Musculoskeletal
Vertebral hemangioma
A common benign spinal blood-vessel tumor that occasionally becomes aggressive and painful, and responds well to moderate-dose radiation.
Definition
Vertebral hemangiomas are benign vascular malformations of the vertebral body, present in roughly 10% of autopsies and found incidentally on imaging. Most are asymptomatic and require no treatment. A minority become symptomatic or "aggressive": they expand the vertebra, cause persistent localized back pain, extend into the posterior elements, or — rarely — compress the spinal cord or nerve roots.
How radiation treats it
Radiation obliterates the endothelium of the abnormal capillary and cavernous channels, causing thrombosis and sclerosis of the malformation while preserving the surrounding bone. Over months the lesion becomes fibrotic and re-calcified, pain subsides, and remodeling halts. It is the treatment of choice for symptomatic lesions without neurologic deficit or acute cord compression, where vertebroplasty or surgery would carry more risk.
Side effects
- Acute effects are limited to a mild skin reaction over the spine and short-lived fatigue.
- Temporary soreness in the treated vertebra is occasionally reported.
- With modern planning and cord constraints, permanent toxicity of the spinal cord is very rare.
Simulation process
The patient is simulated supine with a vacuum-lock or foam cradle to immobilize the spine; for thoracic or lumbar lesions, knees are supported to flatten the lordosis. A contrast-enhanced CT defines the involved vertebral level, and MRI is fused to delineate any epidural extension. The spinal canal and cord are contoured as organs at risk with strict dose limits, and field edges are matched to the vertebral body borders.
Treatment process
Typical prescriptions are 30–40 Gy in 2–3 Gy daily fractions over three to five weeks, delivered with 3D conformal posterior fields, a single posterior–anterior beam, or IMRT if the geometry demands it. Pain relief usually begins two to six weeks into treatment and continues for months. MRI follow-up at six to twelve months confirms sclerosis and confirms that the malformation is no longer expanding.
Key takeaways for students
- Radiation thromboses the abnormal vessels — pain relief is often durable.
- 30–40 Gy fractionated with strict cord constraints.
- Surgery or vertebroplasty is reserved for cord compression or fracture; radiation handles the rest.