MODERATOR::::::::::::::DR.MADANpresented by:Dr.JYOTINDRA SINGH

CASE REPORTCASE REPORT

MIXED INTRAOSSEOUSMIXED INTRAOSSEOUS HAEMANGIOMA OF THE RIB HAEMANGIOMA OF THE RIB A RARE ENTITYA RARE ENTITY

DEPARTMENT OF CT SURGERY NIMS ,HYDERABADDEPARTMENT OF CT SURGERY NIMS ,HYDERABAD

DR.RC MISHRA, DR.AMARESH RAODR.RC MISHRA, DR.AMARESH RAO

Dr.Laxmanswamy,Dr.Jyotindra singhDr.Laxmanswamy,Dr.Jyotindra singh Dr.B Kaladhar Dr.B Kaladhar

PLANPLANINTRODUCTION INTRODUCTION CASE REPORTCASE REPORTINVESTIGATIONS/WORK UPINVESTIGATIONS/WORK UPOPERATIVE MANAGEMENTOPERATIVE MANAGEMENTPOST OP WORKUPPOST OP WORKUPDISCUSSIONDISCUSSIONRECENT UPDATESRECENT UPDATESTAKE HOME MESSAGE TAKE HOME MESSAGE

INTRODUCTIONIntraosseous haemangioma is an uncommon bone tumour accounting for less than 1% of bone tumours.

They occur most frequently in the vertebral column (30-50%) and skull (20%)

Involvement of other sites (including the long bones, short tubular bones, and ribs is extremely rare.

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INTRODUCTIONINTRODUCTION

Half of Primary chest wall tumors are malignant,hence accurate diagnosis is imperative.

The diagnosis of Rib haemangioma is often forgotten in the differential diagnosis of a chest wall tumor.

Hemangiomas occurring in the ribs are extremely rare, with only a handful reported in the literature

INTRODUCTION

As there is a wide range of radiological patterns, accurate preoperative diagnosis of nonclassical skeletal haemangioma is difficult to make.

Bone haemangiomas are usually asymptomatic, and either discovered incidentally or at autopsy

CASE REPORTCASE REPORT

Age – 25 yrs femaleAge – 25 yrs female

Chief complaints –Chief complaints –Upper back pain Upper back pain x 1monthsx 1months Shortness of breath- 15daysShortness of breath- 15days

Past history- Underwent thoracotomy 13 yrs Past history- Underwent thoracotomy 13 yrs back for similar complaintsback for similar complaints

Last 13 yrs she had a fairly asymptommatic Last 13 yrs she had a fairly asymptommatic span.span.

CASE REPORTCASE REPORTOn examination,she was moderately built and On examination,she was moderately built and nourished.nourished.

Vital parameters were stableVital parameters were stable

Systemic examination showed no gross irregularity except decreased breath sounds in the left upper chest and left supra scapular region

WORK UP

Bio-chemical Investigations were within normal limit .

ECG showed Normal Sinus Rhythm.

2D Echo revealed normal sized chambers. No RWMA with good biventricular function. No MR/AR/TR No PE / Clot

X RAY - FINDINGSX ray chest showed a sharp well-defined homogenous opacity is noted in left upper zone, silhoutting the 1st left rib posteriorly.

Air bronchogram was not noted within the lesion.

No satellite lesions noted. Adjacent lung showed no focal parenchymal lesion.

Aortic contour appeared normal.It appeared as posterior lesion as it is crossing above

the clavicle (Cervicothoracic sign )

IMAGINGIMAGING

MDCT – POST CONTRAST IMAGE

CT FINDINGSSagittal reformatted MDCT post-contrast image showed a welldefined globular expansile osteolytic involving posterior aspect of 2nd rib.

The lesion is showed heterogenous intense post-contrast enhancement,with peripheral rim calcification & few scattered foci of calcification.

The lesion seems to be extending posteriorly in the region of apicoposterior segment of left upper lobe.Mediastinum and visualised abdomen appeared normal.

MDCT POST CONTRAST IMAGE

CT FINDINGSA heterogenous expansile osteolytic soft tissue lesion is seen involving 2nd left rib posteriorly with scattered foci of calcification.

The lesion is showing inhomogenous enhancement after contrast administration with few ?vascular sinuses. Lesion is located left and superior to arch of aorta.

Visualised vessels, trachea, esophagus and other structures appears normal

ANGIOGRAM – A ANGIOGRAM - B

ANGIOGRAM FINDINGS(a) Preembolization

Shows tumor blush.i.e. feeding vessels to the rib

lesion(probably from posterior intercostsl artery), indicating vascularity of the lesion .

(b) Postemolization angiographic film after check-up contrast injection which shows significant reduction in tumor blush

OPERATIVE MANAGEMENTOPERATIVE MANAGEMENT

DECISION MAKINGDECISION MAKINGAngiography and Angiography and contrast CT was in contrast CT was in favour of favour of vascular vascular tumour.tumour.

A redo thoracotomy A redo thoracotomy was plannedwas planned

SECOND RIB LESION

INTRA OPERATIVE FINDINGS

A firm to hard mass, measuring 7 x 9 x7 cm was identified as destroying the middle and posterior parts of the Left 2nd rib and protruding into the thoracic cavity.

Adhesions were present between tumour and Posterior segment of left upper lobe of lung .

Excised Specimen

GROSS- DECALCIFIED EXCISED RIB SPECIMEN

II

. INTRAOSSEOUS VASCULAR INGROWTH – RIB CUT PART

MICROSCOPY- HAEMANGIOMA INTERSPERSED IN BONY TRABECULAE

MIXED CAPILLARY AND CAVERNOUS PATTERN

Patient showing the operated wound on 5th postoperative day

CONFIRMATORY DIAGNOSISCONFIRMATORY DIAGNOSISINTRAOSSEOUS HAEMANGIOMAINTRAOSSEOUS HAEMANGIOMA

MIXED CAPILLARY AND CAVERNOUS MIXED CAPILLARY AND CAVERNOUS PATTERNPATTERN

INVOLVEMENT OF ONLY CORTICAL INVOLVEMENT OF ONLY CORTICAL SEGMENTSEGMENT

DISCUSSIONDISCUSSION

Because hemangiomas rarely occur in the ribs, they are often misdiagnosed.

What has been a diagnostic headache in this case was that none of the typically-described radiological appearances, like sunburst or corduroy appearance, was present.

Fibrous dysplasia,Aneurysmal bone cysts and osteochondroma, may have characteristic imaging findings that allow a specific diagnosis

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

BENIGN LESION MALIGNANT

OsteochondromaEnchondroma

Fibrous dysplasia

Eosinophilic granuloma

Aneurysmal bone cysts

Myeloma

Chondrosarcoma

Osteosarcoma

Ewing sarcoma

DISCUSSION

Radiographically a radiolucent, slightly expansile and well defined intraosseous lesion with a radiating trabecular pattern is highly suggestive of hemangioma for extraspinal sites

CT or MRI are useful for assessing changes in bone trabeculae.

MRI FEATURESMRI features of hemangiomas depend on the proportion of fat and vascularity of the lesions.

Fat content reveals high signal intensity on T1-weighted MR images

Vascular parts show high signal intensity on T2-weighted images

BIOPSY Vs RESECTION

A biopsy (fine needle, core or open) of a hemangioma can result in significant bleeding .

Moreover, many bone tumors are inhomogeneous on histological examination; hence, studying small samples (as opposed to a wholly excised specimen) can be misleading.

A complete resection of the rib lesion, if feasible, may be the best option once other investigations confirm that the lesion is solitary.

OPTIONS AVAILABLE

Radiotherapy

LASER

Transarterial Embolization

Alcohol injection

RECENT ADVANCES RECENT ADVANCES

Gallium scintigraphyGallium scintigraphy

Molecular DetectionMolecular Detection

Normal Tumor Sample

Microsatellite AnalysisMicrosatellite Analysis

32-P Isotopic technique

Fluorescent technique

TAKE HOME MESSAGE-TAKE HOME MESSAGE-Which of the twoWhich of the two

TAKE HOME MESSAGETAKE HOME MESSAGE

In symptomatic patients with costal mass haemangioma of the rib should be borne in mind in the differential diagnosis of thoracic bony wall neoplasms.

Haemangioma is slow-growing and there is no known report of malignant degeneration .

TAKE HOME MESSAGETAKE HOME MESSAGE

Radiographically, a radiolucent, slightly expansile and well-defined intraosseous lesion with a radiating pattern is highly suggestive of haemangioma for extraspinal sites

For most cases, masterly inactivity would be the most prudent choice, but in symptomatic cases, preoperative embolisation, surgery, percutaneous vertebroplasty or direct ethanol injection have been used .

HOME WORK

The exceptional rarity of these lesions should make us reflect on their etiology /pathogenesis

Ravel why hemangiomas are more frequent in some areas and so rare in others

REFERENCESREFERENCES1.Shimizu K, Yamashita Y, Hihara J, Seto Y, Toge T. Cavernous hemangioma of the rib. AnnThorac Surg 2002; 74:932−934.

2. Clements RH, Turnage RB, Tyndal EC. Hemangioma of the rib: a rare diagnosis. Am Surg 1998;64:1027−1029.

3.Ortega W, Mahboubi S, Dalinka MK, Robinson T. Computed tomography of rib hemangiomas. J Comput Assist Tomogr 1986; 10:945−947.

4. MURPHEY M. D., FAIRBAIRN K. J., PARMAN L. M., BAXTER K. G.,PARSA M. B., SMITH W. S.From the archives of AFIP.Musculoskeletal angiomatous lesions : radiologicpathologiccorrelation.RadioGraphics, 1995, 15 : 893-917.

5. LY J. Q., SANDERS T. G. Case 65 : haemangioma of the chest wall. Radiology, 2003, 229 : 726-9.

6. Devaney K, Vinh TN, Sweet DE. Surface-based hemangiomas of bone. A review of 11 cases.Clin Orthop Relat Res 1994; (300):233-40.

REFERENCES7. SANTIAGO RECUERDA A., CORPA RODRIGUEZ M. E., GARCIA-SANCHEZGIRON J., DIAZ-AGERO ALVAREZ P., VAZQUEZ PELILLO J., CASILLASPAJUELO M. Vascular tumours arising in the chestwall : 25 years’experience. Arch Broncopnemol, 2005, 41 : 53-56.

8. Jeung MY, Gangi A, Gasser B et al. Imaging of chest wall disorders. RadioGraphics 19:617-637,1999.

9. Tateishi U, Gladish GW, Kusumoto M et al. Chest wall tumors:radiologic findings and pathologic correlation: part 1. Benigntumors. Radiographics. 23:1477-90,2003.

10. Ogose A, Hotta T, Morita T, Takizawa T, Ohsawa H, Hirata Y. Solitary osseous hemangioma

outside the spinal and craniofacial bones. Arch Orthop Trauma Surg 2000; 120:262−266.

11. Feldman F. Case report 104. Sclerosing hemangioma of right seventh rib. Skeletal Radiol 1979; 4:245−248.

HELLO– ANY QUESTIONSHELLO– ANY QUESTIONS

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