Intramuscular haemangioma adjacent to the bone surface with periosteal reaction. Report of three cases and review of the literature

Intramuscular hemangioma causing periosteal reaction and cortical hypertrophy misdiagnosed as osteoid osteoma

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We report a case of intramuscular hemangioma mimicking osteoid osteoma.

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Magnetic resonance image (MRI) is the most precise diagnostic tool for the identification of soft-tissue mass adjacent to the bone.

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Precise preoperative diagnosis is essential to avoid excessive surgery.

Introduction

Intramuscular hemangioma in the periosteal region is rare. Although comprising less than 1% of all hemangiomas, they represent the most common type of intramuscular tumors. When located adjacent to bone, a periosteal reaction can occur. The deep localization of the hemangioma poses the diagnosis difficult. Only 8% to 19% of cases were diagnosed before surgery according to the literature review.

Presentation of case

We present a case of forty-one-year-old female diagnosed with intramuscular hemangioma, mimicking osteoid osteoma, adjacent to the periosteal region of tibia diaphysis treated by surgical excision.

Discussion

When intramuscular hemangioma occurs nearby a bone structure, it can cause cortical, medullary and periosteal bone changes that are frequently misdiagnosed by plain radiography. Due to their infrequency, deep location, and atypical presentation, these lesions are seldom diagnosed at presentation. The hemangioma of the periosteal region can be locally destructive due to compression exerted on neighboring structures. It does not regress spontaneously, and surgical excision is frequently needed.

Conclusion

Intramuscular hemangioma of periosteal region occurs most commonly adjacent to long bones of the lower limb. They can cause hypertrophic periosteal reactions mimicking a periosteal or parosteal tumor. Although osteoid osteoma was considered in the differential diagnosis, MRI with enhancement should be performed to exclude intramuscular hemangioma. This may avoid unnecessary aggressive en-bloc tumor excisions resulting in bone weakness and prolonged rehabilitation.

This case report has been written in line with the SCARE criteria (Agha et al., 2016 [1]).

Intramuscular Haemangioma of the Extensor Pollicis Brevis Muscle with Periosteal Reaction of the Radius: A Case Report and Review of the Literature

We report the rare case of a histologically proven mixed-type intramuscular haemangioma, adjacent to the periosteum of the radius, that caused a periosteal reaction. We also carried out a review of the literature relevant to this case. A 28-year-old male professional drummer presented with an 8-month history of pain and swelling of the dorsal aspect of the right radius. Diagnosis was established on the basis of plain radiographs and magnetic resonance imaging, and was confirmed by histology. The lesion was treated solely by resection of the soft-tissue mass. The patient remained asymptomatic 4 years post-operatively, with no radiographic signs of recurrence. From a review of the literature, it is evident that the terminology for haemangiomas causing regional bone changes is unclear. A new classification of the intramuscular haemangiomas is proposed in order to distinguish between lesions that, according to current knowledge, exhibit radiological and clinical areas of overlap.

Soft tissue hemangioma with osseous extension: a case report and review of the literature

Soft tissue hemangiomas are commonly encountered lesions, accounting for 7-10 % of all benign soft tissue masses (Mitsionis et al. J Foot Ankle Surg 16(2):27-9, 2010). While the literature describes the great majority of hemangiomas as asymptomatic and discovered only as incidental findings, they do have the potential to induce reactive changes in neighboring structures (Pastushyn et al. Surg Neurol 50(6):535-47, 1998). When these variants occur in close proximity to bone, they may elicit a number of well-documented reactive changes in osseous tissue (Mitsionis et al. J Foot Ankle Surg 16(2):27-9, 2010; DeFilippo et al. Skelet Radiol 25(2):174-7, 1996; Ly et al. AJR Am J Roentgenol 180(6):1695-700, 2003; Sung et al. Skelet Radiol 27(4):205-10, 1998). However, instances of direct extension into bone by soft tissue hemangiomas--that is, infiltration of the mass's vascular components into nearby osseous tissue--are currently undocumented in the literature. In these cases, imaging plays an important role in differentiating hemangiomas from malignant lesions (Mitsionis et al. J Foot Ankle Surg 16(2):27-9, 2010; Sung et al. Skelet Radiol 27(4):205-10, 1998; Pourbagher, Br J Radiol 84(1008):1100-8, 2011). In this article, we present such a case that involved the sacral spine. Imaging revealed a soft tissue mass with direct extension of vascular components into osseous tissue of the adjacent sacral vertebrae. Biopsy and subsequent histopathologic examination led to definitive diagnosis of soft tissue hemangioma. While MRI is widely regarded as the gold standard imaging modality for evaluating hemangiomas, in this report we describe how CT can aid in narrowing the differential diagnosis when one encounters a vascular lesion with adjacent osseous changes. Furthermore, we review the literature as it pertains to the imaging of soft tissue hemangiomas that occur in proximity to osseous tissue, as well as correlate this case to current theories on the pathogenesis of hemangiomas. Radiologists should be aware that benign soft tissue hemangiomas demonstrate a spectrum of imaging findings, including aggressive-appearing changes to adjacent bone.

Regional bone change in intramuscular haemangioma mimicking primary bone tumour

Intramuscular haemangiomas are benign soft-tissue tumours, commonly located in the extremities. We present a right-leg intramuscular haemangioma with florid periosteal reaction in adjacent tibia, mimicking a primary bone tumour. Plain radiograph and magnetic resonance imaging features are illustrated with the surgical and histopathological findings. Radiologists need to be familiar with reactive bone changes secondary to deep-seated intramuscular haemangiomas to avoid potential misdiagnosis.

Surface-based haemangioma of the tibia: a case report

We present in this paper a case of surface-based haemangioma of the tibia in a 34-year-old patient which had been misdiagnosed as periostitis. X-ray examination demonstrated a periosteal reaction, confirmed by a MRI showing a soft tissue mass adjacent to bone. We performed an incisional biopsy and made a diagnosis of haemangioma only after examining the histological results. An angiographic study was performed in order to have embolisation of the vessels, but this was not possible because of the excessive number and calibre of afferent arteries. No further symptoms arose after biopsy and therefore an en bloc or radical excision was not performed. Indications for making a correct diagnosis and performing a suitable treatment are presented below.