A CASE REPORT-Mixed intraosseous haemangioma of rib

2. MODERATOR::::::::::::::DR.MADAN
presented by:Dr.JYOTINDRA
SINGH
CASE REPORTCASE REPORT
MIXED INTRAOSSEOUSMIXED INTRAOSSEOUS
HAEMANGIOMA OF THE RIBHAEMANGIOMA 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

3. PLANPLAN
INTRODUCTIONINTRODUCTION
CASE REPORTCASE REPORT
INVESTIGATIONS/WORK UPINVESTIGATIONS/WORK UP
OPERATIVE MANAGEMENTOPERATIVE MANAGEMENT
POST OP WORKUPPOST OP WORKUP
DISCUSSIONDISCUSSION
RECENT UPDATESRECENT UPDATES
TAKE HOME MESSAGETAKE HOME MESSAGE

4. INTRODUCTION
Intraosseous 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.

5. 22
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

6. 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

7. CASE REPORTCASE REPORT
Age – 25 yrs femaleAge – 25 yrs female
Chief complaints –Chief complaints –Upper back painUpper back pain x 1monthsx 1months
Shortness of breath- 15daysShortness of breath- 15days
Past history- Underwent thoracotomy 13 yrsPast history- Underwent thoracotomy 13 yrs
back for similar complaintsback for similar complaints
Last 13 yrs she had a fairly asymptommaticLast 13 yrs she had a fairly asymptommatic
span.span.

8. CASE REPORTCASE REPORT
On examination,she was moderately built andOn 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

9. 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

11. X RAY - FINDINGS
X 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 )

12. IMAGINGIMAGING

13. MDCT – POST CONTRAST IMAGE

14. CT FINDINGS
Sagittal 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.

15. MDCT POST CONTRAST IMAGE

16. CT FINDINGS
A 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

17. ANGIOGRAM – A ANGIOGRAM - B

18. 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

19. OPERATIVE MANAGEMENTOPERATIVE MANAGEMENT

20. DECISION MAKINGDECISION MAKING
Angiography andAngiography and
contrast CT was incontrast CT was in
favour offavour of vascularvascular
tumour.tumour.
A redo thoracotomyA redo thoracotomy
was plannedwas planned

21. SECOND RIB LESION

22. 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 .

23. Excised SpecimenExcised Specimen

24. GROSS- DECALCIFIED EXCISED RIB SPECIMEN

25. II
. INTRAOSSEOUS VASCULAR INGROWTH – RIB CUT PART

26. MICROSCOPY- HAEMANGIOMA INTERSPERSED IN BONY TRABECULAE

27. MIXED CAPILLARY AND CAVERNOUS PATTERN

28. Patient showing the operated wound on 5th postoperative day

29. CONFIRMATORY DIAGNOSISCONFIRMATORY DIAGNOSIS
INTRAOSSEOUS HAEMANGIOMAINTRAOSSEOUS HAEMANGIOMA
MIXED CAPILLARY AND CAVERNOUSMIXED CAPILLARY AND CAVERNOUS
PATTERNPATTERN
INVOLVEMENT OF ONLY CORTICALINVOLVEMENT OF ONLY CORTICAL
SEGMENTSEGMENT

30. 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

31. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
BENIGN LESION MALIGNANT
Osteochondroma
Enchondroma
Fibrous dysplasia
Eosinophilic granuloma
Aneurysmal bone cysts
Myeloma
Chondrosarcoma
Osteosarcoma
Ewing sarcoma

32. 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.

33. MRI FEATURES
MRI 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

34. 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.

35. OPTIONS AVAILABLE
Radiotherapy
LASER
Transarterial Embolization
Alcohol injection

36. RECENT ADVANCESRECENT ADVANCES

37. Gallium scintigraphyGallium scintigraphy

38. Molecular DetectionMolecular Detection
Normal Tumor Sample

40. Microsatellite AnalysisMicrosatellite Analysis
32-P Isotopic
Fluorescent
technique

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

42. 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 .

43. 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 .

44. 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

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47. HELLO– ANY QUESTIONSHELLO– ANY QUESTIONS

48. Thank you
Have A Great Day…