Minimally invasive treatment of a painful osteolytic lumbar lesion secondary to epithelioid hemangioendothelioma

Neurosurgical Management of Spinal Epithelioid Hemangioendothelioma: Systematic Review and Illustrative Case Presentation

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.

Benign Bone Tumors Beyond Osteoid Osteoma: Percutaneous Minimally Invasive Image-Guided Interventions

Painful benign bone tumors often adversely influence quality of life primarily due to skeletal-related events such as unremittable pain, pathologic fracture, neurologic deficit, as well as skeletal growth disturbance. Substantial advances in percutaneous minimally invasive interventions for treatment of painful benign bone tumors beyond osteoid osteoma have been established as safe, efficacious, and durable treatments to achieve definitive cure. This article details the available armamentarium and most recent advances in minimally invasive percutaneous interventions and the role of radiologists for the management of patients with benign bone tumors beyond osteoid osteoma.

Benign Bone Tumors: State of the Art in Minimally Invasive Percutaneous Interventions

Painful benign bone tumors most commonly affect pediatric patients and young adults. They may be associated with skeletal-related events such as intractable pain, pathologic fracture, neurologic deficit as a consequence of nerve or spinal cord compression, as well as growth disturbance. Consequently, they often result in diminished activity and adversely affect quality of life. There have been substantial recent advances in percutaneous minimally invasive image-guided interventions for treatment of painful benign bone tumors including thermal ablation (radiofrequency ablation, cryoablation, microwave ablation, laser photocoagulation, and high-intensity focused US ablation), chemical (alcohol) ablation, cementoplasty, and intralesional injections. The safety, efficacy, and durability of such interventions have been established in the recent literature and as such, the role of musculoskeletal interventional radiologists in the care of patients with benign bone lesions has substantially expanded. The treatment goal of minimally invasive musculoskeletal interventions in patients with benign bone tumors is to achieve definitive cure. The authors detail the most recent advances and available armamentarium in minimally invasive image-guided percutaneous interventions with curative intent for the management of benign bone tumors. ^© RSNA, 2022.

The heterogeneity of Epithelioid Hemangioendothelioma (EHE): A case series and review of the literature with emphasis on treatment options

Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular sarcoma with a very heterogeneous presentation and prognosis. We here present five cases of EHE emphasizing diversity in presentation, treatment, and prognosis. Furthermore, we present a review of the literature on EHE treatment options.

Epithelioid hemangioendothelioma of spine: A case report with review of literatures

Primary epithelioid hemangioendothelioma of the spine is the extremely rare malignant vascular neoplasm with an unpredictable outcome. A case of epithelioid hemangioendothelioma with multiple lytic lesions of thoracolumbar spine and other bones in a 29-year-old male patient is reported. A review of the published data regarding this rare neoplasm is also presented. The features of epithelioid hemangioendothelioma include the occurrence in the young male patient, multiple osteolytic lesions with thin sclerotic rim and hypermetabolic activities. However, its imaging features are not specific. Positron emission tomography/computed tomography is essential for identification of the lesions and subsequent follow-up for treatment.

Bisphosphonates as a therapeutic choice for multifocal epithelioid hemangioma of bone: A case report

RATIONALE

Epithelioid hemangioma (EH) of bone is an intermediate vascular tumor that can be locally aggressive. The optimum management of multifocal EH of bone is not well delineated. We described our experience treating one patient with multifocal EH of bone in an effort to document the effect of bisphosphonates in bone EH.

PATIENT CONCERNS

In this report, a 53-year old male patient presented with back pain which was initially been diagnosed of multiple bone metastatic carcinoma by 18F-FDG PET/CT scan and bone scintigraphy.

DIAGNOSIS

CT-guided bone biopsy of ilium indicated that puncture tissue had irregular hyperplasia of thick and thin-walled blood vessels, immunohistochemistry revealed positive staining for CD31 and CD34, negative for CAMTA-1, PCK and EMA, which confirmed the diagnosis of multiple EH.

INTERVENTIONS

The patient was treated with 4 times of intravenous Zometa (zoledronate, 4 mg each time) with average three-month interval. Bone metabolic markers including serum bone specific alkaline phosphatase (BALP) and type I collagen cross-linked C-terminal telopeptide (CTX) levels were closely monitored before and after use of bisphosphonates each time.

OUTCOME

BALP and CTX were significantly lowered following intravenous Zometa and the back pain improved with integrated therapy including bone graft fusion internal fixation surgery and vertebroplasty.

CONCLUSIONS

EH of multiple bones responded favorably to intravenous Zometa with improvement of bone metabolic markers. After 1 year on follow-up, the patient was doing well with no significant pain. We suggest that bisphosphonates should be considered in the treatment of multifocal osteolytic EH of bone.

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

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.

Reconstruction of a Thoracic Spine Epithelioid Hemangioendothelioma with Antibiotic Impregnated Poly-methyl Methacrylate: A Case Report

A 58-year-old female presented to the hospital with respiratory distress several days after a right hallux amputation. A new lytic lesion within the fourth thoracic (T4) vertebral body and mediastinal lymphadenopathy was noted on chest computed tomography scan. A bone biopsy was performed, revealing bone and collagenous fragments only. Two months later, new imaging revealed approximately 60% lytic destruction of the T4 vertebral body with new right pedicle involvement. Surgical treatment was offered. Intraoperative frozen pathology indicated a hemangioma. An intralesional debulking and stabilization was performed. The right T4 nerve was sacrificed to gain access to the entire vertebral body. Curettage was then used to push the tumor away from the spinal canal into the vertebral body. The spine was reconstructed with 5-10mm beads of Simplex P bone cement (Stryker®, Kalamazoo, MI) which contained 40 grams of poly-methyl methacrylate and 1 gram of tobramycin. Five months after resection, the patient presented with computed tomography and magnetic resonance imaging findings of recurrent disease at T4 and spread to the adjacent T5 vertebral body with lytic changes. At 18 months following her second debulking surgery and radiation treatment, the patient was doing well with no pain or numbness. Long-term imaging compared to the patient’s preoperative imaging displayed improvement in spinal debulking with minimal residual enhancement of tumor despite significant artifact.

Mini-open Lateral En Bloc Corpectomy: Cadaveric Feasibility and Early Clinical Experience

BACKGROUND

Open approaches to the thoracolumbar spine for en bloc vertebral body tumor resection are associated with significant surgical morbidity. Less invasive surgical techniques may reduce complications.

OBJECTIVE

To present our experience with a staged posterior midline and mini-open anterolateral extracoelomic approach to en bloc corpectomy for vertebral body tumor resection in cadaver specimens and patients.

MATERIALS AND METHODS

The feasibility and safety of the staged posterior midline and mini-open anterolateral extracoelomic approach were evaluated in 3 cadaveric specimens. The procedure was performed at 3 levels (L1-L3) in each cadaver specimen (9 levels) and then in 1 clinical case. The cadaveric neurovascular structures were evaluated for tissue injury, whereas the operative experience, patient complications, and early surgical and clinical outcomes were reviewed.

RESULTS

The approach allowed for en bloc corpectomy without any injury to the cadaveric neurovascular structures. The procedure was reproducible in the clinical setting, which showed favorable clinical and radiographic patient outcomes.

CONCLUSIONS

Early clinical experience suggests the staged posterior midline and mini-open anterolateral extracoelomic approach is feasible and safe for en bloc tumor resection compared with open techniques with related morbidity. Long-term studies are needed to understand the strengths and limitations of this technique.

Percutaneous Image-Guided Cryoablation in Vascular Anomalies

Understanding and management of vascular anomalies has always been intriguing. These disorders exhibit an expected pattern of clinical presentation and progression, and characteristic imaging findings. Significant progress in understanding and treating patients with vascular anomalies has been made in the past quarter century. Newer multidisciplinary domains for treating these disorders with medical drugs and less invasive image-guided or surgical procedures are constantly evolving. Vascular anomalies can exhibit aggressive tumor-like behavior resulting in recurrence or persistent symptoms after treatment. Thermal ablation has been widely used in tumor treatment. This has generated interest on using thermal ablation for treating vascular anomalies. Percutaneous image-guided cryoablation is increasingly used for this purpose as compared with other ablation technologies. Availability of small caliber cryoprobes and the ability to monitor the freeze zone in real time have made this an attractive option to interventional radiologists. These experiences are relatively new and limited. It is helpful to understand the emerging role of this technology in the treatment of vascular anomalies.

Epithelioid hemangioendothelioma of the spine: case report and review of the literature

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.

Benign Spine Lesions: Advances in Techniques for Minimally Invasive Percutaneous Treatment

Minimally invasive percutaneous imaging-guided techniques have been shown to be safe and effective for the treatment of benign tumors of the spine. Techniques available include a variety of tumor ablation technologies, including radiofrequency ablation, cryoablation, microwave ablation, alcohol ablation, and laser photocoagulation. Vertebral augmentation may be performed after ablation as part of the same procedure for fracture stabilization or prevention. Typically, the treatment goal in benign spine lesions is definitive cure. Painful benign spine lesions commonly encountered in daily practice include osteoid osteoma, osteoblastoma, vertebral hemangioma, aneurysmal bone cyst, Paget disease, and subacute/chronic Schmorl node. This review discusses the most recent advancement and use of minimally invasive percutaneous therapeutic options for the management of benign spine lesions.