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Hemangioma of the Rib

2011; Elsevier BV; Volume: 91; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2010.07.091

1552-6259

Fernando Conrado Abrão, Mauro Tamagno, Mauro Canzian, Ângelo Fernandez, Benoit Jacques Bibas, Paulo Manuel Pêgo‐Fernandes, Fábio Biscegli Jatene,

Vascular Tumors and Angiosarcomas

An asymptomatic 48-year-old woman presented to our hospital with a tumor of the rib incidentally diagnosed on a chest roentgenogram. The patient was investigated and underwent tumor resection of the chest wall. The pathologic study revealed that it was cavernous hemangioma. This tumor of the bone is a distinctly uncommon benign vascular tumor, generally occurring in the spine or skull. Hemangiomas involving the rib are even more rare, with only 22 cases described in the literature. However, we suggest that this tumor of the rib should be considered in the differential diagnosis, principally in asymptomatic patients. An asymptomatic 48-year-old woman presented to our hospital with a tumor of the rib incidentally diagnosed on a chest roentgenogram. The patient was investigated and underwent tumor resection of the chest wall. The pathologic study revealed that it was cavernous hemangioma. This tumor of the bone is a distinctly uncommon benign vascular tumor, generally occurring in the spine or skull. Hemangiomas involving the rib are even more rare, with only 22 cases described in the literature. However, we suggest that this tumor of the rib should be considered in the differential diagnosis, principally in asymptomatic patients. Hemangioma of the bone is an uncommon benign vascular tumor that accounts for approximately 1% of all bone tumors [1Dofman H.D. Steiner G.C. Jaffe H.L. Vascular tumors of bone.Hum Pathol. 1971; 2: 349-376Abstract Full Text PDF PubMed Scopus (150) Google Scholar]. In 60% to 80% of patients, the tumor occurs in vertebral column or the skull [2Dahlin D.C. Bone tumors: general aspect and data on 6,221 cases.in: 3rd ed. C.C. Thomas, Springfield, IL1981: 137-148Google Scholar]. It is extremely rare in the ribs [3Shimizu K. Yamashita Y. Hirara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar], and reports in the literature are sporadic [4Clements R.H. Turnage R.B. Tyndal E.C. Hemangioma of the rib: a rare diagnosis.Am Surg. 1998; 64: 1027-1029PubMed Google Scholar]; however, hemangioma is part of the differential diagnosis of chest wall tumors [3Shimizu K. Yamashita Y. Hirara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. This case illustrates the manner of presentation, treatment, and our approach of this unusual tumor. A 48-year-old woman was admitted to the thoracic surgery department for an asymptomatic chest mass. There was no history of trauma to the chest wall. The medical histories of the patient and her family were unremarkable. The results of all laboratory studies, including serum tumor markers, were within normal reference ranges. On physical examination, the lesion could be recognized as a dilatation of the left seventh rib. A chest roentgenogram showed a mass shadow measuring 5.0 × 3.8 cm. Chest computed tomography (CT) showed localized expansive growth of the tumor projecting toward the thoracic cavity and disrupted bony cortex, without any lesions in the bilateral lung fields or mediastinum (Fig 1). The patient underwent en bloc surgical resection of the left seventh rib and intercostal muscles. Macroscopically, the tumor measured 4.7 cm in the longest axis and had a firm and bulged surface from the inner part of the seventh rib toward the thoracic cavity. The cut surface of the tumor had a red and multilocular appearance. Disrupted bony cortex was found inside the tumor. Microscopic examination showed the tumor was composed of a homogeneous conglomerate of thin-walled blood vessels with dilating channels (Fig 2). There was no necrosis in the tumor. The pathologic diagnosis of this lesion was hemangioma of the bone. No tumor tissue was detected at the surgical margin. The patient was discharged 4 days after the operation and showed no evidence of recurrence at follow-up. Literature reports that rib tumors represent 5.9% of the primary bone tumors, and 89% are malignant. The differential diagnosis of rib tumor may include metastatic and primary malignant tumors (chondrosarcoma, osteogenic sarcoma, myeloma, and Ewing sarcoma) or benign tumors (fibrous dysplasia, osteochondroma, aneurysmal bone cyst, eosinophilic granuloma, and hemangioma) [5Ceberut K. Aksoy Y.M. Savas F. Müslehiddinoglu A. Asian Cardiovasc Thorac Ann. 2008; 16: e25-e27Crossref PubMed Scopus (4) Google Scholar]. Two types of hemangiomas are identified histologically: cavernous and capillary. The cavernous type consists of large dilated vessels lined by a single layer of endothelial cells surrounded by a fibrous stroma layer. The capillary hemangioma, which is less common, shows numerous tortuous small vascular channels lined with epithelium [5Ceberut K. Aksoy Y.M. Savas F. Müslehiddinoglu A. Asian Cardiovasc Thorac Ann. 2008; 16: e25-e27Crossref PubMed Scopus (4) Google Scholar]. Hemangiomas are usually asymptomatic, and in this patient, it was discovered incidentally on a radiologic study for another reason [3Shimizu K. Yamashita Y. Hirara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. However, a palpable mass may be the first clinical presentation. CT or magnetic resonance imaging can clearly identify the size and extent of cortical destruction caused by the tumor [3Shimizu K. Yamashita Y. Hirara J. Seto Y. Toge T. Cavernous hemangioma of the rib.Ann Thorac Surg. 2002; 74: 932-934Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 5Ceberut K. Aksoy Y.M. Savas F. Müslehiddinoglu A. Asian Cardiovasc Thorac Ann. 2008; 16: e25-e27Crossref PubMed Scopus (4) Google Scholar]. Hemangiomas can have a characteristic sunburst-like appearance. They generally present as well-defined lytic lesions with a coarsened trabecular pattern on plain roentgenograms. On CT images, hemangiomas have a polka dot or honeycomb appearance due to coarsened trabeculae and intervening low-attenuation fat. Magnetic resonance imaging demonstrates high signal intensity on both T1- and T2-weighted images, characteristic of the intralesional fat [6Nakamura H. Kawasaki N. Taguchi M. Kitamura H. Cavernous hemangioma of the rib diagnosed preoperatively by percutaneous needle biopsy.Gen Thorac Cardiovasc Surg. 2007; 55: 134-137Crossref PubMed Scopus (18) Google Scholar]. In this case we chose CT because it is the routine imaging examination for patients with chest wall tumors admitted to our hospital, reserving magnetic resonance imaging for tumors with suspected spinal cord, axillary, or subclavian vessels invasion. Because more than half of rib tumors are malignant, some authors advocate that needle biopsy should be avoided due to the risk of seeding the needle tract, unless multiple myeloma or metastatic disease is highly suspected [4Clements R.H. Turnage R.B. Tyndal E.C. Hemangioma of the rib: a rare diagnosis.Am Surg. 1998; 64: 1027-1029PubMed Google Scholar]. Moreover, a needle biopsy of a cavernous hemangioma may cause bleeding. Some authors, however, have used a fully automated thin needle device, which is safe and useful in obtaining a definite diagnosis, even with hemangioma of the rib [7Roy L. Isler M. Costal hemangioma presenting as rib pain after pneumonia.J Can Chir. 2005; 48: 152Google Scholar]. Open biopsy has some problems that may interfere with a definitive therapy. For example, infection of the biopsy wound may delay initiating the appropriate therapy, and the initial resection may interfere with identification of the area that should be removed in a later radical resection [8Ryan M.B. McMurtrey M.J. Roth J.A. Current management of chest wall tumors.Surg Clin North Am. 1989; 69: 1061-1080PubMed Google Scholar]. On the other hand, excisional biopsy is essential to allow for a correct pathologic diagnosis in many situations (3). In our institution, we do not perform needle biopsy in preoperative patients with bone lesions except when there is need for more elaborate reconstruction, as in the use of a muscle flap or in tumors exceeding 5 cm. Another indication of preoperative biopsy in our institution is when metastases, multiple myeloma, or lymphoma is suspected. We chose this approach for the diagnostic difficulty that occurs due to collected limited material by this method associated with the need for significant tissue samples and often the total lesion for diagnostic confirmation. In the remaining cases, we proceeded to excisional biopsy of the lesion. Therefore, a preoperative biopsy was not performed in this patient. The criticism that can be made by this approach is sometimes the need for widening margins, where the final anatomopathologic study shows that this is sarcoma, without suspicion by frozen biopsy. Hemangioma of the rib is a rare condition that should be considered in the differential diagnosis of chest wall tumors. Preoperative biopsy usually does not change the approach, and the treatment of choice should be the resection of the affected rib as in most tumors of the chest wall. As mentioned, this is to provide adequate tissue for an exact histologic diagnosis and definitive treatment, except in some cases in which the final diagnosis is sarcoma and there is need to expand margins later.