Age / Sex : 18 / M

Chief complaint: Tender mass of right leg for 5 years

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Two weeks later, you can see the final diagnosis with a brief discussion of this case.

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Courtesy: Jin Gyoon Park, Chonnam National University Hospital

Periosteal hemangioma ( or surface-based hemangioma)

Discussion

Findings:

AP radiograph shows eccentric cortical thickening of the diaphysis of the right tibia.

Axial CT image shows focal surface irregularity of the thickened tibial cortex.

Coronal T2WI shows high signal intensity along the outer margin of the thickened tibial cortex. Axial T1WI shows iso signal intensity with high signal spots along irregular outer surface of the thickened cortex, which shows enhancement on post contrast T1WI with fat saturation.

Differential Diagnosis:

Diagnosis:

Periosteal hemagnioma ( or surface-based hemangioma)

Discussion:

Radiographically periosteal hemangiomas are associated with cortical thickening, sclerosis, and erosion of the diaphysis of a long tubular bone, resembling an osteoid osteoma, juxtacortical chondroma. parosteal lipoma, and neurofibroma. Radiographically intracortical hemangiomas are associated with a well defined osteolytic area of the diaphysis of a long tubular bone with or without cortical thickening and periostitis, which is identical to the findings in an osteoid osteoma, osteofibrous dysplasia or cortical abscess.

 There is sometimes clinical and radiographic overlap between periosteal and intracortical hemangiomas, and Devaney et al. reported these tumors as "surface-based hemangiomas of bone". Reported cases of surface-based hemangiomas have been encountered in the long bones. The tibia was the most frequent site of involvement, followed by the fibula, ulna, femur, and humerus, and they were mainly diaphyseal. In a study of 11 patients with surface-based hemangioma, the age ranged from 11 to 31 years at the time of initial symptoms. Sixty percent of the patients were male and 40% were female.

 MRI findings of surface-based hemangiomas are low or intermediate signal intensity on T1WI, high signal intensity on T2WI, and enhancement on post contrast T1WI.

Soft tissue hemangiomas of the extremities frequently result in adjacent osseous change that can be categorized as either periosteal, cortical, or medullary. Only medullary changes correspond with hemangioma size, whereas all three categories of change correlate with the proximity of the hemangioma to the adjacent bone. The presence of osseous change does not correlate with patient symptomatology.

Bone hemangiomas usually occur in the medullary cavity of the vertebral body and skull, accounting for 75%, and in the scapula, ribs, clavicle, and pelvic bones, accounting for an additional 15–20% of all cases . Since most of these lesions are asymptomatic, they are usually discovered incidentally on imaging examination. In contrast, bone hemangiomas of the extremities, though much less frequent than the axial bones, are symptomatic in over 90% of cases.

References:

1. Devaney K, Vinh TN, Sweet DE. Surface-based hemangiomas of bone: a review of 11 cases. Clin Orthop Relat Res, 1994; 300:233–240.

2. Ly JQ, Sanders TG, Mulloy JP, Soares GM, Beall DP, Parsons TW et al. Osseous change adjacent to soft-tissue hemangiomas of the extremities: correlation with lesion size and proximity to bone. AJR 2003; 180:1695-1700