AJR 2004; 183:1799-1804
© American Roentgen Ray Society
Differentiation of Cavernous Hemangioma from Schwannoma of the Orbit: A Dynamic MRI Study
Atsuo Tanaka1,
Futoshi Mihara1,
Takashi Yoshiura1,
Osamu Togao1,
Yasuo Kuwabara1,
Yoshihiro Natori2,
Tomio Sasaki2 and
Hiroshi Honda1
1 Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu
University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan.
2 Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu
University, Higashi-ku, Fukuoka 812-8582, Japan.
Received January 21, 2004;
accepted after revision May 6, 2004.
Address correspondence to A. Tanaka
(atsuo{at}radiol.med.kyushu-u.ac.jp).
Abstract
OBJECTIVE. The purpose of this study was to determine the capability
of dynamic contrast MRI to differentiate hemangioma from schwannoma of the
orbit.
MATERIALS AND METHODS. Sixteen patients (three males and 13 females;
mean age, 39 ± 17.3 [SD] years; age range, 10–71 years) with
unilateral orbital tumors, including eight cavernous hemangiomas and eight
schwannomas, were examined. In addition to conventional MRI, we performed a
dynamic contrast study (fast spin-echo sequence, 20-sec interval) after bolus
administration of the contrast material (gadopentetate dimeglumine, 0.1
mmol/kg). We evaluated the features of the contrast enhancement spread pattern
and the tumors' time–intensity curves.
RESULTS. In the early phase, all the hemangiomas started the
enhancement from one point or portion, although all the schwannomas started
the enhancement from a wide area. The difference in the contrast-enhancement
spread pattern features between the two types of tumors was statistically
significant (p < 0.0001). The gradient of the time–intensity
curve did not show a significant difference.
CONCLUSION. Hemangioma and schwannoma of the orbit can be
differentiated by the contrast-enhancement spread pattern on dynamic MRI.
Introduction
The cavernous hemangioma is one of the most common primary orbital tumors.
Differentiating cavernous hemangiomas from other orbital tumors, especially
from schwannomas, can provide useful information when determining the
appropriate surgical technique (for example, the management of adjacent
structures, such as feeding vessels and nerves)
[1]. However, differentiation
based on conventional methods can be difficult
[2]. We examined the
enhancement pattern and time–intensity curves of dynamic MRI and then
evaluated their ability to differentiate hemangiomas from schwannomas of the
orbit.
Materials and Methods
Eight schwannomas and eight cavernous hemangiomas, all pathologically
proven, were examined retrospectively in three males and 13 females (mean age,
39 ± 17.3 [SD] years; age range, 10–71 years). The MR scanners
used were 1.5-T scanners (Magnetom Vision, Siemens or Signa, GE Healthcare). A
conventional T1-weighted image and a T2-weighted image were obtained by fast
spin-echo sequence for each tumor. Fast spin-echo dynamic MRI (TR/TE range,
300/12–19; number of exitations, 1; matrix, 256 x 192–256)
was performed for 2 min at 20-sec intervals immediately after the injection of
gadopentetate dimeglumine (0.1 mmol/kg, Magnevist, Berlex). Delayed imaging
was performed 5–18 min after the dynamic MRI study. In some cases,
unenhanced CT scans also were obtained (Figs.
1A and
2A). This study was approved by
the ethics committee of Kyushu University Hospital.
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Fig. 1A. —49-year-old woman with cavernous hemangioma. Conventional
images show homogeneous density and signal intensity on unenhanced CT scan
(A) and T1-weighted (B) and T2-weighted (C) fast
spin-echo images.
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Fig. 2A. —71-year-old man with schwannoma. Conventional images show
homogeneous density and signal intensity on unenhanced CT scan (A) and
T1-weighted (B) and T2-weighted (C) fast spin-echo images.
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The spread pattern of the contrast enhancement was assessed and divided
into two groups: one starting from a small point or portion and the other
starting from a wide area (Fig.
1A). An oval region of interest was situated to cover the entire
area of the tumor, and a time–intensity curve was obtained. Changes in
signal intensity during the first 20 sec on the time–intensity curve
were used to define the dynamic enhancement gradient: We labeled an increase
of signal intensity greater than 40% as rapid and any increase smaller than
40% as gradual (Fig. 1B). The
statistical analysis of chisquare test results was performed using SAS
software (SAS Institute). A p value of less than 0.05 was considered
significant.
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Fig. 1B. —49-year-old woman with cavernous hemangioma. Conventional
images show homogeneous density and signal intensity on unenhanced CT scan
(A) and T1-weighted (B) and T2-weighted (C) fast
spin-echo images.
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Results
All the orbital tumors showed hyperintensity on T2-weighted images and
isointensity on T1-weighted images compared with extraocular muscles. All the
hemangiomas showed homogeneous signal intensity both on T1- and T2-weighted
images. Seven schwannomas showed homogeneous signal intensity on T1-weighted
images, and three schwannomas showed homogeneous signal intensity on
T2-weighted images (Figs. 1A,
1B,
1C and
2A,
2B,
2C).
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Fig. 1C. —49-year-old woman with cavernous hemangioma. Conventional
images show homogeneous density and signal intensity on unenhanced CT scan
(A) and T1-weighted (B) and T2-weighted (C) fast
spin-echo images.
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Fig. 2B. —71-year-old man with schwannoma. Conventional images show
homogeneous density and signal intensity on unenhanced CT scan (A) and
T1-weighted (B) and T2-weighted (C) fast spin-echo images.
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Fig. 2C. —71-year-old man with schwannoma. Conventional images show
homogeneous density and signal intensity on unenhanced CT scan (A) and
T1-weighted (B) and T2-weighted (C) fast spin-echo images.
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At the early phase, all the hemangiomas started enhancement from one point
or portion (Fig. 3A,
3B,
3C,
3D,
3E,
3F,
3G,
3H); however, this enhancement
pattern was not observed in schwannomas. All the schwannomas started the
enhancement from a wide area (Fig.
4A,
4B,
4C,
4D,
4E,
4F,
4G,
4H). The difference in the
contrast-enhancement spread pattern for the two types of tumors was
statistically significant (p < 0.0001). In the analysis of the
time–intensity curves, all eight hemangiomas showed delayed enhancement.
Four schwannomas showed rapid enhancement, and four schwannomas showed a
gradual enhancement pattern. The difference was not statistically significant
(p > 0.05).
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Fig. 3A. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 0 and 20 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from one central point of
tumor.
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Fig. 3B. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 0 and 20 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from one central point of
tumor.
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Fig. 3C. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 3D. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 3E. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 3F. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 3G. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 3H. —61-year-old woman with cavernous hemangioma. Dynamic MR
images obtained at 40, 60, 80, 100, 120, and 300 sec, respectively, after
administration of gadopentetate dimeglumine show enhancement starts from one
central point of tumor.
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Fig. 4A. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4B. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4C. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4D. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4E. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4F. —25-year-old man with schwannoma. Dynamic MR images obtained
at 0, 20, 40, 60, 80, and 100 sec, respectively, after administration of
gadopentetate dimeglumine show enhancement starts from marginal wide area of
tumor.
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Fig. 4G. —25-year-old man with schwannoma. Dynamic MR images obtained
at 120 and 300 sec, respectively, after administration of gadopentetate
dimeglumine show enhancement starts from marginal wide area of tumor.
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Fig. 4H. —25-year-old man with schwannoma. Dynamic MR images obtained
at 120 and 300 sec, respectively, after administration of gadopentetate
dimeglumine show enhancement starts from marginal wide area of tumor.
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Discussion
The cavernous hemangioma is one of the most common primary orbital tumors.
This tumor occurs in females more frequently than in males and has its peak
incidence in early middle age
[3], and it may enlarge during
pregnancy [4]. Painless and
progressive reducible unilateral proptosis causing a variable degree of
hyperopia is the usual clinical presentation
[5,
6], and amaurosis fugax can
occur [7]. Multiple cavernous
hemangiomas are rare but can occur simultaneously or be separated by long
intervals [3,
8]. Schwannomas are
encapsulated and usually have a slow-growing and noninvasive character. They
also can cause exophthalmos, optic neuropathy, and diplopia, like cavernous
hemangiomas [9,
10]. It is difficult to
differentiate these conditions clinically.
He et al. [11] reported the
histopathologic classification and distribution of orbital diseases in 3,476
patients. They reported that the 10 leading diseases were cavernous
hemangioma, leiomyoma, inflammatory pseudotumor, dermoid, schwannoma,
meningioma, benign mixed tumor of the lacrimal gland, mucocele, varix, and
lacrimal gland epithelial tumor. Except for the cavernous hemangioma and
schwannoma, all the other tumors have distinct characteristic features and
usually can be identified using conventional MRI.
With respect to surgical management, differentiating those two tumors is
not crucial, but such differentiation could provide useful information for
better results, especially vessel management. Moreover, it would be beneficial
to treat these tumors without biopsy or surgical treatment, such as
radiotherapy.
The usefulness of MRI of orbital mass lesions is well known
[2,
12–19].
MRI shows hemangiomas to be well-defined masses that usually are oval
[2]. The signal intensity and
homogeneity of the hemangioma are usually characteristic on conventional MRI
[14–19].
Thorn-Kany et al. [20]
reported that an intraconal, well-defined, associated homogeneous signal;
isointensity relative to muscle on T1-weighted images; hyperintensity on
T2-weighted images; and progressive filling on gadopentetate dimeglumine
enhancement are typical findings of a cavernous hemangioma. Our study
revealed, however, that these features also can be observed in schwannomas and
are not very useful in differentiating these two tumors.
Our results suggest that the contrast-enhancement spread pattern can be
used to distinguish these tumors. Ohtsuka et al.
[21] reported the enhancement
pattern of two hemangiomas. On early MRI after the gadopentetate dimeglumine
injection, one small point of enhancement initially was noted and then the
tumor was enhanced homogeneously. Our results from hemangioma enhancement are
similar to theirs. The initial enhancement point appearing in the hemangioma
would represent the entry of the feeding vessels
[21]. On the other hand, the
enhancement pattern of schwannomas is clearly different from that of
hemangiomas, and this feature may help to distinguish these two tumors. The
gradient of the time–intensity curve did not show a significant
difference.
Sonography is a good technique for this purpose
[22], but weaknesses may
include subjective differences among reviewers; previous knowledge of some
artifacts [22,
23]; and difficulty making
decisions in cases of multiple, treated, or smaller tumors.
We also have a few results of a dynamic CT study (not published), which
look almost identical to this dynamic MRI study. A drawback is that CT study
requires somewhat heavy and repeated radiographic exposure of the orbit.
Conclusion
We believe that schwannomas and cavernous hemangiomas of the orbit can be
distinguished by the contrast-enhancement spread pattern, and not by the
enhancement gradient on dynamic MRI.
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Abstract
Introduction
