Hemangioma of bone

Tumor biology and incidence

• Benign lesion; may be associated with disappearing bone disease
• Often incidental findings in spine: Autopsy findings suggest up to 10% of population may have spine hemangiomas
• Approximately 1% of all investigated benign bone lesions

Age

Most commonly affects persons 40-60 years of age

Gender

M:F = 1:2

Associated syndromes

• Disappearing bone disease of Gorham, also known as massive osteolysis, can affect any bone
• Related to hemangioma or lymphangioma-like proliferations in the bone
• Etiology unknown
• Rare condition; more often affects children or young adults
• May be self-limited condition, but progression unpredictable

Presentation

Incidental finding in majority of cases

Physical Findings

• Spine lesions may present with neurologic symptoms if there is hematoma secondary to fracture
• Expansion or collapse may cause direct cord compression (rare)

Plain films

Site

• Thoracic spine > craniofacial > femur or humerus > hands and feet
• Usually involves vertebral body with secondary extension into lamina, pedicles, spinous processes, or transverse processes

Size

Variable

Tumor effect on bone

• Coarse vertical striations caused by linear, reactive ossification around areas of rarefied hemangiomatous lesions
  • Striations known as "jailhouse" or "corduroy " vertebra
• "Honeycombing" pattern may be present due to the dilated vascular channels between residual enlarged bony trabeculae

Bone response to tumor

Rarefaction and may have reactive ossification around hemangiomatous elements

Matrix

None

Cortex

• Rarely breached by lesion
• Ballooning of cortex may occur

Soft tissue mass

Rarely present

CT scan

• Classically shows "polka dot" sign
  • Polka dots represent cross-sectional arrangement of vertical striations seen on plain films

MRI

Bright T1- and T2-weighted signal intensity classically seen (representative of intralesional fat and cellularity)

Differential diagnosis

For spinal lesions

• Paget’s
  • Differentiated by a picture frame appearance and expansion of vertebral body
• Myeloma
• Metastases
  • Myeloma and metastases distinguished from hemangioma by the lack of striations and fact that they are usually radiolucent

Pathology

• Gross: Hemorrhagic tissue with cystic spaces may be present
• Microscopic: Proliferation of vessels; can be of varying sizes
• Most commonly dilated capillaries intersect between bone trabeculae

Diagnosis and treatment

• For spinal lesions, plain radiographs usually diagnostic
  • CT or MRI used to confirm the diagnosis
  • Once the vertebrae collapses, conventional radiographs may no longer be diagnostic
• If lesion is asymptomatic, no treatment required.
• Tumor is usually resected anteriorly if there is:
  • Neurologic deficit
  • Collapse with neurologic change or chronic painful kyphus
• Consider pre-operative embolization