Bone & joints

• Benign tumor of bone composed of small or large caliber vascular channels (Skeletal Radiol 2000;29:63)
• Vessels are thin walled and lined by a single layer of bland endothelial cells
• Majority arise in vertebral bodies and are incidental findings (Crit Rev Oncol Hematol 2024;195:104268)
• Multifocal occurrence is frequent (Surg Pathol Clin 2021;14:645)
• Known as angiomatosis when involving a large region or if widespread throughout the skeleton (Skeletal Radiol 2000;29:63)

• Hemangioma; conventional hemangioma; intraosseous hemangioma
• Gorham-Stout syndrome (also known as vanishing bone disease): diffuse angiomatosis with massive osteolysis (Skeletal Radiol 2000;29:63)

• Plain radiograph: vertically oriented, thickened trabeculae in vertebral lesions (corduroy sign) and irregular and lytic lesions with a honeycomb appearance in long bones (J Neuroradiol 2010;37:37, BMC Musculoskelet Disord 2021;22:27)
• Computed tomography (CT): lucent lesion containing fat and coarse, vertically oriented trabeculae (polka dot sign on axial images and corduroy sign on coronal and sagittal images) (Skeletal Radiol 2022;51:1743)
• Magnetic resonance imaging (MRI): typical high signal intensity on both T1 and T2 because of abundant adipocytes, blood vessels and interstitial edema, although intermediate to low signal intensity is seen in lipid poor hemangiomas (BMC Musculoskelet Disord 2021;22:27, Skeletal Radiol 2022;51:1743)

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Contributed by Lucas F. Abrahao Machado, M.D., Ph.D.

Contributed by Lucas F. Abrahao Machado, M.D., Ph.D.

• WHO Classification of Tumours Editorial Board: Soft Tissue and Bone Tumours, 5th Edition, 2020

Which of the following is one of the most common tumors of the vertebral column and is rarely clinically significant?

1. Conventional hemangioma
2. Enchondroma
3. Epithelioid hemangioma
4. Plasmacytoma

A. Conventional hemangioma. Hemangioma is the most common type of vascular tumor of the skeleton and one of the most common tumors of vertebrae in general. However, the vast majority are asymptomatic; clinically significant tumors account for < 1% of primary bone tumors. Answer D is incorrect because, in plasmacytoma, the vertebrae are more commonly involved as part of a diffuse process (multiple myeloma) by which the bone marrow is affected; therefore, it is usually a symptomatic and clinically significant tumor. Answer C is incorrect because epithelioid hemangioma is an uncommon variant of hemangioma and the majority arises in long tubular bones. Answer B is incorrect because enchondroma of the spine is very rare. Chondroid lesions occurring in the vertebrae should be carefully investigated as they are generally aggressive, if they are not reactive or metaplastic in nature.

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Reference: Hemangioma

A 34 year old man underwent biopsy of a lesion in the third lumbar vertebra found incidentally after an abdominal CT scan. Microscopically, as shown in the image above, the lesion revealed numerous vascular channels lined by a single layer of endothelial cells without nuclear atypia, interspersing the pre-existing trabeculae. What is the diagnosis?

1. Angiosarcoma
2. Epithelioid hemangioendothelioma
3. Epithelioid hemangioma
4. Hemangioma of bone

D. Hemangioma of bone. The image and microscopic description depict a hemangioma of bone, a benign and generally asymptomatic vascular tumor. Answer B is incorrect because epithelioid hemangioendothelioma usually presents with symptoms of pain and swelling and it is histologically characterized by epithelioid cells arranged in cords or clusters within a distinctive myxohyaline stroma, without the formation of vascular lumina. Answer A is incorrect because angiosarcoma usually arises as an ill defined and destructive mass, showing atypical endothelial cells lining irregular vascular channels. Answer C is incorrect because epithelioid hemangioma has a different morphology from conventional hemangioma, revealing larger, epithelioid cells with abundant eosinophilic cytoplasm.

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Reference: Hemangioma