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Angiomatous lesions of the musculoskeletal system are common and can involve both soft-tissue and osseous structures. Soft-tissue hemangiomas are particularly frequent, constituting 7% of all benign tumors, and are the most commonly encountered soft-tissue neoplasm of infancy and childhood. Pathologically, hemangiomas can be divided into capillary, cavernous, arteriovenous, and venous lesions. Osseous hemangiomas often have a characteristic appearance on radiographs, with coarsened vertical trabeculae in the spine, a radiating weblike trabecular pattern in the skull, or multifocal honeycomb areas of bone lysis at other sites. MR imaging is particularly useful in the identification of soft-tissue hemangiomas, with typical findings of serpentine vascular channels and fat overgrowth. Phleboliths, most frequently occurring in cavernous hemangiomas, are best seen at radiography and CT. Secondary changes that can result from hemangiomas include bone and soft-tissue overgrowth, as well as arthritic manifestations from repetitive, intraarticular bleeding. Occasionally, MR imaging can allow differentiation between the various types of hemangiomas by showing larger cystic spaces in cavernous lesions versus predominantly serpentine vascular channels with high flow in arteriovenous hemangiomas or with low flow in venous hemangiomas.
Angiomatous tissue can also diffusely infiltrate bone or soft tissue (angiomatosis) or be associated with a variety of conditions, including Maffucci syndrome, Osler-Weber-Rendu disease, Klippel-Trnaunay-Weber syndrome, Kasabach-Merritt syndrome, and Gorham disease. More aggressive vascular lesions such as hemangioendothelioma, hemangiopericytoma, and angiosarcoma can involve bone or soft tissue. Osseous lesions characteristically show aggressive, multifocal areas of bone destruction. In the soft tissues, these more aggressive vascular neoplasms cannot be distinguished from one another with imaging. However, MR imaging findings of prominent serpentine vascular structures, infiltrative margins, and lack of fat overgrowth should suggest one of these lesions and allow it to be differentiated from a simple hemangioma.
Imaging characteristics of angiomatous lesions are important for radiologists to recognize for purposes of diagnosis and to help guide our clinical colleagues in the treatment of patients with these lesions.
Summary