The Role of Radiotherapy and Surgery in the Management of Aggressive Vertebral Hemangioma: A Retrospective Study of 20 Patients

Electrochemotherapy in Aggressive Hemangioma of the Spine: A Case Series and Narrative Literature Review

(1) Background: this case series and literature review aims to evaluate the efficacy and safety of electrochemotherapy in the management of aggressive spinal hemangiomas, presenting two distinct cases. (2) Methods: we present two cases of spinal aggressive hemangioma which were refractory to conventional treatments and underwent electrochemotherapy. Case 1 involves a 50-year-old female who presented with an aggressive spinal hemangioma of L1, who previously underwent various treatments including surgery, radio-chemotherapy, and arterial embolization. Case 2 describes a 16-year-old female with a T12 vertebral hemangioma, previously treated with surgery and stabilization, who faced limitations in treatment options due to her young age and the location of the hemangioma. (3) Results: in Case 1, electrochemotherapy with bleomycin was administered following the failure of previous treatments and resulted in the reduction of the lesion size and improvement in clinical symptoms. In Case 2, electrochemotherapy was chosen due to the risks associated with other treatments and was completed without any adverse events. Both cases demonstrated the potential of electrochemotherapy as a viable treatment option for spinal hemangiomas, especially in complex or recurrent cases. (4) Conclusions: electrochemotherapy with bleomycin is a promising treatment for aggressive spinal hemangiomas when conventional therapies are not feasible or have failed. Further research is needed to establish definitive protocols and long-term outcomes of electrochemotherapy in spinal hemangioma management.

Surgical Options for Aggressive Vertebral Hemangiomas：A case series, literature review and treatment recommendations

Purpose

We retrospectively study twenty-nine surgical cases of aggressive vertebral hemangiomas (AVHs) with neurological deficits and extradural compression to determine the optimal surgical treatment strategy for AVHs at a single institution.

Methods

Patients with AVHs with neurological deficits who underwent partial tumor resection plus decompression with or without vertebroplasty (VP), and radiotherapy between 2010 and 2021 were included in this study. Clinical characteristics, surgical outcomes, and follow-up data of the patients were reviewed retrospectively.

Results

Twenty-nine AVH cases with neurological deficits and spinal instability were included in this study and treated surgically. The mean operation time of patients with decompression surgery plus VP (Groupe A) was 215.9 (120-265 min), shorter than that of decompression surgery without VP (Group B) 240.2 (120-320 min). Intraoperative blood loss was 273.3 (100-550 mL) in group A and 635.3 (200-1600 mL) in group B. In addition, a significant reduction in blood loss was observed in group A compared to the group B (p=0.0001). All patients experienced immediate pain relief and improvement in their neurological symptoms. Neurological function was assessed by the Frankel score, ASIA score, and the visual analogue scale (VAS) pain score decreased from 7.4 (4-9) to 1.3 (0-3). Of twenty-nine patients in this study,  only 7% (2/29 patients) showed signs of recurrence.

Conclusion

Decompression plus VP achieve good tumor control and decrease surgical complication. Preoperative vascular embolization and VP can reduce intraoperative bleeding in the treatment of AVH surgery. Moreover, postoperative radiotherapy seems to be a good technique to prevent tumor recurrence.

Surgical management of symptomatic vertebral hemangiomas: a single institution experience and literature review

Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans. In this review article, a single institution's experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.

A less aggressive approach to the treatment of aggressive vertebral hemangioma of the thoracic spine: A case report and literature review

BACKGROUND

Different treatments are available for aggressive vertebral hemangioma [AVH], but a consensus is yet to be reached about the best therapeutic approach.

PURPOSE

To explore the possibility that selecting a less aggressive therapeutic approach for AVH decreases the intraoperative and postoperative complications while providing similar clinical, radiographic, and disease-free survival results to more aggressive therapeutic methods.

STUDY

We report the case of an AVH of the thoracic spine at the T5 level, treated via perioperative selective arterial embolization plus surgical decompression via laminectomy and reconstruction with polymethylmethacrylate (PMMA) vertebroplasty.

PATIENT

The patient was a 17-year-old male referred to our center with the chief complaint of low back pain from two months earlier, without any response to analgesics, and with neurologic manifestations as paraparesis (one month) and progressive sphincter problems (one week). Upon imaging, the impression was an aggressive spinal tumor with cord compression.

OUTCOME MEASURES

After the operation, the patient's pain immediately improved, and his neurologic manifestations progressively improved.

RESULTS

The patient started walking with help about three weeks after the operation. Roughly six months later, he achieved a complete neurological recovery. At present, about two years following the operation, he has a normal life without any neurological problems.

CONCLUSION

Based on our experience with AVH, the selection of less aggressive therapeutic approaches such as perioperative diagnostic angiography and selective embolization decrease the intraoperative and postoperative complications like intraoperative bleeding and neurological injury, while achieving similar clinical, radiographic, and disease-free survival outcomes to more aggressive therapeutic methods.

Vertebral hemangioma - the current radiation therapy perspective

Vertebral hemangiomas are benign tumors of the spine, most often detected incidentally and on other instances, when signs and symptoms of the disease arise. About 10% of the population are affected worldwide with a female to male ratio of 2:1. The majority of these cases are asymptomatic and no intervention is generally required. Less often, back pain and neurological deficit may occur. Such hemangiomas are termed aggressive by the Enneking staging and warrant treatment. In this review, staging and diagnostics are discussed in detail followed by treatment options. Treatment options entail Surgical intervention, Percutaneous ethanol injection, radiofrequency ablation and Radiation Therapy. There are no set guidelines on preference or order of the treatment options. Further, in this review, studies favouring Radiation therapy regimes and their outcomes are elaborated.

Atypical aggressive vertebral hemangioma of the sacrum with postoperative recurrence: A case report

BACKGROUND

Aggressive vertebral hemangioma (VH) is an uncommon lesion in the adult population. The vast majority of aggressive VHs have typical radiographic features. However, preoperative diagnosis of atypical aggressive VH may be difficult. Aggressive VHs are likely to recur even with en bloc resection.

CASE SUMMARY

A 52-year-old woman presented with a 3-mo history of numbness and pain in her right lower extremity. Physical examination showed sacral tenderness and limited mobility, and the muscle strength was grade 4 in the right digital flexor. Computed tomography revealed osteolytic bone destruction from S1 to S2. Magnetic resonance imaging (MRI) showed that the mass was compressing the dural sac; it was heterogeneously hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI, and gadolinium contrast enhancement showed that the tumor was heterogeneously enhanced and invading the vertebral endplate of S1. The patient developed progressive back pain and numbness in the bilateral extremities 6 mo postoperatively, and MRI examination showed recurrence of the mass. The mass was larger in size than before the operation, and it was extending into the spinal canal.

CONCLUSION

The radiographic findings of atypical aggressive VH include osteolytic vertebral bone destruction, extension of the mass into the spinal canal, and heterogeneous signal intensity on T1-, T2-, and enhanced T1-weighted MRI. These characteristics make preoperative diagnosis difficult, and biopsy is necessary to verify the lesion. Surgical decompression and gross total resection are recommended for treatment of aggressive VH. However, recurrence is inevitable in some cases.

Piecemeal resection of aggressive vertebral hemangioma using real-time navigation-guided drilling technique

Vertebral hemangiomas are the most common benign vertebral tumors and are usually asymptomatic. Aggressive subtypes of the tumor, called aggressive VHs (AVHs), can become symptomatic with extraosseous extensions and require surgical removal. We present a case of AVH in a 36-year-old man presenting with low back pain and right leg pain that persisted for three months. Imaging studies showed a Th12 vertebral tumor that extended into the spinal canal and was squeezing the spinal cord. Computed tomography (CT)-guided biopsy indicated vertebral hemangimoa. Following preoperative arterial embolization, piecemeal gross total resection was attained under navigation guidance. He was left with no neurological deficit and remained well at the 12-month postoperative folow-up. Since AVHs are benign tumor, piecemeal removal of the tumor can be selected. However, disadvantage of the approach include difficulty of making decision how much to remove the front part of the vertebral body close to thoracic descending aorta. Furthermore, when the tumor tissue is too hard to curett, manipulation in tight spaces near the spinal cord carries the risk of damaging it. Navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor especially in the anterior cortical surface of the vertebral body and easily resection even hard tumors. This method results in reducing residual tumor and maintaining safety resection.

Long-term outcomes of pediatric and young adult patients receiving radiotherapy for nonmalignant vascular anomalies

BACKGROUND

Nonmalignant vascular anomalies (VA) comprise a heterogeneous spectrum of conditions characterized by aberrant growth or development of blood and/or lymphatic vessels and can cause significant morbidity. Little is known about outcomes after radiotherapy in pediatric and young adult patients with nonmalignant VA.

METHODS

Thirty patients who were diagnosed with nonmalignant VA and treated with radiotherapy prior to 2017 and before the age of 30 were identified. Clinical and treatment characteristics and outcomes were recorded.

RESULTS

Median age at first radiotherapy was 15 years (range 0.02-27). Median follow-up from completion of first radiotherapy was 9.8 years (range 0.02-67.4). Lymphatic malformations (33%), kaposiform hemangioendothelioma (17%), and venous malformations (17%) were the most common diagnoses. The most common indication for first radiotherapy was progression despite standard therapy and/or urgent palliation for symptoms (57%). After first radiotherapy, 14 patients (47%) had a complete response or partial response, defined as decrease in size of treated lesion or symptomatic improvement. After first radiotherapy, 27 (90%) required additional treatment for progression or recurrence. Long-term complications included telangiectasias, fibrosis, xerophthalmia, radiation pneumonitis, ovarian failure, and central hypothyroidism. No patient developed secondary malignancies. At last follow-up, three patients (10%) were without evidence of disease, 26 (87%) with disease, and one died of complications (3.3%).

CONCLUSIONS

A small group of pediatric and young adult patients with nonmalignant, high-risk VA experienced clinical benefit from radiotherapy with expected toxicity; however, most experienced progression. Prospective studies are needed to characterize indications for radiotherapy in VA refractory to medical therapy, including targeted inhibitors.

Aggressive vertebral hemangioma masquerading as neurological disease in a pediatric patient

Aggressive hemangioma is a rare vertebral lesion in pediatric patients which can present with deteriorating neurological function. It can mimic malignancy on imaging, particularly as it regularly has an extrasosseous soft tissue component. We present a case of a 13-year-old male who presented with a three month history of lower extremity weakness that was found to have an infiltrative mass at T10 with associated cord compression from epidural extension of the lesion. In this report we review the characteristic imaging findings associated with aggressive hemangioma, including its appearance on read-out segmented diffusion-weighted images. It is imperative that radiologists who interpret studies of children be aware that this lesion exists and what it looks like, as it can be associated with massive hemorrhage if encountered unexpectedly during surgery.

Hemangioma of the Lumbar Spine Involving the Spinous Process: A Rare Case Report and Review of the Literature

Hemangiomas of the spine are usually benign and asymptomatic. They can cause devastating complications such as pathological fractures of the spine and neurological disability. This report documents an atypical location of a hemangioma in a lumbar spinous process, in combination with a spondylolisthesis at the same level, which makes it even more uncommon. Surgery can be effective and safe and can significantly improve patient outcomes. Moreover, prior embolization can prevent acute hemorrhage in addition to providing careful diagnosis and evaluation.

Pronator Quadratus Hemangioma (PQH): A Rare Case Report and Review

The intramuscular hemangioma is a rare clinical entity in the upper extremity. Pronator quadratus hemangioma poses a considerable morbidity in the functional quality of life of an individual. MRI remains the gold standard modality in diagnosing this rare entity. Additionally, histopathological examination of the lesion corroborates for the same. PQH follows an individualized protocol in the management of the tumour. A 35-year-old female presented with pain over her right wrist from past 1 year which was dull aching, non-radiating, localised to the palmar aspect of distal 1/3rd of the right forearm. There was no history of trauma or infection over the right wrist. Swelling was present over the palmar aspect of distal 1/3rd of right forearm, which was non-pulsatile, non-fluctuant, non-transilluminant, non-compressible, non-reducible and skin over the swelling was pinchable. The movements of the right wrist were painful and restricted. There was no distal neurovascular deficit. The MRI of her right wrist and hand suggested the presence of low flow vascular malformation within pronator quadratus muscle. The patient underwent excision biopsy of pronator quadratus in toto without any neurological complications. No recurrence was noted in the follow-up period for 12 months. The pronator quadratus hemangioma is a rare clinical entity where the natural course of disease and pathophysiology remains controversial. MRI serves as the gold standard in the diagnosis of intramuscular hemangioma. The management of such tumour has to be individualized based on the functional needs of the patient. The natural course of the disease has to be elicited to decrease the morbidity and enhance the functional quality of life of the patient.

French Multidisciplinary Approach for the Treatment of MSK Tumors

Several interventional treatments have recently been integrated into the therapeutic armamentarium available for the treatment of bone tumors. In some scenarios (e.g., osteoid osteoma), interventional treatments represent the sole and definitive applied treatment. Due to the absence of widely shared protocols and the complex multivariate scenarios underlying the clinical presentation of the remaining bone tumors including metastases, therapeutic strategies derived from a multidisciplinary tumor board are essential to provide effective treatments tailored to each patient. In the present review, we present the multidisciplinary therapeutic strategies commonly adopted for the most frequent bone tumors.

Long-Term Outcomes of Excision Surgery for Aggressive Vertebral Hemangiomas

OBJECTIVE

We describe the clinical outcomes in patients with aggressive vertebral hemangiomas (AVHs) after total tumor excision and discuss the treatment options for AVHs.

METHODS

A retrospective data review of 15 patients (6 men, 9 women) with AVHs who underwent total excision between 1996 and 2018 was performed.

RESULTS

In total, 13 thoracic and 2 lumbar lesions were involved with 8 type A-D tumors and 7 type B-D tumors based on the Weinstein-Boriani-Biagini classification. All tumors showed low or low-iso signal intensity by T1-weighted magnetic resonance imaging. All patients received a combination of preoperative transarterial embolization and total tumor excision including the tumor margins. Eleven patients underwent total tumor excision as the initial surgery (total en bloc spondylectomy = 10 patients, piecemeal total tumor excision = 1 patient), and 4 underwent it as either a revision procedure 2 weeks after ineffective laminectomy or in the long-term follow-up (4-14 years) as a piecemeal total tumor excision. Intraoperative blood loss ranged from 150 to 3400 mL (mean, 1314 mL). None of the cases had a recurrence during the mean follow-up period of 128.4 ± 88.6 months.

CONCLUSIONS

Low signal intensity on T1-weighted magnetic resonance imaging was observed in all the patients with AVHs. The long-term clinical results of the preoperative transarterial embolization and total tumor excision were satisfactory. The effect of decompressive incomplete tumor excision is temporary for AVHs, and repeated tumor excision may be necessary because of tumor recurrence in the long term. Reliable total tumor excision during the initial surgery is desirable.

Prognostic Determinants Analysis and Nomogram for Bone Malignant Vascular Tumors: A Surveillance, Epidemiology and End Results (SEER) Analysis

Background

The aim and objective of our investigations were to explore the prognostic value of various clinical and pathological factors of bone malignant vascular tumors and establish a nomogram for their outcome predictions.

Material/Methods

All data of primary bone malignant vascular tumors (MVTs) patients were randomly selected from the Surveillance, Epidemiology and End Results (SEER) database. However, selected patients were clinically diagnosed with various cancers during 1988–2015. The potential prognostic factors were analyzed using SPSS (Windows, version 22.0). All prognostic factors were combined to formulate a nomogram to predict the overall survival (OS).

Results

A total of 266 selected patients were included in our study. In the univariate model, age (P<0.001), sex (p=0.0255), primary site (P<0.001), surgery (P<0.001), histologic type (P<0.001), metastasis (p=0.000), and pathological grade (P<0.001) were statistically significant for patient survival. The results of Cox analysis revealed that age (≥64) HR: 3.636, 95% CI [1.955–6.762], p=0.000, the primary site in skull HR: 2.6, 95% CI [1.584–4.268], p<0.001], without surgery HR: 1.473 95% CI [1.239–1.751], p<0.001, metastasis HR: 3.076 95% CI [1.983–4.771] p=0.000, man HR 1.802, 95% CI [1.032–3.004], p=0.045, and high malignant grade HR: 3.029, 95% CI [2.101–4.366], p=0.003 were independent unfavorable prognostic factors. Angiosarcoma had highest mortality rate among all vascular malignancies. The nomogram predicting overall survival achieved a C-index of 0.694 (95% CI 0.631, 0.745) in the SEER cohort.

Conclusions

Surgery can significantly increase OS survival time for bone MVTs, and low-grade malignancy is a significant factor for OS. However, advanced age, tumor metastasis, primary site in skull, AS, and male sex are predictors of poor prognosis.

Intraoperative injection of absorbable gelatin sponge (AGS) mixed with cement followed by spinal decompression to treat elderly with vertebral hemangiomas

Background

Elderly patients with vertebral hemangiomas are rare and might require surgery. Thus, the choice of surgery for these lesions remains controversial because of the rarity of these lesions. This study aimed to analyze the clinical efficacy of the intraoperative injection of absorbable gelatin sponge mixed with cement followed by spinal decompression to treat the elderly with typical vertebral hemangiomas. The risk factors for hemangioma recurrence were investigated through a literature review.

Methods

We retrospectively analyzed 13 patients with typical aggressive hemangiomas between January 2009 and January 2016. Of these patients, 7 were treated with spinal decompression combined with intraoperative vertebroplasty (Group A), and 6 patients were treated with decompression with intraoperative vertebroplasty and absorbable gelatin sponge (Group B). The general data and perioperative data of the patients were compared. Patients were followed up for at least 3 years, and postoperative complications and recurrence rates were recorded and compared.

Results

All patients had typical aggressive hemangiomas. The average age of all patients was 64.4 ± 3.3 years. The preoperative data did not differ significantly between the two groups (P > 0.05). The blood loss of groups A and B was 707.1 ± 109.7 ml and 416.7 ± 103.3 ml, respectively (P = 0.003) (P = 0.003), and the average surgery durations were 222 ± 47.8 min and 162 ± 30.2 min, respectively (P = 0.022). The average follow-up duration was 62 ± 19 months, and no cases of recurrence were found at the final follow-up assessment.

Conclusions

Multimodal treatment significantly alleviated the clinical symptoms of elderly patients with typical aggressive vertebral hemangiomas. Intraoperative absorbable gelatin sponge injection is a safe and effective way to reduce blood loss and surgery duration.

Vertebral hemangiomas: Diagnosis and management. A single center experience

OBJECTIVE

Vertebral hemangiomas (VH) are common benign lesions involving the spine. Owing to the multiplicity of treatments, the management of VH has not always been consistent. In this retrospective review of a single center experience, indications and options available for the treatment of VH are outlined.

PATIENTS AND METHODS

This is a retrospective review of 71 cases of VH managed at our institution between 2005 and 2019. Sixty of these cases were managed non-operatively, with 11 cases undergoing operative intervention. Of the 11 cases that underwent surgery, there were 2 cervical cases and 9 in the thoracic spine. Ten cases were symptomatic, and 1 incidental. Three patients presented with localized pain, and the remaining 7 had neurological deficit. Decompression with maximal resection of the hemangioma was undertaken in 10 cases, and vertebroplasty in 1.

RESULTS

Of the 60 patients who were managed non-operatively, 13 patients had presented with back/neck pain, with the remaining 47 patients being asymptomatic and diagnosed incidentally. Among the 13 symptomatic patients, all were offered surgical intervention for pain management, but given lack of severity of symptoms, all had opted for conservative approaches of pain control. In the 11 patients who underwent surgery, the preoperative diagnosis of VH was accurate in all but 1 case. There were 2 cervical cases treated with corpectomy. One patient was treated with vertebroplasty, and the remaining 8 with decompression. Radiation was used in 2 cases. Of the 10 patients undergoing decompression, 7 patients had improvement of the neurologic deficit, with resolution of pain in the remaining 3. None of our cases demonstrated deterioration.

CONCLUSION

VH are often discovered incidentally during evaluation of spinal pain. Except in rare cases, the diagnosis of VH is made correctly from the radiographic and MRI studies. Observation for the asymptomatic lesion is appropriate. For VH presenting with deficit or intractable pain, decompressive surgery is recommended. Radiation is appropriate in cases of recurrent VH.

Treatment of Typical Enneking Stage 3 Thoracic Aggressive Vertebral Hemangiomas with Pain and Neurologic Deficits: Results After at Least 36 Months of Follow-Up

OBJECTIVE

To evaluate the efficiency of a comprehensive treatment strategy for patients with Enneking stage 3 thoracic aggressive vertebral hemangioma (AVH).

METHODS

A retrospective analysis of radiographic and clinical outcomes was performed for 17 patients who received treatment for Enneking stage 3 thoracic AVH accompanied by pain and neurologic deficits between January 2010 and February 2015. A visual analog scale (VAS) was used to clinically evaluate the level of pain. Neurologic examinations were performed to assess the patients' sensory symptoms, motor deficits, and Frankel grade.

RESULTS

The average operative time was 181.8 ± 37.1 minutes, and the average intraoperative blood loss was 1226.5 ± 151.2 mL (range, 900-1450 mL). All patients underwent preoperative embolization to minimize intraoperative blood loss. All patients experienced immediate pain relief and resolution of their neurologic symptoms. All 17 patients achieved Frankel grade D at the final follow-up; moreover, they reported that their pain was relieved (mean VAS score, 2.82 ± 0.81; P < 0.05) and their neurologic deficits had resolved. No surgery-related complications were noted. No patients exhibited signs of recurrence.

CONCLUSIONS

We recommend a comprehensive treatment strategy for patients with Enneking stage 3 thoracic AVH that includes preoperative embolization, vertebroplasty, posterior decompression, and internal fixation. We recommend that absorbable gelatin sponge particles be used for intraoperative embolization prior to the injection of bone cement, which may significantly reduce intraoperative bleeding, operative time, and occurrence of surgery-related complications.

Atypical Radiographic Features of Aggressive Vertebral Hemangiomas

BACKGROUND

Vertebral hemangioma (VH) is one of the most common benign spinal tumors and can be aggressive in some cases. While most aggressive VHs have typical radiographic features, including vertical striations, a honeycomb appearance, and/or a "polka-dot sign" in computed tomography (CT) scans, cases with atypical features might complicate diagnosis. This study aimed to determine the range and frequency of these atypical features.

METHODS

In this retrospective study, to identify the typical and atypical features of aggressive VH, pretreatment CT and magnetic resonance imaging (MRI) were reviewed retrospectively by 1 radiologist and 1 orthopaedic surgeon. Percutaneous biopsies were performed to confirm the VH in atypical cases.

RESULTS

A total of 95 patients with aggressive VHs were treated in our hospital from January 2005 to December 2017. Thirty-four (36%) of the lesions showed at least 1 atypical radiographic feature: 16 patients (17%) had a vertebral compression fracture, 11 patients (12%) had expansive and/or osteolytic bone destruction without a honeycomb appearance and/or "polka-dot sign", 11 patients (12%) had obvious epidural osseous compression of the spinal cord, 12 patients (13%) had involvement of >1 segment, 9 patients (10%) had a VH centered in the pedicle and/or lamina, and 8 patients (8%) had atypical MRI signals. Forty-three patients underwent percutaneous biopsies, which had an accuracy of 86%.

CONCLUSIONS

Based on radiographic analysis, aggressive VH can be classified as typical or atypical. More than one-third of aggressive VH lesions may have at least 1 atypical feature. CT-guided biopsies are indicated for these atypical cases.