DIFFUSE SKELETAL HEMANGIOMATOSIS: REPORT OF TWO CASES AND REVIEW OF LITERATURE

Diffuse Skeletal Hemangiomatosis Mimicking Metastastic Disease on 18F-FDG PET/CT

Diffuse skeletal hemangiomatosis is a rare vascular proliferation disorder involving multiple bones and may be confused with metastatic bone malignancy. We present a case of a 53-year-old man suffering back and proximal right femur pain underwent F-FDG PET/CT scan. Multiple hypermetabolic lesions of bone were concerning for metastatic carcinoma. Since no primary malignancy was found, open biopsy was performed and histologic examination led to a diagnosis of diffuse skeletal angiomatosis. This case highlighted the importance of including diffuse skeletal hemangiomatosis in the differential diagnosis of multiple hypermetabolic skeletal lesions on F-FDG PET/CT.

Systemic Cystic Angiomatosis Mimicking Metastatic Cancer: A Case Report and Review of the Literature

Systemic cystic angiomatosis is a rare benign disorder due to the maldeveloped vascular and lymphatic system with less than 50 cases reported in literature so far. We report here a case of systemic cystic angiomatosis (SCA) with multisystem involvement affecting the neck, thyroid, thoracic cavity, and skeletal system. The patient initially presented in her 4th decade of life with isolated lymphangioma in the neck requiring surgery. However, she experienced full-blown manifestations of SCA in her 6th decade which closely mimicked metastatic cancer. The diagnosis of SCA could only be established after multiple biopsies. The radiological and histological features of SCA with its course over 31 years in this patient have been described.

Cystic angiomatosis, a heterogeneous condition: Four new cases and a literature review

BACKGROUND

Cystic angiomatosis (CA) is a rare disorder causing bony cysts. It displays some similarity to Gorham-Stout disease (GSD), but has a much better local prognosis, despite the larger number of cysts. These 2 conditions also differ in terms of their location, visceral involvement, and response to treatment.

METHODS

We report 4 cases of CA, including 1 sclerosing form, which we compare with cases from a literature review performed with PRISMA methodology.

RESULTS

We reviewed 38 articles describing 44 other patients. Mean age at diagnosis for the 48 patients (our 4 patients + the 44 from the review) was 22.5 years, and 28 of the patients were men. The femur was involved in 81% (n = 39), the pelvis in 73% (n = 35), the humerus in 52% (n = 25), the skull in 48% (n = 23), and the vertebrae in 44% (n = 21). Visceral lymphangiomatosis (either clinical, or detected on autopsy) was also reported in 35% (n = 18) of the patients. The spleen was the most frequently involved organ (n = 12), followed by the lungs and pleura (n = 8). Liver cysts and/or chylothorax were rarely reported (5 cases), but were invariably fatal. Radiation therapy on bone or soft tissue masses was ineffective, as was interferon alpha, in the 2 patients in which this drug was tested. The efficacy of bisphosphonate was at best equivocal.

CONCLUSION

The progression of CA is unpredictable and treatments effective against GSD, such as bisphosphonates and radiotherapy, have proved ineffective for this condition. New treatments are thus urgently required.

[An exceptional localization of an intraosseous haemangioma]

The intraosseous capillary haemangioma is classified as a benign vascular bone tumor. It is extremely rare in the hand. We present the case of a carpometacarpal capillary haemangioma involving the capitate and the bases of third and fourth metacarpals. To our knowledge it is the first case reported at this site.

Temporal progression of skeletal cystic angiomatosis

Cystic angiomatosis is a rare, benign, multifocal disorder of bone and viscera, in which angiomatous deposits of both vascular and lymphatic elements result in bone lysis and organ dysfunction. We report on a case of late-onset cystic angiomatosis in a Caucasian woman who first presented at age 35 years with a lytic expansile lesion of the proximal humerus, initially diagnosed as low-grade hemangio-endothelioma. This was treated with injection of cement and prophylactic pinning. However, the lesion continued to grow, and, 5 years later, she was discovered to have disseminated bony involvement, initially thought to represent metastatic disease. However, further investigation revealed a diagnosis of cystic angiomatosis, and the patient was treated with bisphosphonates. Follow-up over a 15-year period since her initial presentation at age 35 years has shown osteosclerotic conversion of many of the lesions, with development of numerous pathologic stress fractures that have failed to heal, despite operative intervention.

Benign primary tumours of the ribs

Benign primary tumours of the ribs are rare and may be identified during the investigation of a clinically suspected abnormality or as an incidental finding. This review describes the spectrum of benign tumours that can involve the rib and illustrates the radiographic, computed tomography (CT) and magnetic resonance (MR) imaging appearances that may facilitate diagnosis.

Progressive development of diffuse liver hemangiomatosis

Diffuse liver hemangiomatosis is extremely rare. The etiology and natural history of the disease are unknown. It is also unclear whether tumor growth is induced or modulated by drug therapy. Tumor recurrence after ablative therapy has not been described in patients with diffuse liver hemangiomatosis. Diffuse hemangiomatosis of the left hepatic lobe was suspected in a 35-year-old woman by ultrasonography, CT and hepatic arteriography, and confirmed by laparotomy and biopsies. The patient denied any drug or estrogen use. The tumor was removed by left hepatectomy. Two and six years later, the patient was again hospitalized with progressive tumor growth into the right hepatic lobe. Although diffuse liver hemangiomatosis is a rare disease, its diagnosis should be considered in patients with progressive tumor growth in one or both hepatic lobes. The absence of drug intake or estrogen use does not exclude the diagnosis.

Case report: sclerotic skeletal haemangiomatosis presenting with spinal cord compression--CT and MRI findings

We report the case of a 59-year-old man with skeletal haemangiomatosis who presented with progressive bilateral lower extremity weakness. Computed tomography (CT) and magnetic resonance imaging (MRI) located the causative lesion in the neural arch of the T4 vertebra. CT demonstrated osseous expansion with a mixed lytic and sclerotic pattern. MRI of the lesion showed hypointensity on T1 weighted images, mixed signal intensity on T2 weighted images and moderate contrast enhancement. Similar but less extensive lesions were present in other vertebrae as well as ribs.

Skeletal-extraskeletal angiomatosis. A clinicopathological study of fourteen patients and nosologic considerations

We reviewed the consultation files of the ARmed Forces Institute of Pathology for 1951 through 1989 and identified fourteen patients who had had skeletal-extraskeletal angiomatosis. Skeletal-extraskeletal angiomatosis was defined as a benign vascular proliferation involving the medullary cavity of bone and at least one other type of tissue. The age of the patients at the time of initial biopsy ranged from nine months to sixty-nine years (average, twenty-two years; median, ten years). Ten of the patients were male and four were female. The presenting signs and symptoms were highly variable; they included pain (four patients), a mass noted at birth (three patients), a painless mass that developed after birth (two patients), both pain and a mass (one patient), a localized deformity of the thoracic spine (one patient), and anemia associated with chronic bleeding of the gastrointestinal tract (one patient); in this last patient, skeletal lesions subsequently were found and biopsied. Skeletal-extraskeletal angiomatosis was an incidental finding in the remaining two patients. Multiple bones were involved in thirteen of the fourteen patients. Histologically, three patterns of lesion could be identified: cavernous lymphangioma (six patients), cavernous hemangioma (six patients), and arteriovenous hemangioma (two patients). Five of the patients died (three of sepsis associated with persistent lesions of angiomatosis and two of unrelated causes); eight of the patients survived but had residual disease, and one survived and had no evidence of residual disease.

Cystic angiomatosis of bone with sclerotic changes mimicking osteoblastic metastases

Five unusual cases of cystic angiomatosis of bone which presented with the radiologic appearance of osteoblastic lesions are reported. Three patients were female (ages 37, 41, and 65 years) and two were male (ages 24 and 66 years). Although cystic angiomatosis of bone usually produces widespread osteolytic lesions with a honeycombed appearance in the skeletal system, multiple osteoblastic lesions mimicking metastatic osteoblastic carcinoma are sometimes seen. This radiological presentation has not been well emphasized in previous reports. Histologically, in addition to the angiomatous lesions, both mature thickened lamellar bone trabeculae and immature trabeculae of woven bone were found. In one of our patients, increasing density of the osteoblastic lesions was noted over time. One previous study has suggested that the age of the lesions of cystic angiomatosis is related to radiographic density. It is important to recognize this uncommon variant of cystic angiomatosis and to include this entity among the radiologic differential diagnoses when multiple osteoblastic lesions are encountered.

Arteriovenous shunting and cholestasis in hepatic hemangiomatosis associated with metoclopramide

Diffuse hemangiomatosis of the liver became apparent in a 22-year-old woman while she was receiving medication with metoclopramide and experiencing the well-known adverse effect of the drug, hyperprolactinemia with secondary amenorrhea and galactorrhea. The hemangiomatosis was demonstrated by ultrasonography, computerized tomography, arteriography, and laparotomy with biopsy. When arteriovenous shunting became life-threatening and severe abdominal pain and cholestasis developed, the patient's name was placed on the waiting list for liver transplantation. However, after stopping the medication with metoclopramide, abdominal pain disappeared, cholestasis decreased, and the arteriovenous shunts in the liver closed completely. This course of disease represents either a spontaneous or a drug-induced activation and regression of hepatic hemangiomatosis. However, the long-term metoclopramide medication indicates a potential role of this drug in the promotion of hepatic angiogenesis. Hepatic angiomatosis in the adult seems to be neither a static nor a steadily progressive disorder but a process with active and regressive phases probably induced by a transient imbalance of angiogenic and angiostatic factors. Such a course should be kept in mind when major surgery or liver transplantation for hepatic hemangiomatosis is planned. It seems prudent to obtain a thorough drug history of all patients with hepatic hemangiomatosis. Whether hepatic hemangiomatosis can be drug induced or not, further investigation of the factors involved in hepatic angiogenesis is warranted.

Systemic hemangiomatosis

An autopsy case of unusual vasoformative tumor is presented. The distribution of this tumor was restricted to the organ of the hematopoietic system such as the spleen, liver, and whole bone marrow. Although it may be considered as a variant of certain splenic hemangiosarcoma because of widespread dissemination, both the benign-looking histological features and specific distribution of this tumor suggest its hamartomatous nature. Several additional similar cases in the literatures are briefly reviewed from the viewpoint of systemic hemangiomatosis.

Perspectives on massive osteolysis. Report of a case and review of the literature

Massive osteolysis is a rare, chronic disease characterized by the progressive dissolution of contiguous osseous structures. There is no regeneration following the osteolysis. Pathologic fracture often leads to its discovery. The etiology and pathophysiology of the disease remain obscure. Chemo- and radiotherapeutic attempts at arresting the osteolytic process are generally unsuccessful. Bone grafting has proved disappointing, as the graft usually undergoes osteolysis. A new case of facial bone involvement in a 13-year-old boy is presented. The literature is reviewed, and the clinical experience gained from treating the disease is discussed.

Successful treatment of skeletal hemangioma and Kasabach-Merritt syndrome with aminocaproic acid. Is fibrinolysis "defensive"?

A young man presented with a disabling skeletal hemangioma. Fibrinolysis seemed to be a major component of coagulopathy and persisted after steroid therapy and irradiation of the lesions. Three weeks after therapy with epsilon-aminocaproic acid, there was dramatic alleviation of pain and eventual disappearance of laboratory evidence of fibrinolysis. Epsilon-aminocaproic acid therapy was discontinued. The patient remained free from symptoms and coagulopathy. There was evidence of new bone formation nine months later. Fibrinolysis may be a primary or sustaining feature of hemangioma. Epsilon-aminocaproic acid may be beneficial in the treatment of selected patients with these lesions.

Osseous haemangiomas

Osseous haemangiomas are rather rare. They usually present with vague symptoms and bizarre radiological pictures. Clinical suspicion and radiological speculation can only be confirmed by proper histopathological examination. Localised lesions are curable following excision. Others should be subjected to radiotherapy. This paper presents observation on 29 cases of osseous haemangiomas.

Hemangioma of the lunate (Klippel-Trénaunay syndrome). Case report

An intraosseous hemangioma of the lunate was diagnosed as the cause of wrist complaints. At angiography considerable arteriovenous shunting within the bone was shown. Replacement of the lunate by a SILASTIC implant relieved the pain. The intraosseous hemangioma, however, appeared to be only a part of more wide-spread disease which fulfilled the criteria for a Klippel-Trénaunay syndrome.

A case of disseminated hemangiomatosis with cutaneous, hepatic and skeletal manifestations and increased urinary excretion of glycosaminoglycans

A case of disseminated hemangiomatosis with cutaneous hepatic and extensive skeletal manifestations is reported. The diagnosis was established by means of bone X-ray, hepatic angiography, and skin and bone biopsies. A moderately increased urinary excretion of glycosaminoglycans (GAG) was found. The main GAG fraction excreted was tentatively identified as a heparan sulphate.