eMedicine Specialties > Radiology > Musculoskeletal

Hemangioma, Bone

Author: Ishmael Chasi, MB, ChB, FRCR, Consultant Radiologist, Department of Radiology, University Hospital of North Durham, UK
Coauthor(s): Geoff Hide, MBBS, MRCP, FRCR, Consultant Musculoskeletal Radiologist, Department of Radiology, Freeman Hospital; Honorary Clinical Lecturer, Faculty of Medical Sciences, University of Newcastle upon Tyne
Contributor Information and Disclosures

Updated: Jun 24, 2009

Introduction

Background

Bone hemangiomas are benign, malformed vascular lesions, overall constituting less than 1% of all primary bone neoplasms. They occur most frequently in the vertebral column (30-50%) and skull (20%), whereas involvement of other sites (including the long bones, short tubular bones, and ribs) is extremely rare.

Pathophysiology

Bone hemangiomas usually occur in the medullary cavity, but uncommonly, surface-based hemangiomas are encountered in the cortex, periosteum, and subperiosteal regions.³ Gross pathology usually reveals well-demarcated, unencapsulated lesions with cystic red cavities. Microscopic examination shows hamartomatous proliferations of vascular tissue within endothelium-lined spaces.

There are 4 histologic variants of hemangioma, classified according to the predominant type of vascular channel: cavernous, capillary, arteriovenous, and venous. These types can coexist. Bone hemangiomas are predominantly of the cavernous and capillary varieties. Cavernous hemangiomas most frequently occur in the skull, whereas capillary hemangiomas predominate in the vertebral column; overall, the former type is most common in bone.^4,5,6,7

Various types of nonvascular tissues may form the matrix within which the angiomatous tissue is interspersed, typically in cavernous hemangiomas. These include fat, smooth muscle, bone trabeculae, fibrous tissue, and clotted blood products. A greater proportion of fat in vertebral hemangiomas is associated with a reduced likelihood of symptoms. Conversely, neural compression is more likely to be associated with a greater proportion of hypervascular or hemangiomatous tissue.

Hemangiomas are slow growing, and malignant degeneration is virtually unknown. Rarely, locally aggressive growth patterns are recognized; hemangiomas with these patterns can mimic malignant lesions.

Epithelioid hemangiomas are benign vascular neoplasms usually occurring in the skin and superficial tissues. They are encountered uncommonly in bone. Cytologically, they may be confused with malignant tumors. Indentation or erosion of bone cortex with or without reactive bone formation may occur as a result of secondary involvement from soft-tissue hemangiomas.⁸

In one study, the clinical and pathologic features of 50 epithelioid hemangiomas of bone were analyzed in 29 males and 21 females 10-75 years of age (mean age, 35 years). The hemangiomas were present in long tubular bones (40%), short tubular bones of the distal lower extremity (18%), flat bones (18%), vertebrae (16%), and small bones of the hands (8%). Nine patients had involvement of more than 1 bone.⁸

Frequency

United States

Vertebral hemangiomas are common, with a rate of 10-12% in autopsy series. Osseous hemangiomas are less frequent at other sites.

Mortality/Morbidity

Complications arising from osseous hemangiomas are rare, and their severity depends on the location of the lesions.

• Lesions in the spine and other sites may cause pain and discomfort from pressure effects, displacement or invasion of adjacent structures, and pathologic fracture.
• Vertebral collapse complicating spinal hemangiomas can cause neural compression due to impingement from bone, hematoma, or extraosseous/epidural soft-tissue extension of the hemangioma itself. This may result in paraplegia (cord compression), radiculopathy (nerve-root impingement), or varying degrees of autonomic neurologic dysfunction. Expansion and collapse of previously asymptomatic spine hemangiomas has been known to occur in pregnancy.
• Bone overgrowth with limb-length discrepancy may occur in long bones as a result of localized hypervascularity.
• Hemorrhagic complications can occur; these are usually iatrogenic and are due to biopsy or surgery. Fatalities have been reported, although these are rare.
• Thrombocytopenic coagulopathies due to platelet sequestration within intraosseous or subperiosteal hemangiomas, most commonly in flat bones, have been known to occur, but this phenomenon is better associated with cutaneous or soft-tissue hemangiomas in infancy.

Race

There is no documented racial variation in the frequency of hemangiomas.

Sex

Osseous hemangioma generally occurs more commonly in females than in males, with a ratio of 3:2.

Age

The peak incidence is in the fifth decade, although osseous hemangiomas can be encountered at any age. The rare periosteal and other surface-based hemangiomas tend to occur in younger patients.

Anatomy

Vertebral hemangiomas are the most common benign tumor of the spinal column, and they occur most frequently in the lower thoracic and upper lumbar spine. The lesions are most often solitary, but they may be multiple in up to one third of cases. Spinal hemangiomas usually are localized to the vertebral body, less frequently extending into or exclusively affecting the posterior arch.

Presentation

The large majority of lesions are asymptomatic; clinically significant symptoms develop in only 1-2% of patients. Other more common causes of back pain, such as spondylosis or disk prolapse, should be excluded before ascribing the symptoms to hemangioma. When symptoms occur, they can be vague and nonspecific. Vertebral collapse and epidural and/or extraosseous extension can result in back pain. Neural compression can produce paralysis and/or paraplegia or bladder and bowel dysfunction, whereas radicular symptoms occur from nerve-root impingement.

Calvarial lesions tend to be most significant clinically.⁹ Craniofacial hemangiomas may result in a palpable lump, although local pressure effects or aggressive growth patterns can cause pain. Localized swelling, limb hypertrophy, and pain can be characteristics of hemangiomas in the extremities. Hemorrhage can occur, usually in the setting of trauma, biopsy, surgery or other medical or dental interventions.

Preferred Examination

Plain radiography is useful for evaluation as the first-line imaging modality in most cases. Radiographic appearances differ depending on the anatomic site and histologic variant of the lesion. However, the radiographic hallmark of bone hemangiomas is a prominent trabecular pattern.

Radiographic patterns may be nonspecific, necessitating further imaging or histology to achieve diagnosis. This is especially true in extraspinal hemangiomas occurring in an age group and location in which other more ominous diagnostic entities, such as myeloma or metastases, are more common.

When plain radiographs do not suffice and appearances remain equivocal, cross-sectional imaging is crucial for further characterization of these lesions. CT is especially useful for assessing changes in bone trabeculae; the results support the plain radiographic findings and provide greater detail.

The superior soft-tissue and bone marrow contrast resolution of MRI allows for better evaluation of extraosseous extension and depiction of the characteristic fatty content in vertebral hemangiomas and also flow patterns in general. The multiplanar capabilities of MRI are also crucial in defining the extent of neural involvement in the spine and planning therapeutic interventions.¹⁰

Limitations of Techniques

Despite the added diagnostic information available with CT and MRI, the angiomatous nature of many extraspinal lesions can be confirmed only with histologic analysis.

Differential Diagnoses

Aneurysmal Bone Cyst
Bone Metastases
Lymphoma, Bone
Multiple Myeloma
Osteosarcoma, Classic
Paget Disease

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