Vertebral Hemangioma with Unexpected Juxtaposed Plasma Cell Neoplasm Treated with Intralesional Ethanol as a Preoperative Adjunct: Case Report
Dean G. Karahalios, MD**
Nicholas Theodore, MD***
Allan D.O. Levi, MD, PhD****
Stephen W. Coons, MD*
Cameron G. McDougall, MD
Volker K.H. Sonntag, MD
Divisions of Neurological Surgery and *Neuropathology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
**Evanston Hospital, Evanston, Illinois
***Naval Medical Center San Diego, San Diego, California
****University of Miami, Miami, Florida
A 38-year-old man complained of severe back pain but had a normal neurological examination. Radiographic studies demonstrated compression of the T12 vertebral body with associated spinal canal compromise and kyphosis as well as features consistent with a vertebral hemangioma. The patient underwent angiography with embolization of the lesion followed by computed tomography-guided intralesional sclerotherapy, an anterior decompression via a combined transthoracic and retroperitoneal approach, and reconstruction and fixation. Intraoperatively, the lesion was significantly devascularized, which greatly facilitated its safe removal. The patient recovered well from surgery. The final pathologic diagnosis confirmed the presence of the vertebral hemangioma and, unexpectedly, a juxtaposed plasma cell tumor. The patient was referred to medical oncology to rule out multiple myeloma or systemic disease and to plan further treatment. Minimally invasive techniques are effective treatments for symptomatic vertebral hemangiomas. However, when patients meet criteria for surgical intervention, these techniques also can play a significant role as adjuncts to surgery. The classic appearance of a vertebral hemangioma may disguise additional underlying pathology. In planning conservative nonsurgical management of symptomatic vertebral hemangiomas, one might consider performing biopsies despite a low index of suspicion for a coexistent malignancy.
Key Words: intralesional ethanol, plasma cell neoplasm, vertebral hemangioma
Figure 1. Axial computed tomography scan of the T12 vertebral body. The heterogeneous density of this tissue creates a 'popcorn' or 'honeycomb' appearance, which is pathognomonic for a vertebral hemangioma.
This report describes the treatment of a patient who was thought to harbor a symptomatic vertebral hemangioma with associated vertebral collapse, kyphosis, and spinal canal compromise. The case is interesting because intralesional ethanol sclerotherapy and endovascular embolization were used as preoperative adjuncts to surgery. Unexpectedly, a plasma cell tumor was found juxtaposed to the vertebral hemangioma. This coincidental finding is exceedingly rare but not completely surprising. The incidence of vertebral hemangiomas is relatively high (10 to 12%),[8,38,43,46] and plasma cell tumors are the most common primary malignant neoplasms of the adult spine.
A 38-year-old Brazilian man presented with severe back pain that persisted after he had sustained an injury 6 months earlier while playing squash. With coughing, sneezing, or the Valsalva maneuver, pain radiated into his right lower extremity. He denied numbness, weakness, or bowel and bladder dysfunction. Otherwise, the patient was healthy and took no medications. A detailed neurological examination revealed no evidence of radiculopathy or myelopathy. There was no tenderness to palpation over the spine, but the pain restricted his movement.
Figure 2. (A) Sagittal and (B) axial magnetic resonance images of the T12 vertebral lesion. The magnitude of spinal canal compromise is clearly evident in both views. The axial image also demonstrates numerous flow voids emphasizing the extensive vascularity of this lesion.
Plain radiography showed compression of the T12 vertebral body with significant kyphosis. Computed tomography (CT) demonstrated an enhancing lesion predominantly involving the anterior elements. Its trabeculated and "honeycomb-like" pattern was classic for a vertebral hemangioma (Fig. 1). On magnetic resonance (MR) imaging (Fig. 2A), the heterogeneously enhancing mass involved the T12 vertebral body. The lesion extended into the ventral spinal canal and compressed the spinal cord. Axial MR images (Fig. 2B) showed flow voids within the lesion ventrally and also involving the posterior elements. These findings were consistent with the diagnosis of vertebral hemangioma.
Routine preoperative laboratory studies were unremarkable except that urinalysis revealed occult blood and 1+ protein. Liver enzyme studies were mildly elevated.
Figure 3. (A) Selective angiography of the left T12 pedicle shows an extensive vascular network within the vertebral lesion. (B) After embolization, the vascularity of the lesion was reduced markedly.
Preoperative Endovascular and Intralesional Treatments
The vascular character of the presumptive hemangioma indicated that a preoperative attempt to decrease the vascularity of the lesion might facilitate resection and decrease blood loss during surgery. Selective spinal angiography was performed with a 6-French introducer sheath, Bentson guide wire, and a 5-French Cobra-2 catheter (Cook, Bloomington, IN). The artery of Adamkiewicz was identified at T9 on the left. The hemangioma appeared to be supplied primarily and bilaterally by the T12 radicular arteries (Fig. 3A). At each level the subcostal arteries were occluded with 3- to 5-mm straight-fibered platinum coils (Target Therapeutics, Fremont, CA). Next, provocation tests were performed by injecting lidocaine proximally into the vascular pedicles. No neurological sequelae ensued. Polyvinyl alcohol (Target Therapeutics, Fremont, CA) particles (250-350 microns) were used to embolize the vascular supply to the lesion to stasis. Finally, selective catheterizations and angiographic runs were performed bilaterally at T11-L1 to ensure that the collateral vessels had not replaced the embolized T12 pedicles. There was no significant residual blood supply to the lesion (Fig. 3B).