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Epithelioid Hemangioma of Vertebra Mimicking Metastasis on FDG PET/CT in a Patient With Renal Cell Cancer

Yanagisawa, Fumi MD; Amano, Yasuo MD; Omori, Yuko MD; Takagi, Ryo MD; Tang, Xiaoyan MD

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doi: 10.1097/RLU.0000000000003428
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Abstract

FIGURE 1
FIGURE 1:
A 61-year-old man with back pain was admitted to our hospital. CT reveals a large renal cell carcinoma (RCC). FDG PET/CT was examined for staging RCC. FDG MIP (A, arrows) and fusion images (B, C) demonstrate high uptake of FDG not only in RCC but also in the thoracic vertebral body, indicating vertebral metastasis. Transverse CT (D) shows the osteolytic lesion with a cortical disruption but no extraosseus expansion. The SUVmax of the vertebral tumor is 11.4, whereas that of RCC is 4.5.
FIGURE 2
FIGURE 2:
On MRI, the vertebral lesion shows isointensity relative to the muscle on T1-weighted images and hyperintensity accompanying vascular flow voids on T2-weighted images (A, arrows). Histological diagnosis was derived from the biopsy of the lesion. Hematoxylin-eosin stain of the specimen shows a vascular proliferation composed predominantly of well-formed capillary channels lined by epithelioid endothelial cells that appeared to protrude into the vascular lumina (B). Immunohistochemical staining reveals that the endothelial cells were positive for CD31 (C). The diagnosis of an epithelioid hemangioma (EH) of the bone is made, and RCC is a clear cell cancer. Considering a history of large RCC and the osteolytic appearances and FDG uptake of an EH in this case, EH can be clinically and radiologically confused with a malignant bone tumor, especially vertebral metastasis.1 Epithelioid hemangioma is a rare intermediate vascular tumor with a ubiquitous location, including soft tissue and bone.2–5 The World Health Organization recommends separating EH from conventional hemangiomas because of its local aggression and high recurrence.6,7 There are several reports of high FDG accumulation of the vertebral hemangiomas.8,9 To our knowledge, only one report showed high uptakes of FDG in EHs of skeletal lesions.10 The FDG uptake in EH can be caused by its characteristics of high cellularity and local aggression.10 In this case, the SUVmax of the vertebra was more than twice as high as RCC. The uptake was too high for metastasis of RCC: the uptake of RCC was relatively low because of the lower glucose metabolism.11 In addition, MRI indicated the vascular lesion showing high intensity and flow voids on T2-weighted images. This case highlights the potential to misdiagnose vertebral EH as metastasis from RCC on FDG PET/CT. Nonetheless, the careful interpretation of SUVmax and MRI can help differentiating the lesion from metastasis from RCC, even if we could not make the diagnosis of EH.

REFERENCES

1. Zhou Q, Lu L, Fu Y, et al. Epithelioid hemangioma of bone: a report of two special cases and a literature review. Skeletal Radiol. 2016;45:1723–1727.
2. Nielsen GP, Srivastava A, Kattapuram S, et al. Epithelioid hemangioma of bone revisited: a study of 50 cases. Am J Surg Pathol. 2009;33:270–277.
3. Antonescu CR, Chen HW, Zhang L, et al. ZFP36-FOSB fusion defines a subset of epithelioid hemangioma with atypical features. Genes Chromosomes Cancer. 2014;53:951–959.
4. Errani C, Zhang L, Panicek DM, et al. Epithelioid hemangioma of bone and soft tissue: a reappraisal of a controversial entity. Clin Orthop Relat Res. 2012;470:1498–1506.
5. Okada EMD, Matsumoto MMD, Nishida M, et al. Epithelioid hemangioma of the thoracic spine: a case report and review of the literature. J Spinal Cord Med. 2019;42:800–805.
6. Doyle LA. Sarcoma classification: an update based on the 2013 World Health Organization Classification of Tumors of Soft Tissue and Bone. Cancer. 2014;120:1763–1774.
7. Zambo I, Vesely K. WHO Classification of Tumours of Soft Tissue and Bone 2013: the main changes compared to the 3rd edition. Cesk Patol. 2014;50:64–70.
8. Nakayama M, Okizaki A, Ishitoya S, et al. “Hot” vertebra on (18)F-FDG PET scan: a case of vertebral hemangioma. Clin Nucl Med. 2012;37:1990–1993.
    9. Itabashi T, Emori M, Terashima Y, et al. Hemangioma of the rib showing a relatively high 18F-FDG uptake: a case report with a literature review. Acta Radiol Open. 2017;6:2058460117728416.
      10. Tang L, Chen G, Wang Q, et al. Bisphosphonates as a therapeutic choice for multifocal epithelioid hemangioma of bone: a case report. Medicine (Baltimore). 2019;98:e18161.
      11. Takahashi M, Kume H, Koyama K, et al. Preoperative evaluation of renal cell carcinoma by using 18F-FDG PET/CT. Clin Nucl Med. 2015;40:936–940.
      Keywords:

      epithelioid hemangioma; FDG PET/CT; SUVmax; vertebra

      Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.