Pseudohemangioma of the vertebra: an unusual radiographic manifestation of primary Ewing's sarcoma

Abstract

Primary Ewing's sarcoma (ES) of the spine is uncommon, exhibiting a variety of appearances on plain-film radiographs and cross-sectional images. We report the unusual CT imaging manifestations of a primary ES with a coarse trabecular pattern that mimicked an aggressive hemangioma of the cervical spine.

fig 1.

Lateral plain film of lower cervical spine shows compression of C7 vertebra with preservation of C6–7 disk space. fig 2. Axial CT scan without contrast (bone window) shows course trabecular pattern with disruption of cortex of vertebral body. Left neural foramen is slightly widened.

fig 3.

Midline sagittal T1-weighted image of cervical spine shows homogeneous extradural mass compressing spinal cord posteriorly. Mass is low in signal and roughly isointense to gray matter. C7 vertebra is compressed and is decreased in signal with preservation of intervertebral disk spaces. fig 4. Sagittal T2-weighted image of cervical spine slightly to left of midline better shows preservation of intervertebral disk spaces. Extradural mass is fairly homogeneous and intermediate-to-high in signal. Compression of C7 vertebra with increase in anteroposterior diameter is obvious. fig 5. Midline sagittal T1-weighted image with contrast shows heterogeneous enhancement of extradural mass and C7 vertebral body. There is no abnormal enhancement of the spinal cord.

fig 6.

A, T1-weighted axial image through C6–7 intervertebral disk shows extradural mass compressing spinal cord posteriorly. Mass crosses midline and extends out of left neural foramen (arrows). B, T1-weighted axial image with contrast shows heterogeneous enhancement of mass.

fig 7.

Superselective angiogram of left costocervical trunk. Late arterial-phase projection shows staining in region of epidural mass.

fig 8.

Photomicrograph reveals that tumor is composed of densely packed small, round-to-oval cells (lower left) with high nuclear-to-cytoplasmic ratio (“small blue cell tumor;” several representative cells are highlighted with small arrowheads). Tumor has infiltrated medullary space of vertebrae. Note bone spicule (letter A) on right of figure. Faint thin-walled vascular channels are present (outlined by large arrowheads) (hematoxylin and eosin, original magnification × 200). Cells were immunopositve for CD99 and immunonegative for LCA and PGP 9.5. (not shown).

fig 9.

A, Proton density–weighted sagittal image of 53-year-old woman with aggressive VH of L3 vertebra. There is decrease of signal in L3 vertebral body. There is a large, homogeneous, low-signal extraosseous mass within spinal canal compressing thecal sac. There is growth of tumor superiorly and inferiorly along posterior aspect of L3 vertebral body. Note that there is preservation of intervertebral disk spaces. B, T2-weighted sagittal images (from same patient as 9A) shows that signal in extraosseous component increases on T2-weighted image. T2-weighted image better shows how tumor extends beyond inferior disk space (arrow).