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Ann Thorac Surg 2002;74:932-934
© 2002 The Society of Thoracic Surgeons

Case report

Cavernous hemangioma of the rib

Katsuhiko Shimizu, MD*a, Yoshinori Yamashita, MDa, Jun Hihara, MDa, Yoshihiro Seto, MDa, Tetsuya Toge, MDa

a Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, and Department of Surgery, Hiroshima Mitsubishi Hospital, Hiroshima, Japan

Accepted for publication May 1, 2002.

* Address reprint requests to Dr Shimizu, Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima 734-8553, Japan
e-mail: kshimizu{at}hiroshima-u.ac.jp


   Abstract
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 Abstract
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A 59-year-old man with an enlarged left chest wall mass that had been followed up for 3 years underwent surgical resection. The mass was pathologically diagnosed as cavernous hemangioma of the rib. This is the fourth case of this rare disease to be reported. However, it suggests that hemangioma of the rib should be considered in the differential diagnosis of rib tumors, especially in asymptomatic patients.


   Introduction
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Cavernous hemangioma of the bone is an uncommon benign vascular tumor. Almost all such tumors occur in the spine or in the skull; they are extremely rare in the rib. We report the case of a patient with cavernous hemangioma of the rib who underwent resection after a 3 year follow-up.

A 59-year-old man was admitted in 2000 for a left chest wall mass. The lesion had been discovered on a screening chest computed tomographic scan in 1997, and the patient had had a follow-up scan every year for the next 3 years. The mass was observed to enlarge gradually. The patient had no history of fractures of or injuries to the chest wall. He had experienced no pain, cough, hemoptysis, or other respiratory symptoms.

A chest roentgenogram showed a mass shadow with an extrapleural sign in the left upper lung field. A rib radiograph revealed a mass shadow with bony destruction measuring 7.5 cm along the left fourth rib (Fig 1). Serial chest computed tomograms showed local enlargement of the mass over 3 years. It measured 1.8 x 0.9 cm in 1997, 2.8 x 1.2 cm in 1998 and 1999, and 3.1 x 2.4 cm in 2000 (Fig 2). Magnetic resonance imaging showed a low signal on T1-weighted images, a high signal on T2-weighted images, and enhancement by contrast medium. Bone scintigraphy using 99m-labeled technetium revealed accumulation in the left fourth rib. The patient underwent Enbloc surgical resection of the left fourth rib and intercostal muscles.



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  		Fig 1. Rib radiograph showing a mass shadow with bony destruction measuring 7.5 cm along the fourth left rib.

 


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  		Fig 2. Chest computed tomogram showing localized expansion of mass, which measured 3.1 x 2.4 cm in 2000.

 
Macroscopically, the tumor measured 6.0 x 2.0 x 1.5 cm and bulged from the inner surface of the fourth rib toward the thoracic cavity. It was covered with normal pleura. The cut surface of the resected tumor had a policystic appearance and contained fresh blood. Microscopically, the tumor was composed of dilated vessels in the marrow (Fig 3). These vessels comprised a single layer of endothelial cells, which showed no atypia or mitosis. The pathological findings were compatible with those of cavernous hemangioma. No tumor tissue was detected at the surgical margin.



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  		Fig 3. Microscopically, the tumor was composed of dilated vessels with a single layer of endothelial cells, which showed no atypia or mitosis. (Hematoxylin and eosin; x400 before % reduction.)

 
The patient had an uneventful postoperative course and was discharged on the 14th postoperative day. He has been followed up for 2 years without evidence of recurrence.


   Comment
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The features of primary chest wall mesenchymal lesions have been described in several reports [1–4]. Such lesions are classified into various categories, such as bone or cartilage, malignant or benign, and epidermal or mesodermal. Overall, approximately half of such lesions are malignant. In one large series from the Mayo Clinic [1] involving more than 2,000 bone tumors, 126 (6%) of them occurred in the ribs. In a series reported by Dahlin [4], bone hemangiomas represented about 1% of the bone tumors. In 60% to 80% of the cases, the tumor occurred in the vertebra or the skull. To date, only three cases of hemangioma of the rib have been reported in the literature [5–7].

Hemangioma of the rib has been discovered incidentally on a chest roentgenogram made for another reason. Plain radiography remains the initial method to determine staging for almost all primary chest wall tumors. The size and the extent of cortical destruction can be more clearly demonstrated by computed tomography and magnetic resonance imaging. Special staining and immunocytochemical techniques can contribute to the final diagnosis. In many cases, wide excision is necessary to provide adequate tissue for exact histological diagnosis. Surgical resection of the affected rib is the treatment of choice for hemangioma of the rib. Because more than half of all primary rib tumors are malignant, prompt investigation, accurate tissue diagnosis, and usually generous surgical excision are required. Surgical resection remains the mainstay for the treatment of most chest tumors. Cavernous hemangioma of the rib is an extremely rare tumor that has been found incidentally, and it should be considered in the differential diagnosis of rib tumors, especially in asymptomatic patients.


   References
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 Abstract
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 Comment
 References
 

  1. Stelzer P., Gay W.A., Jr Tumors of the chest wall. Surg Clin North Am 1980;60:779-791.[Medline]
  2. Graeber G.M., Snyder J.R., Fleming A.W., et al. Initial and long-term results in the management of primary chest wall neoplasms. Ann Thorac Surg 1982;34:664-673.[Abstract/Free Full Text]
  3. Evans K.G., Miller R.R., Muller N.L., Nelems B. Chest-wall tumors. Can J Surg 1990;33:229-232.[Medline]
  4. Dahlin D.C. Bone tumors: general aspect and data on 6,221 cases. Springfield I: C Thomas, 1981:137-148.
  5. Clements R.H., Turnage R.B., Tyndal E.C. Hemangioma of the rib: a rare diagnosis. Am Surg 1998;64:1027-1029.[Medline]
  6. Filosso P.L., Oliaro A., Ruffini E., et al. Hemangioma of the rib. A case report. J Cardiovasc Surg (Torins) 1995;36:97-98.[Medline]
  7. Okumura T., Asamura H., Kondo H., Matsuno Y., Tsuchiya R. Hemangioma of the rib: a case report. Jpn J Clin Oncol 2000;30:354-357.[Abstract/Free Full Text]



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