The debate is still open; benign or malignant: a case report of a multifocal epithelioid haemangioma of fibula

Abstract

In this case, we report an epithelioid haemangioma (EH) of the fibula with ill-defined multifocal lesions and a resultant pathologic fracture. Based on radiographic appearance, these lesions were initially thought to represent a malignant process, such as primary malignant bone tumour, metastases or multiple myeloma. Osseous EHs are rare. Although they can present as multifocal lesions, the majority of bony EHs are solitary and arise in the diaphysis or metaphysis of long tubular bones, with a predilection for the lower extremity. Non-specific radiological findings, debatable cytological appearance and unpredictable clinical growth patterns commonly cause misdiagnosis of malignancy. To the best of our knowledge, a case of EH with multiple growing lesions of the fibula has not yet been reported in the literature.

Figure 1.

Two lytic lesions (circles) in the fibula demonstrate permeative appearance and a wide zone of transition. Differential diagnosis would include metastatic disease, multiple myeloma, lymphoma and, less likely, primary neoplasm.

Figure 2.

Technetium-99m methylene diphosphonate bone scintigraphy demonstrates avid radiopharmaceutical uptake within the two left fibular lesions.

Figure 3.

2 months later: increased size of the previous lesions with a new third lesion (circle).

Figure 4.

Tumour blushes of left fibular haemangiomas, with supplying branches mainly from the PA and partially from the ATA. ATA, anterior tibial artery; PA, peroneal artery; PTA, posterior tibial artery.