ASYMPTOMATIC VERTEBRAL OSTEOLYTIC LESION IN A CHILD – HAEMANGIOMA OR METASTATIC EWING’S TUMOUR?

Abstract

Introduction: The foot is an unusual site for presentation of Ewings tumour. Haemangioma of the vertebra is a common finding in adults, but is rarely reported in children.¹ Although rarely symptomatic, the lesion may cause diagnostic confusion particularly in the presence of comorbidity. A previous case report details an adult patient with a ‘pseudohaemangioma’ that was subsequently found to be an Ewings tumour.²

Methods: A review of the literature and a case report is presented of a boy with a Ewing’s sarcoma of the foot presenting with an asymptomatic lytic lesion in the spine.

Results: The 12-year-old male initially presented with pain and swelling in the right foot. Subsequent investigation and biopsy confirmed a diagnosis of Ewing’s sarcoma in the second metatarsal. The child received 5 cycles of combined chemotherapy, and the primary tumour was excised from the metatarsal with fibular graft reconstruction.

Part of the clinical work up had included an isotope bone scan, which revealed a focal area of increased uptake in the L1 vertebra. On MRI, the vertebral lesion had a ‘halo’ of high intensity signal with infraction of the upper vertebral endplate. There were no clinical symptoms arising from the vertebral lesion. The differential diagnosis of the L1 lesion suggested was either a meta-static Ewing’s tumour or an aggressive haemangioma. Given the possibility of a multifocal or metastatic lesion, a vertebrectomy and reconstruction with femoral allograft was performed. A second stage posterior stabilisation from T12 to L2 was performed. Histological examination of the resected vertebra revealed a benign capillary haemangioma. On recent review one year after treatment, the patient remains in remission from his tumour and has successful graft incorporation with minimal symptoms from his spine.

Discussion: Haemangioma is a benign tumour commonly found in the vertebral body. Asymptomatic spinal haemangiomas do not require surgical excision. Clinico-pathological distinction between vertebral haemangioma and metastatic disease can be difficult, particularly in children where the haemangiomata may be in a ‘blastic’ phase. The combination of an extremely unusual age of presentation and the presence of a separate malignant primary bone tumour in this patient introduced a significant clinical dilemma in treatment.