Australas Radio1 1992 36: 124-126
CT Evaluation of Orbital Osseous Hemangioma SAMEER SOOD, M.D. Senior Resident S. VASHISHT,M.D.,M.N.A.M.S. Additional Professor S.M. BETHARIA, M.D. Associate Professor M. BERRY, M.D. Professor and Head All India Institute of Medical Sciences,New Delhi - 110029 India
ABSTRACT Two patients with osseous hemaqgioma of the orbit, and with typical features on plain radiography and computed tomography, are reported. The typical features of O S ~ ~ O Uhemangioma S of the orbit on computerised tomography (CT) are: expansile bony lesion limited by a thin sclerotic rim, bony trabeculae radiating from the centre to the periphery of the lesion, and absence of an associated extra-tumoral soft tissue mass. To the best of our knowledge this is the first report of osseous hemangioma of the orbit evaluated by CT. INTRODUCTION Osseous hemangioma is a rare entity. Dahlin (1957) (1) analysed 2276
cases of primary bone tumours at Mayo Clinic and reported an incidence of 0.6%. Sherman and Wilner (1961 (2) identified more than half of these hemangiomas in the skull and spine. Until recently, osseous hemangiomas were diagnosed by conventional radiography (2,3,4). Ortega et a1 (1986) ( 5 ) reported 3 cases of rib hemangioma investigated by computed tomography (CT). We could not find any earlier report in the English literature of an osseous hemangioma of the orbit evaluated by CT.
Key words: Hernangianaorbit cl-scan
Addrces for: -
Dr.Sushma Vashisht Additional Professor
hpattment of Radio-Diagnosis
A.I.I.M.S. NcwDclhi- I10029 India
124
FIGURE 1A - PA view of the orbit; circular rarefied zone with radially arranged bony spicules from centre to the periphery involving the roof and medial wall of left orbit, left frontal sinus and superior d i t a l rim.
Case 1 A 50 years male presented with painful, progressive proptosis involving the left eye and associated with gradual diminution of vision, and restricted movements of the eyeball, for one year. Examination of the orbit revealed proptosis of the left eye with a bony, hard mass palpable along the left superior orbital margin. No pulsations or dilated vessels were seen over the mass. The fundus could not be evaluated. The right eye and orbit were normal.
Plain films of the orbit (Figure 1A) revealed an ill-defined, circular zone of rarefaction, with sunray spiculations extending from the centre towards the periphery and involving the left frontal sinus, superior orbital rim, roof and medial wall of the left orbit. In addition there was evidence
of pressure erosion and displacement of the floor of the left orbit downwards. CT scan of the orbit (Figure 1B) demonstrated that the proptosis of the left eye was caused by an expansile osseous mass. The mass was outlined by a thin expanded cortex (thin sclerotic rim) involving the roof and the medial wall of the left orbit, and the ipsilateral frontal sinus. The internal architecture consisted of slender bony trabeculae radiating from the centre to the periphery and separated by soft tissue density. Surgery was performed. There was excessive bleeding during the procedure and only a small part of the
Submitted for publication on 24th Apnl. 1991 Accepted for publication on 23rd July. 1991 Australasian Radiology. Vol. 36, No. 2 . May, 1992
CT EVALUATION OF ORBITAL OSSEOUS HEMANGIOMA was displacing the right eyeball antexiorly and inferiorly resulting in right proptosis. The internal architecture of the mass revealed slender bony trabeculae radiating from centre to the periphery of the lesion and separated by soft tissue density. The CT scan and plain roentgenographic findings were considered diagnostic of osseous hemangioma and surgery was planned. The patient refused operation.
F I G W 1B scan coronal section (bone window): expansile bony lesion with thin expanded cortex and radially arranged bony spicules from centre to the periphery of the lesion.
DISCUSSION Histologically, two types of osseous hemangiomas are recognized; cavernous and capillary. The cavernous type consists of large thin walled vessels, and sinuses which asc lined by a single layer of endohlial cells interspersed amongst resorbed bony trabeculae. The capillary type is composed of fine capillary loops which tend to spread outwards. Cavernous hemangiomas are commonly found in the vertebrae and skull, whilst the capillary type are more common in the metaphyses of long bones and in flat bones
(6).
FIGURE 2A - PA view of the orbit: circular rarefied area involving roof and lateral wall of right orbit with sunray spicules. Superiororbit fissure obscured by expanded bone overlying i t
tumour could be excised. Histopathology revealed this to be the cavernous type of osseous haemangioma. Case 2 A 54 year old man presented with progressive painless proptosis of the right eye associated with gradual loss of vision over the last one year. On examination there was non-pulsatile proptosis involving the right eye and there were no prominent vessels seen over it. Examination of the fundi revealed papilloedema on the right side. The left eye and orbit were normal. Australasian Radiology. Vol.36. No. 2, May, 1992
Plain films of the orbit (Figure 2A) demonstrated a circular rarefied area involving the roof and lateral wall of the right orbit with sunray spicules extending radially from the centre of the lesion towards the periphery. The superior orbital fissure was ill-defined on the right side. The left orbit was normal. CT scan (Figure 2B) revealed a well defined bony mass, with a thin sclerotic rim, involving the roof, superior half of the medial and lateral walls of the right orbit and with extension up to the apex of the orbit. The mass
The osseous hemangiomas of the skull are usually oval or round in shape and represented by single area of rarefaction and ranging from one to seven cms in diameter. The internal pattern is characterized by fine delicate stria which give rise to a honeycomb appearance which might be so gross as to present a “sunburst” appearance. The margin of the lesion is sharp and well delineated from the surrounding normal bone. A fine margin of bone condensation may be seen at the periphery (2). Both the patients described exhibited the classical “sunburst” pattern on plain roentgenograms, and CT depicted a thin expanded cortex at the periphery of the lesion, better delineation of the slender radially arranged bony spicules and the absence of any extratumoral associated soft tissue mass. The internal architecture of the hemangioma, demonstrated by CT,closely resembled the histological description of the cavernous type of osseous hemangioma where dilated blood spaces are separated by slender bony trabeculae. The CT features observed by us are very similar to the CT features reported by m e g a et a1 ( 5 ) in three patients with rib hemangiomas. Conditions which need to be considered in differential diagnosis of osseous hemangioma are meningioma, osteosarcoma, multiple myeloma and metastatic cancer. 125
S . S O D et a1 REFERENCES Dahlin DC. Bone tumours. general aspects and an anaiysis Of 2, 276 Cases. Springfield, Charles C. Thomas 1957: 84-89. 2. Shmnan SR and Wilner D. The Roentgen diagnosis of hemangioma of bone. AJR 1%1; 86: 1146-1159. 3. Unni KK, Ivins CJ,Beabout WJ and Dahlin CD. Hemangioma, hemangiopericytoma and hemangioendothelioma (Angiosarcoma) of bone. Cancer 1971; 27: 1.
1403-1414. 4. Wilner D. Radiology of bone turnours and allied disorders Vol 1. Washington, W.D. Saunders Company. 1982; 662-704. 5. m e g a W. Mahboubi S, Dalinka KM and Robinson T. Computed Tomography of rib hemangioma JCAT 1986; 10: 945-947. 6. Schinz HR, Baensch WE, Fried1 E and
Vehvinger E. Roentgen - Diagnostics Vol. 2, New York, Grune and Stratton 1951;
882-887. 7. Naidu RC, Reddy DR. Kishore LT and Subbarao K. Unusual haemangiorna of the skull. IJRI 1989; 43: 79-80.
FIGURE 2B - CT scan axial section (bone window): osseous hemangioma involving right ohital roof showingclassical CT s c ~ nfeatures.
Osseous changes produced by meningioma may result in closely placed striations in the skull, but these tend to be parallel rather than radially arranged as in hemangioma. Erosion of the skull vault occurs from within in cases of meningioma, leading to increased inner table involvement as compared to outer table. A meningioma frequently produces dense and extensive hyperostotic changes, a feature lacking in hemangioma (4). All the above features are better appreciated on CT scan vis-a-vis plain roentgenograms. A soft tissue mass associated with meningioma, and its characteristic enhancement with intravenous contrast seen on CT, can further distinguish it from hemangioma.
26
Osteogenic sarcoma in the skull may produce spiculation with a sunburst pattern, but the bony spicules tend to be thicker, more irregular and not radially arranged. Irregular bone destruction and associated soft tissue mass (better delineated by CT)help to differentiate osteosarcoma from osseous hemangioma (4,7). Multiple myeloma and metastatic cancer are similarly distinguishable by the disorganized nature of bone destruction, irregularity of internal pattern and often by multiplicity of the defects (4).
Australasian Radiology. Vol.36. No. 2 , May. I992
CT Evaluation of Orbital Osseous Hemangioma SAMEER SOOD, M.D. Senior Resident S. VASHISHT,M.D.,M.N.A.M.S. Additional Professor S.M. BETHARIA, M.D. Associate Professor M. BERRY, M.D. Professor and Head All India Institute of Medical Sciences,New Delhi - 110029 India
ABSTRACT Two patients with osseous hemaqgioma of the orbit, and with typical features on plain radiography and computed tomography, are reported. The typical features of O S ~ ~ O Uhemangioma S of the orbit on computerised tomography (CT) are: expansile bony lesion limited by a thin sclerotic rim, bony trabeculae radiating from the centre to the periphery of the lesion, and absence of an associated extra-tumoral soft tissue mass. To the best of our knowledge this is the first report of osseous hemangioma of the orbit evaluated by CT. INTRODUCTION Osseous hemangioma is a rare entity. Dahlin (1957) (1) analysed 2276
cases of primary bone tumours at Mayo Clinic and reported an incidence of 0.6%. Sherman and Wilner (1961 (2) identified more than half of these hemangiomas in the skull and spine. Until recently, osseous hemangiomas were diagnosed by conventional radiography (2,3,4). Ortega et a1 (1986) ( 5 ) reported 3 cases of rib hemangioma investigated by computed tomography (CT). We could not find any earlier report in the English literature of an osseous hemangioma of the orbit evaluated by CT.
Key words: Hernangianaorbit cl-scan
Addrces for: -
Dr.Sushma Vashisht Additional Professor
hpattment of Radio-Diagnosis
A.I.I.M.S. NcwDclhi- I10029 India
124
FIGURE 1A - PA view of the orbit; circular rarefied zone with radially arranged bony spicules from centre to the periphery involving the roof and medial wall of left orbit, left frontal sinus and superior d i t a l rim.
Case 1 A 50 years male presented with painful, progressive proptosis involving the left eye and associated with gradual diminution of vision, and restricted movements of the eyeball, for one year. Examination of the orbit revealed proptosis of the left eye with a bony, hard mass palpable along the left superior orbital margin. No pulsations or dilated vessels were seen over the mass. The fundus could not be evaluated. The right eye and orbit were normal.
Plain films of the orbit (Figure 1A) revealed an ill-defined, circular zone of rarefaction, with sunray spiculations extending from the centre towards the periphery and involving the left frontal sinus, superior orbital rim, roof and medial wall of the left orbit. In addition there was evidence
of pressure erosion and displacement of the floor of the left orbit downwards. CT scan of the orbit (Figure 1B) demonstrated that the proptosis of the left eye was caused by an expansile osseous mass. The mass was outlined by a thin expanded cortex (thin sclerotic rim) involving the roof and the medial wall of the left orbit, and the ipsilateral frontal sinus. The internal architecture consisted of slender bony trabeculae radiating from the centre to the periphery and separated by soft tissue density. Surgery was performed. There was excessive bleeding during the procedure and only a small part of the
Submitted for publication on 24th Apnl. 1991 Accepted for publication on 23rd July. 1991 Australasian Radiology. Vol. 36, No. 2 . May, 1992
CT EVALUATION OF ORBITAL OSSEOUS HEMANGIOMA was displacing the right eyeball antexiorly and inferiorly resulting in right proptosis. The internal architecture of the mass revealed slender bony trabeculae radiating from centre to the periphery of the lesion and separated by soft tissue density. The CT scan and plain roentgenographic findings were considered diagnostic of osseous hemangioma and surgery was planned. The patient refused operation.
F I G W 1B scan coronal section (bone window): expansile bony lesion with thin expanded cortex and radially arranged bony spicules from centre to the periphery of the lesion.
DISCUSSION Histologically, two types of osseous hemangiomas are recognized; cavernous and capillary. The cavernous type consists of large thin walled vessels, and sinuses which asc lined by a single layer of endohlial cells interspersed amongst resorbed bony trabeculae. The capillary type is composed of fine capillary loops which tend to spread outwards. Cavernous hemangiomas are commonly found in the vertebrae and skull, whilst the capillary type are more common in the metaphyses of long bones and in flat bones
(6).
FIGURE 2A - PA view of the orbit: circular rarefied area involving roof and lateral wall of right orbit with sunray spicules. Superiororbit fissure obscured by expanded bone overlying i t
tumour could be excised. Histopathology revealed this to be the cavernous type of osseous haemangioma. Case 2 A 54 year old man presented with progressive painless proptosis of the right eye associated with gradual loss of vision over the last one year. On examination there was non-pulsatile proptosis involving the right eye and there were no prominent vessels seen over it. Examination of the fundi revealed papilloedema on the right side. The left eye and orbit were normal. Australasian Radiology. Vol.36. No. 2, May, 1992
Plain films of the orbit (Figure 2A) demonstrated a circular rarefied area involving the roof and lateral wall of the right orbit with sunray spicules extending radially from the centre of the lesion towards the periphery. The superior orbital fissure was ill-defined on the right side. The left orbit was normal. CT scan (Figure 2B) revealed a well defined bony mass, with a thin sclerotic rim, involving the roof, superior half of the medial and lateral walls of the right orbit and with extension up to the apex of the orbit. The mass
The osseous hemangiomas of the skull are usually oval or round in shape and represented by single area of rarefaction and ranging from one to seven cms in diameter. The internal pattern is characterized by fine delicate stria which give rise to a honeycomb appearance which might be so gross as to present a “sunburst” appearance. The margin of the lesion is sharp and well delineated from the surrounding normal bone. A fine margin of bone condensation may be seen at the periphery (2). Both the patients described exhibited the classical “sunburst” pattern on plain roentgenograms, and CT depicted a thin expanded cortex at the periphery of the lesion, better delineation of the slender radially arranged bony spicules and the absence of any extratumoral associated soft tissue mass. The internal architecture of the hemangioma, demonstrated by CT,closely resembled the histological description of the cavernous type of osseous hemangioma where dilated blood spaces are separated by slender bony trabeculae. The CT features observed by us are very similar to the CT features reported by m e g a et a1 ( 5 ) in three patients with rib hemangiomas. Conditions which need to be considered in differential diagnosis of osseous hemangioma are meningioma, osteosarcoma, multiple myeloma and metastatic cancer. 125
S . S O D et a1 REFERENCES Dahlin DC. Bone tumours. general aspects and an anaiysis Of 2, 276 Cases. Springfield, Charles C. Thomas 1957: 84-89. 2. Shmnan SR and Wilner D. The Roentgen diagnosis of hemangioma of bone. AJR 1%1; 86: 1146-1159. 3. Unni KK, Ivins CJ,Beabout WJ and Dahlin CD. Hemangioma, hemangiopericytoma and hemangioendothelioma (Angiosarcoma) of bone. Cancer 1971; 27: 1.
1403-1414. 4. Wilner D. Radiology of bone turnours and allied disorders Vol 1. Washington, W.D. Saunders Company. 1982; 662-704. 5. m e g a W. Mahboubi S, Dalinka KM and Robinson T. Computed Tomography of rib hemangioma JCAT 1986; 10: 945-947. 6. Schinz HR, Baensch WE, Fried1 E and
Vehvinger E. Roentgen - Diagnostics Vol. 2, New York, Grune and Stratton 1951;
882-887. 7. Naidu RC, Reddy DR. Kishore LT and Subbarao K. Unusual haemangiorna of the skull. IJRI 1989; 43: 79-80.
FIGURE 2B - CT scan axial section (bone window): osseous hemangioma involving right ohital roof showingclassical CT s c ~ nfeatures.
Osseous changes produced by meningioma may result in closely placed striations in the skull, but these tend to be parallel rather than radially arranged as in hemangioma. Erosion of the skull vault occurs from within in cases of meningioma, leading to increased inner table involvement as compared to outer table. A meningioma frequently produces dense and extensive hyperostotic changes, a feature lacking in hemangioma (4). All the above features are better appreciated on CT scan vis-a-vis plain roentgenograms. A soft tissue mass associated with meningioma, and its characteristic enhancement with intravenous contrast seen on CT, can further distinguish it from hemangioma.
26
Osteogenic sarcoma in the skull may produce spiculation with a sunburst pattern, but the bony spicules tend to be thicker, more irregular and not radially arranged. Irregular bone destruction and associated soft tissue mass (better delineated by CT)help to differentiate osteosarcoma from osseous hemangioma (4,7). Multiple myeloma and metastatic cancer are similarly distinguishable by the disorganized nature of bone destruction, irregularity of internal pattern and often by multiplicity of the defects (4).
Australasian Radiology. Vol.36. No. 2 , May. I992
