, Tamagno M, Canzian M, Fernandez Â, Bibas J, Fernandes PM, et al. Hemangioma of the rib. Ann Thorac Surg 2011;91:595-6.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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