Multifocal vascular lesions of bone imaging characteristics

Objective. Multifocal vascular processes which arise in bone are a very inhomogeneous class of diseases. Four of these processes are derived from endothelial precursors, however, and share a similar radiographic spectrum. These four entities are reviewed in order to clarify their imaging patterns and the diagnostic utility of imaging modalities. Methods. Eight cases of cystic angiomatosis, multifocal hemangioma, hemangioendothelioma and angiosarcoma presenting to a tertiary referral center over a 7-year period were reviewed. The medical literature was also reviewed for information concerning the imaging of these processes. Results. All four diseases produced radiolucent defects on plain radiographs with variable margination reflecting the aggressiveness of the lesions. Computed tomography was used to examine five patients and provided supportive, though generally non-diagnostic, information in the five cases in which it was performed. Radionuclide bone scintigraphy, as reported in the literature, underestimated the extent of skeletal involvement in all eight cases, though some lesions were identified. Radionuclide imaging with labeled red blood cells, performed in three cases, did not add any information, which is contrary to some reports in the literature. Magnetic resonance imaging proved the most sensitive for identifying lesions, although the imaging characteristics were not diagnostic. Conclusions. Plain radiographs are the mainstay for imaging multifocal endothelial processes. Radiographs provide information on aggressiveness, multifocality and distribution of lesions. Computed tomography provides similar information. Magnetic resonance imaging often detects additional lesions. The insensitivity of radionuclide bone scintigraphy is surprising. Reports of unique deposition of radionuclide in tagged red blood cell scanning has been reported to support the diagnosis of vascular lesions, but it did not do so in these cases.