Hemangiomas are congenital vascular malformations, classified according to the predominant vascular morphology: cavernous, capillary, arteriovenous, or venous. Capillary hemangiomas are the most common subtype overall as they occur frequently in skin and oral mucosa of infants and children. However, primary intraosseous hemangiomas are uncommon, representing approximately 0.5 to 1% of all intraosseous tumors. Their description varies from benign vasoformative neoplasms to true hamartomatous proliferations of endothelial cells forming a vascular network with intermixed fibrous connective tissue stroma.
Primary intraosseous hemangiomas are rare lesions of likely congenital origin that areas with previous trauma, and often present as a bony outgrowth. Generally primary intraosseous hemangiomas occur in the vertebral skeleton and calvarium and facial bones. Capillary hemangioma of rib is exceedingly rare, and it was reported first until 2010 [3], and there has been no corresponding report since then. We present the case of a 67-year-old man who was admitted to hospital with rib lesion, which was discovered on the follow-up of lobectomy. This pathology was diagnostic of capillary hemangioma of rib. The postoperative course was uneventful, the aesthetic outcome was excellent, and to date, there is no evidence of recurrence. Generally, these benign tumors have a very favorable prognosis.
Trauma is believed to be the most common etiology of intraosseous hemangiomas. The patient was performed lobectomy before, but it hard to say that the trauma of the surgery was directly related to the lesion. We also look forward to the emergence of similar cases to assess the possibility of this association.
The postoperative reconstruction method is more controversial, but lesions that affect the stability of the thorax generally require reconstruction. For intraosseous hemangiomas occur on calvarium or facial bones, en bloc resection with primary reconstruction using autogenous bone grafts will be the most commonly utilized if necessary [4]. There may be a new role for alloplastic materials in reconstructing these deficits, and several reports have utilized alloplastic implant prostheses, such as the PEEK implant [5–6].
Intraosseous hemangiomas commonly present as a firm, painless swelling lesions. Therefore, despite the vascular nature of these lesions, hemorrhage is a rare complication. Though hemorrhage is a potential serious complication, more cases reported brisk bleeding during incisional biopsies (12.2%) than during resection (8.2%) [7]. However, capillary hemangiomas of rib can show malignant pleural effusions and bone destruction, and this makes it more distinguishable from other lesions. The imaging features are not specific, even show some imaging findings of malignant bone tumors, so the differential diagnosis of the intrabony mass should include osteosarcoma, chondrosarcoma, and other tumors such as plasmacytoma, lymphoma, hemangioblastoma.
Various imaging modalities can be utilized to characterize these benign outgrowths. CT scan remains the diagnostic imaging modality of choice for the diagnosis of intraosseous hemangiomas and was the most common imaging modality utilized by clinicians for evaluating these lesions. The radiographic appearance is often described as “honeycomb,” “soap bubble,” or “sunburst,” [8]. Though these lesions may initially raise concern for osteosarcoma, upon close inspection the cortical border will be intact, highlighting the benign nature of these lesions. However, previous case reports also mentioned the existence of rib capillary hemangioma accompanied by obvious bone destruction, refractory pleural effusion and other malignant manifestations, so the identification significance of CT is limited. PET-CT examination is a good choice to make accurate judgments if allowed. In addition, MRI may have a better effect than CT for lesions in soft tissue parts such as the spinal cord [9].
Because these lesions are benign, short-term follow-up is an option for asymptomatic individuals. Given the expanding nature of these lesions, surgery remains the treatment of choice. In contrast to soft-tissue venous malformations in which various treatment options have been described, complete surgical resection remains the treatment of choice for primary intraosseous hemangiomas.
In conclusion, findings in present patient showed that the primary capillary hemangioma of rib could show malignant manifestations on symptoms and radiographic findings. Since this patient has received surgical treatment of lobectomy before, it is still questionable whether the trauma during the operation caused the onset of this lesion. We hope to have more reports of primary rib capillary hemangioma to reassess whether capillary hemangioma originating in the rib is more different from other sites.