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      Giant vertebral hemangioma masquerading as aggressive tumor: Tc-99m tagged RBC scan can help to solve the diagnostic conundrum!

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          Abstract

          Hemangiomas are the most common benign lesions involving the spine. Metastasis is the most common malignant condition. The diagnosis of typical hemangiomas on conventional CT and MRI imaging is straightforward. However, when the hemangiomas are very large they may have atypical features making their diagnosis on these conventional imaging modalities inconclusive. In such cases nuclear medicine techniques such as Tc-99m RBC may aid in resolving the diagnostic conundrum. Awareness and use of proper diagnostic modality can prevent unnecessary biopsy. In this case report we try to highlight the added value of Tc-99m RBC scan to conventional imaging techniques in differentiating giant vertebral hemangioma from more aggressive malignant tumors.

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          Vertebral hemangiomas: fat content as a sign of aggressiveness.

          J Laredo, M Wybier, F Gelbert … (1990)
          Thirty-two vertebral hemangiomas (VHs) were evaluated with nonenhanced computed tomography (CT), T1-weighted magnetic resonance (MR) imaging, CT enhanced with contrast material, and selective spinal arteriography. The stroma between the osseous trabeculae was found to correspond to either fatty tissue or soft tissue or both. All 11 asymptomatic VHs showed complete fatty stroma at CT and increased signal intensity at MR imaging. In contrast, all four compressive VHs had soft-tissue attenuation at CT. Three compressive VHs showed low signal intensity on MR images. Predominantly fatty stroma at CT and increased signal intensity at MR imaging were associated with normal or only slightly increased vascularization at selective spinal arteriography or contrast-enhanced CT, while soft-tissue stroma at CT and low signal intensity at MR imaging were associated with distinct hypervascularization. The authors' experience suggests that fatty VHs may represent inactive forms of VH, while soft-tissue content at CT and low signal intensity at MR imaging may indicate a more active vascular lesion with potential to compress the spinal cord. CT and MR imaging may be especially valuable for evaluating patients with clinical signs or symptoms of uncertain origin and findings compatible with VH at plain radiography.
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            Vertebral hemangiomas: MR imaging.

            M T Modic, Andrew J. Ross, J. Carter … (1987)
            Vertebral hemangiomas, unlike most bone lesions, show increased signal on T1- and T2-weighted magnetic resonance (MR) images. To define the basis for these signal characteristics, a retrospective review was done of the MR imaging findings in ten vertebral hemangiomas (eight patients), and these were correlated with the findings from plain radiographic, computed tomographic (CT), and histopathologic studies. MR images showed mottled increased signal in T1- and T2-weighted images from the osseous portions of the tumors. In three patients, the extraosseous components failed to show increased signal on T1-weighted images. Chemical shift images and histologic studies demonstrated that adipose tissue caused the increased signal on T1-weighted images. The extraosseous components of the tumor contained little, if any, adipose tissue, which explained the lack of high-intensity signal on T1-weighted images. These signal changes appear to make a specific constellation of findings for the diagnosis of vertebral hemangioma with MR imaging.
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              Evaluation of hemangioma by positron emission tomography: role in a multimodality approach.

              Kazuhisa Hatayama, HIDEOMI WATANABE, Adel Refaat Ahmed … (2015)
              The relative utility of various preoperative diagnostic imaging modalities for the evaluation of hemangioma of the extremities, including positron emission tomography (PET) (using 18F-fluoro-2-deoxy-D-glucose [FDG] and fluorine-18 alpha-methyltyrosine [FMT]), computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA), was investigated. Imaging findings in 16 patients with 16 histopathologically documented hemangiomas of the extremities were retrospectively reviewed. Preoperative imaging included: FDG-PET (n = 16), FMT-PET (n = 12), MRI (n =16), CT (n =11), and DSA (n =14). All 16 lesions examined by PET with FDG and/or FMT showed accumulation. The standardized uptake values (SUVs) for FDG-PET for the 16 examined tumors ranged from 0.7 to 1.67; for FMT-PET, they ranged from 0.14 to 1.00. The SUVs with both tracers indicated the benign nature of the tumor. Computed tomography demonstrated variable attenuation and phleboliths in two patients. The MRI signal characteristics were relatively consistent: heterogeneous signals were slightly higher than those of skeletal muscle on T1-weighted images and brighter than those of subcutaneous fat on T2-weighted images. The pooling and cotton-wool staining depicted in DSA was found to be significantly correlated with FDG accumulation, suggesting that localized blood retention-induced ischemia may accelerate anaerobic glycolysis, which leads to high FDG uptake. Although plain radiography, CT, MRI, and angiography may provide anatomic extent and be pathognomonic, FDG-PET and FMT-PET may be the most reliable among the studied imaging modalities for differentiating benign hemangiomas from other soft tissue tumors, especially malignant neoplasms.
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                Author and article information

                Contributors
                Islam Ahmed Shehata Elhelf: Role: MD
                Ravishankar Pillenahalli Maheshwarappa
                Jared Hodgson: Role: MD
                Christina K. Hodgson: Role: MD
                Janet Pollard: Role: MD
                Yusuf Menda: Role: MD
                Journal
                Journal ID (nlm-ta): Radiol Case Rep
                Journal ID (iso-abbrev): Radiol Case Rep
                Title: Radiology Case Reports
                Publisher: Elsevier
                ISSN (Electronic): 1930-0433
                Publication date PMC-release: 06 September 2019
                Publication date Collection: November 2019
                Publication date (Electronic): 06 September 2019
                Volume: 14
                Issue: 11
                Pages: 1360-1363
                Affiliations
                [a ]Department of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215
                [b ]Division of Nuclear Medicine, Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
                [c ]Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
                [d ]Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, USA
                Author notes
                [* ]Corresponding author at: University of Iowa Hospitals and Clinics, 200, Hawkins Drive, Iowa City-52242, IA, USA ravishankar-pm@ 123456uiowa.edu
                Article
                Publisher ID: S1930-0433(19)30279-1
                DOI: 10.1016/j.radcr.2019.08.016
                PMC ID: 6734535
                PubMed ID: 31516653
                SO-VID: a2724b7b-686e-425d-bb04-177a35c85b81
                Copyright © © 2019 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 14 May 2019
                Date revision received : 25 May 2019
                Date accepted : 23 June 2019
                Categories
                Subject: Nuclear Medicine

                Keywords: giant vertebral hemangioma,tc-99m tagged rbc scan,aggressive,tumor,mimic
                Data availability:
                Keywords: giant vertebral hemangioma, tc-99m tagged rbc scan, aggressive, tumor, mimic

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