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Bialek S, Villeneuve LM, Bauer A, Phan M, Johnston A, Spence C, Graffeo CS. Neurosurgical Management of Spinal Epithelioid Hemangioendothelioma: Systematic Review and Illustrative Case Presentation. World Neurosurg 2024; 188:99-110. [PMID: 38734166 DOI: 10.1016/j.wneu.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor predominantly arising in soft tissue. We report a rare case of thoracic spinal EHE with pulmonary metastasis. METHODS Case report and systematic review of spinal EHE. RESULTS A 36-year-old man presented with bilateral lower extremity weakness, progressive paresthesia, and urinary incontinence. He underwent open surgical resection of the tumor and decompression of the spinal cord, with subsequent improvement in neurologic function. Systematic review identified 84 cases of spinal EHE, 73 of which were primary, and 14 of which developed extra-spinal metastases. CONCLUSION EHE is an exceedingly rare tumor that may present with a wide swath of clinical symptoms. At present, no guidelines or formal treatment recommendations have been established. Surgical debulking has demonstrated efficacy as a front-line treatment, particularly in the setting of compressive neurologic dysfunction; data regarding adjuvant chemoradiation are less consistently reported, mandating further study.
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Affiliation(s)
- Shannan Bialek
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Lance M Villeneuve
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrew Bauer
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Minh Phan
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Johnston
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Caple Spence
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Christopher S Graffeo
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Liang P, Zhu BB, Ren XC, Gao JB. Imaging Findings and Clinical Features of Primary Spinal Epithelioid Hemangioendothelioma. Front Oncol 2022; 12:713947. [PMID: 35707348 PMCID: PMC9190255 DOI: 10.3389/fonc.2022.713947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Rationale and Objectives Primary spinal epithelioid hemangioendothelioma (SEHE) is an extremely rare angiocentric vascular neoplasm with inherent metastatic potential, which pursues a clinical course intermediate between hemangioma and angiosarcoma. The present study sought to present computed tomography (CT) and magnetic resonance imaging (MRI) findings and clinical features of primary SEHE and review the literature. Materials and Methods Clinical data of four patients with primary SEHE confirmed by pathology from January 2011 to May 2020 were analyzed retrospectively. Two cases underwent CT scan, while 3 cases underwent MRI scan. Image observation included the tumor location, bone changes, morphology, density/signal characteristics, and enhanced features. Results The four patients were all women who ranged in age from 25 to 74 years. Four cases of the lesions were in the vertebral body; among them, two cases involved the accessory of the vertebra. Soap bubble appearance was detected in 2 cases, honeycomb osteolytic appearance in 2 cases, a sclerotic margin in 3 cases, and accompanying vertebral compression fracture in 1 case. CT showed a slightly inhomogeneous low density with punctate high-density foci. MRI showed an inhomogeneous low signal on T1-weighted image (T1WI) and a high signal on T2WI. Contrast-enhanced CT/MRI demonstrated moderate to intensive inhomogeneous enhancement of the lesions. The discs were normal. In one case, lesions presented a dural tail sign. Conclusions Primary SEHE is so rare in the clinic as an aggressive vascular tumor. The relatively typical clinical features and radiographic findings can help in preoperative diagnosis.
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Challenges in Management of Epithelioid Hemangioendothelioma of the Spine: The Report of a Rare Cause of Cauda Equina Syndrome. ARCHIVES OF NEUROSCIENCE 2019. [DOI: 10.5812/ans.85206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Witte HM, Riecke A, Mayer T, Hackenbroch C, Steinestel K, Gebauer N, Puckhaber D, Mathieu R, Mauer UM, Schulz C. Multifocal and hormone-dependent epithelioid hemangioendothelioma with osteolysis of the second cervical vertebral body: report of an unprecedented surgical approach by using autologous bone graft. Br J Neurosurg 2019:1-9. [PMID: 31583911 DOI: 10.1080/02688697.2019.1668542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report the case of a 28-year-old female patient who complained of extreme neck pain when giving birth to a child. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an osteolytic lesion at the second cervical vertebral body (C2). In this presentation, we highlight a transoral surgical approach in order to prevent instability of this osteolytic lesion. To the best of our knowledge, this is the first time that such a route of access has been described for this tumor entity. A histopathologic examination led to the diagnosis of epithelioid hemangioendothelioma. During a follow-up period of 33 months, the patient had no complaints.
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Affiliation(s)
- Hanno M Witte
- Department of Hematology and Oncology, German Armed Forces Hospital of Ulm , Ulm , Germany.,Department of Hematology and Oncology, UKSH Campus Lübeck , Lübeck , Germany
| | - Armin Riecke
- Department of Hematology and Oncology, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Thomas Mayer
- Department of Hematology and Oncology, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Carsten Hackenbroch
- Department of Radiology, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Konrad Steinestel
- Institute of Pathology and Molecular Pathology, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Niklas Gebauer
- Department of Hematology and Oncology, UKSH Campus Lübeck , Lübeck , Germany
| | - Dirk Puckhaber
- Department of Neurosurgery, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - René Mathieu
- Department of Neurosurgery, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Uwe Max Mauer
- Department of Neurosurgery, German Armed Forces Hospital of Ulm , Ulm , Germany
| | - Chris Schulz
- Department of Neurosurgery, German Armed Forces Hospital of Ulm , Ulm , Germany
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Ofluoglu AE, Aydogan M, Erdogan U, Ofluoglu O. Epithelioid hemangioendothelioma of the craniocervical junction; case report and review. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:342-346. [PMID: 28478911 PMCID: PMC6197577 DOI: 10.1016/j.aott.2017.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/27/2015] [Accepted: 12/24/2015] [Indexed: 11/26/2022]
Abstract
Epithelioid hemangioendotheliomas are uncommon vascular neoplasms and their spinal location is even rarer. We report clinical course of a 31-year-old man with an epithelioid hemangioendothelioma at the cranio-cervical junction. A cervical magnetic resonance imaging revealed tumor that caused posterior cervical cord compression. C1,2,3 total laminectomy and surgical excision of the tumor was performed. Postoperative external beam radiation was performed on the surgical field especially around the right vertebral artery. At 2-year follow-up there was no neurological deficit and no tumor recurrence.
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Albakr A, Schell M, Drew B, Cenic A. Epithelioid hemangioendothelioma of the spine: case report and review of the literature. JOURNAL OF SPINE SURGERY 2017; 3:250-259. [PMID: 28744509 DOI: 10.21037/jss.2017.05.05] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Epithelioid hemangioendothelioma (EHE) has been described as a rare vascular bone lesion with histological features between hemangioma and high-grade angiosarcoma. Spinal EHE is a quite rare disease with few case reports and series reported in the literature. The tumor cells are positive for vimentin, CD31and CD34, factor VIII related antigen, ERG, and FLI1. Radiological features are not specific; it may appear as an osteolytic lesion. It can present as a multifocal disease in 40% of cases. No clear correlation with age and sex; however, it is slightly more common in males. Focal neck or back pain is the most common presenting symptom. The natural history of spinal EHE is unpredictable, and currently, there is no standard of care for treatment. Treatment options include preoperative embolization, and surgical resection followed by radiotherapy and/or chemotherapy. A 34-year-old previously healthy male presented with mid-thoracic back pain. Magnetic resonance imaging (MRI) of the spine revealed a decrease in vertebral body height at T5 with an enhancing mass. He underwent T5 balloon kyphoplasty and needle vertebral body biopsy. Results of the biopsy samples were non-diagnostic. Approximately 3 months after surgery, the patient presented with unsteady gait. A subsequent MRI revealed progression of the T5 compression fracture with cord compression. The patient subsequently underwent T4-T6 bilateral posterior decompression for epidural tumor and T3-T7 posterior instrumentation with pedicle screws. Pathology of the lesion revealed EHE. The patient was started on local radiation therapy (RT). On follow-up, 3 months after the second surgery, the thoracic spinal pain had improved dramatically. Our review highlights the diagnosis, clinical presentation, and treatment of spinal EHE. Complete resection is associated with good outcome. Radiotherapy has been used in partially resected lesions. However, the role of radiotherapy as primary treatment is not yet defined. Further studies should develop a treatment algorithm for this rare tumour.
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Affiliation(s)
- Abdulrahman Albakr
- Division of Neurosurgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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[Epithelioid hemangioendothelioma of the spine: A case report]. Cancer Radiother 2017; 21:222-225. [PMID: 28478891 DOI: 10.1016/j.canrad.2016.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/21/2016] [Accepted: 11/23/2016] [Indexed: 11/20/2022]
Abstract
with intensity modulation. During the follow-up, a second inoperable spinal location necessitated a new sequence of radiotherapy in modulation of intensity with integrated boost. The patient was alive at 24 months of follow-up without evidence of local relapse or distance. This observation is followed by a discussion with review of the literature on other epithelioid hemangioendothelioma cases treated with radiation.
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Kelahan LC, Sandhu FA, Sayah A. Multifocal hemangioendothelioma of the lumbar spine and response to surgical resection and radiation. Spine J 2015; 15:e49-56. [PMID: 26165479 DOI: 10.1016/j.spinee.2015.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/03/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Epithelioid hemangioendothelioma rarely occurs in the lumbosacral spine, with very few case reports of spinal hemangioendothelioma in the literature. There is variability in aggressiveness of these lesions without established treatment guidelines. PURPOSE The aim was to present a case of epithelioid hemangioendothelioma in the lumbar spine, including magnetic resonance imaging (MRI) findings, which rapidly progressed over a 2-month period as regional multifocal lumbosacral spinal lesions with epidural extension causing severe spinal canal stenosis. STUDY DESIGN/SETTING This was a case report in a university hospital setting. PATIENT SAMPLE The sample included an otherwise healthy adult male with low back pain. METHODS Multimodality imaging was performed to help with diagnosis and management including computed tomography, MRI, and positron emission tomography (PET). The patient was treated by embolization, L5 corpectomy and L4-S1 stabilization, and radiation therapy. The diagnosis was confirmed by tissue biopsy. RESULTS The patient initially presented with severe back and leg pain after a vertebroplasty for an L5 compression fracture at an outside hospital where biopsy was negative for malignancy. Magnetic resonance imaging showed diffuse abnormality of L5 with several smaller lesions in the sacrum. Due to progressive pain 2 weeks after the vertebroplasty, the patient underwent an L5 laminectomy, L4-S1 instrumented posterior fusion, and attempted partial corpectomy for stenosis. At this surgery, the L5 corpectomy was aborted owing to profound bleeding. Pathology was again negative for malignancy. Presumed to be an atypical hemangioma, the lesion was embolized before repeat surgery where the thecal sac was decompressed by partial L5 corpectomy. Biopsy at this time revealed a vascular neoplasm, with hemangioendothelioma not excluded. Approximately 2 months after the stabilization procedure, the patient had increasing pain and bilateral lower extremity weakness. Magnetic resonance imaging was performed and demonstrated marked local progression of disease with new multifocal lesions involving L4 through S2 vertebrae and new severe spinal canal stenosis. These lesions were subsequently treated with localized radiation therapy. Magnetic resonance imaging 2 months after radiation therapy showed significant regression of the epidural tumor although a new metastatic lesion was discovered at T6 vertebra. CONCLUSIONS Spinal hemangioendothelioma is a rare disease and can present in variable forms, including as a multifocal regional process--which may be mistaken for infection. Additionally, there are no standard treatment protocols for this entity. We present the extensive imaging and treatment of a single case of rapidly progressive lumbar epithelioid hemangioendothelioma, which to our knowledge has not been described with this multifocal appearance in the lumbar spine.
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Affiliation(s)
- Linda C Kelahan
- Department of Radiology, Medstar Georgetown University Hospital, 3800 Reservoir Rd NW, CG201, Washington, DC 20007, USA.
| | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd NW, 7PHC, Washington, DC 20007, USA
| | - Anousheh Sayah
- Department of Radiology, Medstar Georgetown University Hospital, 3800 Reservoir Rd NW, CG201, Washington, DC 20007, USA
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Ciliberti MP, Caponio R, Pascali A, Matichecchia G, Lioce M. A rare case of intravascular epithelioid hemangioendothelioma of the cephalic vein treated with surgery and postoperative radiation therapy: a case report and review of the literature. J Med Case Rep 2015; 9:91. [PMID: 25924932 PMCID: PMC4437253 DOI: 10.1186/s13256-015-0565-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 03/04/2015] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Epithelioid hemangioendothelioma (EHE) is a rare endothelial tumor with an intermediate grade of malignancy. Few cases of primary vascular hemangioendothelioma have been described in the literature. Surgery is the treatment of choice, but radiation therapy and chemotherapy should also be considered in particular cases. CASE PRESENTATION We present the case of a 44-year-old Caucasian woman affected by EHE of the cephalic vein, treated by complete surgical removal of the mass and postoperative local radiation therapy. At 5-year follow-up, our patient is alive, with no signs of local or distant relapse and with no late radiation-related effects. CONCLUSIONS Postoperative radiotherapy may play a role in cases in which tumor margins are close or cannot be assessed or when high-risk features are present.
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Affiliation(s)
- Maria Paola Ciliberti
- U.O. Radioterapia - National Cancer Research Centre - Istituto Tumori "Giovanni Paolo II", viale Orazio Flacco, 65-70124, Bari, Italy.
| | - Raffaella Caponio
- U.O. Radioterapia - National Cancer Research Centre - Istituto Tumori "Giovanni Paolo II", viale Orazio Flacco, 65-70124, Bari, Italy.
| | - Antonio Pascali
- U.O. Radioterapia - National Cancer Research Centre - Istituto Tumori "Giovanni Paolo II", viale Orazio Flacco, 65-70124, Bari, Italy.
| | - Gabriele Matichecchia
- U.O. Radioterapia - National Cancer Research Centre - Istituto Tumori "Giovanni Paolo II", viale Orazio Flacco, 65-70124, Bari, Italy.
| | - Marco Lioce
- U.O. Radioterapia - National Cancer Research Centre - Istituto Tumori "Giovanni Paolo II", viale Orazio Flacco, 65-70124, Bari, Italy.
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Epithelioid hemangioendothelioma of the spine: results at seven years of average follow-up in a series of 10 cases surgically treated and a review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24:2156-64. [PMID: 25118684 DOI: 10.1007/s00586-014-3510-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/03/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To review a series of ten cases with epithelioid hemangioendothelioma of the spine, that have undergone surgery to describe clinical presentation, results and complications associated with surgical treatment; a review of literature reporting the main characteristics of the cases already published has been reported. METHODS A review of patients affected by epithelioid hemangioendothelioma surgically treated by the senior author from 1995 to 2012 was carried out. Ten cases were identified and clinical and radiological characteristics, therapy, complications and survival were valued. RESULTS Wide margin was achieved in two out of ten cases, marginal margin in seven and intralesional margin in one case. Average intraoperative blood loss was about 2,800 ml. Reported complications were one case of cord injury, one of dural tear, two cases of massive blood loss, a case of reconstruction failure, a wound dehiscence with deep infection, a pneumonia episode and a deep vein thrombosis with pulmonary embolism. Average follow-up was 84.4 months. Two local recurrences, after 32 and 37 months and two deaths for metastasis, after 14 and 36 months, were reported. Although several chemotherapy protocols are available for the treatment of EH of soft tissue, they are not relevant for the bone. CONCLUSIONS Wide surgery is probably associated with a better prognosis. Indeed most deaths and local recurrences reported in literature happened after intralesional surgery or chemotherapy/RT alone. The presenting study suggests that the best approach to achieve long-term local control and a major survival could be wide surgery, nevertheless more cases series are necessary to verify survival rate.
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Guy JB, Trone JC, Chargari C, Falk AT, Khodri M, Magné N. Epithelioid hemangioendothelioma of the spine treated with RapidArc volumetric-modulated radiotherapy. Med Dosim 2014; 39:242-5. [PMID: 24833300 DOI: 10.1016/j.meddos.2014.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/24/2014] [Accepted: 03/19/2014] [Indexed: 02/04/2023]
Abstract
Radiotherapy for epithelioid hemangioendothelioma (EHE) using volumetric intensity-modulated arc radiotherapy (VMAT). A 48-year-old woman was referred for curative irradiation of a vertebral EHE after failure of surgery. A comparison between VMAT and conventional conformal tridimensional (3D) dosimetry was performed and potential advantage of VMAT for sparing critical organs from irradiation's side effects was discussed. The total delivered dose on the planning target volume was 54 Gy in 27 fractions. The patient was finally treated with VMAT. The tolerance was excellent. There was no acute toxicity, including no increase in pain. With a follow-up of 18 months, no delayed toxicity was reported. The clinical response consisted of a decrease in the dorsal pain. The Dmax for the spinal cord was reduced from 55 Gy (3D-radiotherapy [RT]) (which would be an unacceptable dose to the spine because of the risk of myelopathy) to 42.8 Gy (VMAT), which remains below the recommended dose threshold (45 Gy). The dose delivered to 20% of organ volume (D20) was reduced from 47 Gy (3D-RT) to 3 Gy (VMAT) for the spinal cord. The study shows that VMAT allows the delivery of curative treatment for vertebral EHEs because of critical organ sparing.
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Affiliation(s)
- Jean-Baptiste Guy
- Department of Radiotherapy, Institut de Cancérologie de la Loire, St Priest en Jarez, France
| | - Jane-Chloé Trone
- Department of Radiotherapy, Institut de Cancérologie de la Loire, St Priest en Jarez, France
| | - Cyrus Chargari
- Department of Radiation Oncology, HIA du Val de Grâce, Paris, France
| | | | - Mustapha Khodri
- Department of Physics, Institut de Cancérologie de la Loire, St Priest en Jarez, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie de la Loire, St Priest en Jarez, France.
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Ma J, Wang L, Mo W, Yang X, Xiao J. Epithelioid hemangioendotheliomas of the spine: clinical characters with middle and long-term follow-up under surgical treatments. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:1371-6. [PMID: 21512841 DOI: 10.1007/s00586-011-1798-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 03/03/2011] [Accepted: 04/08/2011] [Indexed: 01/04/2023]
Abstract
Epithelioid hemangioendothelioma, an aggressive vascular tumor has the rarity of morbidity that arises in the spine. There were few cases reported in literatures in recent years, and little was known about this disease. A review study of the patient files in our constitutions between 1996 and 2006 showed that five patients were treated for spinal epithelioid hemangioendothelioma. Although only five patients, this study attempts to bring more informations about this rare lesion. This patient group included two males and three females. The lesions located in the cervical (case 1) or thoracic (case 2-4) or lumbar spine (case 5). Treatments included: laminectomy and cytoreductive surgery followed by external beam irradiation (one patient), expanded resection in piece meal with postoperative external beam irradiation (three patients), and total en bloc resection alone (one patient). Reconstruction of the spinal stability was performed in four patients. Follow-up period ranged from 25 to 72 months, averaged 47.4 months. The neurologic function of patients got a satisfactory progress except the paraplegic patient at diagnosis. The patient who received laminectomy and cytoreductive surgery followed by external beam irradiation still presented with tumor local progress, metastasis, and she died at 34 months after operation. No local recurrence or distant metastasis was detected in the other four patients. Epithelioid hemangioendothelioma of the spine is so rare in clinic as a primary aggressive vascular tumor. Based on our experience, a valid expanded resection of the tumor with adjunct radiation therapy or total en bloc excision may present with acceptable results.
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Affiliation(s)
- Junming Ma
- Department of Orthopaedics, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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