Collisions lesions are rare neoplasms where two histologically distinct tumors coexist in the same organ or anatomical site. Vertebral hemangiomas (VHs) are the most common lesions involving the vertebral bodies and imaging findings of typical and atypical hemangiomas, variant forms of hemangioma such as aggressive hemangiomas are well known, but collision lesions involving VHs are extremely rare. This article presents a case report of a 73-year-old male patient diagnosed with clear cell renal cancer in a rare presentation of a bone metastasis coinciding with the same anatomical position as a VH (collision lesion). This required a multidisciplinary approach involving various diagnostic techniques to determine the best therapeutic management.

BACKGROUND: Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.
METHODS: A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included \"vertebral hemangioma,\" \"back pain,\" \"weakness,\" \"radiculopathy,\" and \"focal neurological deficits.\" Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.
RESULTS: VHs are benign vascular proliferations that cause remodeling of bony trabeculae in the vertebral body of the spinal column. Horizontal trabeculae deteriorate leading to thickening of vertical trabeculae which causes a striated appearance on sagittal magnetic resonance imaging (MRI) and computed tomography (CT), \"Corduroy sign,\" and a punctuated appearance on axial imaging, \"Polka dot sign.\" These findings are seen in \"typical vertebral hemangiomas\" due to a low vascular-to-fat ratio of the lesion. Contrarily, atypical vertebral hemangiomas may or may not demonstrate the \"Corduroy\" or \"Polka-dot\" signs due to lower amounts of fat and a higher vascular component. Atypical vertebral hemangiomas often mimic other neoplastic pathologies, making diagnosis challenging. Although most VHs are asymptomatic, aggressive vertebral hemangiomas can present with neurologic sequelae such as myelopathy and radiculopathy due to nerve root and/or spinal cord compression. Asymptomatic vertebral hemangiomas do not require therapy, and there are many treatment options for vertebral hemangiomas causing pain, radiculopathy, and/or myelopathy. Surgery (corpectomy, laminectomy), percutaneous techniques (vertebroplasty, sclerotherapy, embolization), and radiotherapy can be used in combination or isolation as appropriate. Specific treatment options depend on the lesion\'s size/location and the extent of neural element compression. There is no consensus on the optimal treatment plan for symptomatic vertebral hemangioma patients, although management algorithms have been proposed.
CONCLUSIONS: While typical vertebral hemangioma diagnosis is relatively straightforward, the differential diagnosis is broad for atypical and aggressive lesions. There is an ongoing debate as to the best approach for managing symptomatic cases, however, surgical resection is often considered first line treatment for patients with neurologic deficit.

This case report describes the treatment of a recurrent T2 vertebral hemangioma in a 46-year-old man who had prior decompression and fusion surgery. Despite initial stability, the patient developed worsening symptoms, leading to a comprehensive approach involving embolization, microscopic excision, and posterior fixation. Recurrence prompted the choice of Stereotactic Body Radiotherapy (SBRT) over redo surgery. Administered with 30 Gy in five fractions, SBRT significantly reduced hemangioma size and resolved neurological symptoms. The case highlights the effectiveness of hypofractionated SBRT as a promising intervention for aggressive vertebral hemangiomas.

Vertebral hemangiomas (VHs) are relatively common, symptomatic benign tumors of the spine with a reported estimated incidence up to 11%. They usually appear in the body of the vertebrae; however, they can extend into pedicles, laminae, and epidural space. They may cause pain, neurologic deficits. and fractures.
In this retrospective, single-center study, we reviewed our cases with VH and we propose the novel classification system that evaluates these lesions per their views on magnetic resonance imaging and clinical findings under 4 main categories.
Our novel classification system proposes that grade I lesions occupy less than 50% of the vertebral body, whereas grade II lesions occupy more than 50% and grade III lesions occupy the whole corpus. Grade IV lesions show an epidural and pedicular extension. We propose that grade I lesions may not be worthwhile for follow-up, whereas asymptomatic grade II (a) lesions to be worthy for a biannual imaging and symptomatic thoracolumbar grade II (b) and thoracolumbar grade III lesions to be considered for percutaneous vertebroplasty. We imply that decompression, posterior spinal instrumentation, and open vertebroplasty may be performed for thoracolumbar grade IV lesions. We further consider cervical grade IIb, III, and grade IV lesions as operable because of the disadvantages of percutaneous vertebroplasty.
We suggest that our novel classification system may be useful for the determination of diagnostic and therapeutic procedures in the management of VH. Further multicentric trials on larger series are warranted to validate this system and popularize its utility in larger populations.

OBJECTIVE: Preoperative elastoplasty could be an alternative strategy for treating aggressive vertebral hemangiomas (VHs) in frail patients needing for spinal cord decompression, combining the advantages of embolization and vertebroplasty.
METHODS: Three elderly patients with spinal cord compression from thoracic aggressive VHs underwent XperCT-guided percutaneous injection of silicone (VK100), filling the whole affected vertebra, followed by a decompressive laminectomy. At 12-months follow-up no recurrences, vertebral collapse or segmental kyphosis were noted at the CT scans, with patients reporting an improvement of preoperative neurological deficits, VAS and Smiley-Webster pain scale (SWPS) parameters.
RESULTS: With its elastic modulus, non-exothermic hardening, and lower viscosity than PMMA, VK100 allowed a preoperative augmentation of the affected vertebral body, pedicles, and laminae without complications, with a controlled silicone delivery even in part of VH\'s epidural components thanks to XperCT-guidance.
CONCLUSIONS: When facing highly bony erosive VH encroaching the spinal canal, VK100 combines the advantages of embolization and vertebroplasty especially in elderly patients, permeating the whole VH\'s angioarchitecture, significantly reducing tumor.

Somatostatin receptor scintigraphy is a key diagnostic tool in the initial staging and therapeutic evaluation of neuroendocrine tumors. Its specificity can be compromised by the presence of false positives. We illustrate here the case of a vertebral hemangioma detected on 99mTc-Tektrotyd scintigraphy as an incidental finding in a 34-year-old man referred for the staging of a well-differentiated neuroendocrine tumor of the ampulla of Vater (Fig. 1).

A 57 years old woman was diagnosed with well-differentiated lung neuroendocrine tumor (NET) by laboratory assessment, computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI) and bronchoscophy with transbroncial biopsy of nodular lung lesion located in the right lower lobe. Staging Ga-68 positron emission tomography-CT (PET-CT) showed two pathological uptake regions in the superior segment of the right lung lower lobe (SUVmax: 80.61) and 6th thoracic vertebral body (SUVmax: 3.70). Contrast-enhanced MRI findings suggested that vertebral lesion may be compatible with atypical hemangioma or osseous metastasis due to T1 isointensity, T2 hyperintensity and contrast-enhancement on the lesion. Therefore, characteristic imaging findings of hemangioma were seen on axial and sagittal or coronal sections of CT, respectively called as \'polka dot\' and \'corduroy cloth\'. Thus the mild vertebral Ga-68 DOTATATE uptake was accepted as false positive finding. Surgical intervention was decided. She underwent a right lung lobectomy. The last follow-up of the patient was done 2 years after the initial diagnosis. The follow-up Ga-68 DOTATATE PET-CT revealed no pathological increased uptake in the whole-body except the 6th vertebra showing similar uptake (SUVmax: 3.50) with the previous scan without size increase on CT. The patient was asymptomatic with normal serum chromogranin A level.

Vertebral hemangiomas (VHs), formed from a vascular proliferation in bone marrow spaces limited by bone trabeculae, are the most common benign tumors of the spine. While most VHs remain clinically quiescent and often only require surveillance, rarely they may cause symptoms. They may exhibit active behaviors, including rapid proliferation, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots (\"aggressive\" VHs). An extensive list of treatment modalities is currently available, but the role of techniques such as embolization, radiotherapy, and vertebroplasty as adjuvants to surgery has not yet been elucidated. There exists a need to succinctly summarize the treatments and associated outcomes to guide VH treatment plans. In this review article, a single institution\'s experience in the management of symptomatic VHs is summarized along with a review of the available literature on their clinical presentation and management options, followed by a proposal of a management algorithm.

Percutaneous vertebroplasty consists of an injection of polymethylmethacrylate in the vertebral body, with the aim of reinforcing the bone structure, preventing vertebral collapse, and achieving analgesic and antitumor effects. It is used in the treatment of patients with aggressive vertebral hemangiomas, as well as compression fractures of traumatic etiology and pathological fractures. Forestier\'s disease is also known as senile ankylosing hyperostosis of the spine. It is characterized by hypertrophy of the anterior longitudinal ligament. Depending on the most prominent place of ossification of this ligament, its clinical symptoms vary, with intense pain being the most relevant. Here, we present the case of a 73-year-old female with complaints of intense, constant pain that did not improve with conservative treatment, located at the level of the Th4Th10 vertebrae, radiating along the intercostal spaces, with eight months of evolution with muscular hypertonism. Magnetic resonance imaging of the thoracic spine showed osteochondritis of the thoracic spine and right-sided scoliosis. For hemangioma of the Th6 vertebral body, the patient was referred to the vertebrology department, where she was admitted to undergo percutaneous vertebroplasty of the affected level under fluoroscopic control. In this study, we report the use of percutaneous vertebroplasty as a minimally invasive treatment in a patient with Forestier\'s disease, obtaining excellent results, rapid recovery, and minimal hospitalization time, without having to subject the patient to major surgery.

BACKGROUND: Aggressive vertebral hemangioma (VH) is an uncommon lesion in the adult population. The vast majority of aggressive VHs have typical radiographic features. However, preoperative diagnosis of atypical aggressive VH may be difficult. Aggressive VHs are likely to recur even with en bloc resection.
METHODS: A 52-year-old woman presented with a 3-mo history of numbness and pain in her right lower extremity. Physical examination showed sacral tenderness and limited mobility, and the muscle strength was grade 4 in the right digital flexor. Computed tomography revealed osteolytic bone destruction from S1 to S2. Magnetic resonance imaging (MRI) showed that the mass was compressing the dural sac; it was heterogeneously hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI, and gadolinium contrast enhancement showed that the tumor was heterogeneously enhanced and invading the vertebral endplate of S1. The patient developed progressive back pain and numbness in the bilateral extremities 6 mo postoperatively, and MRI examination showed recurrence of the mass. The mass was larger in size than before the operation, and it was extending into the spinal canal.
CONCLUSIONS: The radiographic findings of atypical aggressive VH include osteolytic vertebral bone destruction, extension of the mass into the spinal canal, and heterogeneous signal intensity on T1-, T2-, and enhanced T1-weighted MRI. These characteristics make preoperative diagnosis difficult, and biopsy is necessary to verify the lesion. Surgical decompression and gross total resection are recommended for treatment of aggressive VH. However, recurrence is inevitable in some cases.