Atypical vertebral hemangioma

Case contributed by Leo Martinez

Presentation

Thoracic back pain started on the right side during the last year. Pain is worse with deep breaths, twisting, or pressure.

Patient Data

Age: 40 years
Gender: Female

Chest radiographs

x_ray

There is mild loss of height and diffuse sclerosis of the T7 vertebral body. The superior endplate cortex is not well visualized. There is mild T6-T7 intervertebral disc space narrowing, but the inferior endplate of T6 appears normal. The remainder of the vertebral bodies and discs are normal. 

CT chest

ct

There is sclerosis with loss of height at the T7 vertebral body. There are small subchondral plate radiolucencies in the superior endplate of the T5 vertebral body and superior/inferior endplates of the T7 vertebral body. There is a small typical hemangioma in the T8 vertebral body. Several additional sclerotic foci better characterized by MR.

MRI thoracic spine

mri

There are numerous lesions within the T5, T6, T7, and T11 vertebral bodies with heterogeneous enhancement, low T1 signals, and high T2 signals. There is the greatest involvement in the T7 vertebral body where there is mild loss of height of the superior endplate. The remaining vertebral body heights are preserved. Small lesions are also seen within the T9 vertebral body. 

CT PET imaging

Nuclear medicine

Sclerotic bone lesions appear similar to prior imaging and without increased radiotracer uptake.

CT-guided biopsy

ct

CT-guided core biopsy of T7 vertebral body.

Chest radiograph 1 year later

x_ray

Sclerosis and mild loss of height of the T7 vertebral body appear similar to prior examination. Radiolucency in the superior endplate of T5 is similar to prior examination.

Case Discussion

Work-up failed to reveal malignancy, and there was a negative blood work-up for myeloma.  Biopsy of the T7 vertebral body demonstrated bone with hypocellular marrow, scattered plasma cells, and reactive changes without evidence of myeloma, lymphoma, or carcinoma.  In situ hybridization for kappa and lambda light chains did not reveal clones. After an extensive work-up, a final diagnosis of atypical hemangioma of the T7 vertebral body was provided. A Follow-up chest radiograph was performed one year later and demonstrated the stability of the T7 and T5 vertebral body lesions. Given the challenge of distinguishing metastatic disease from atypical vertebral hemangiomas in radiologic studies, some authors have proposed the use of advanced MRI imaging (T1 weighted dynamic contrast-enhanced MRI, among others) to distinguish atypical hemangiomas from vertebral metastatic disease.

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