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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 611-612
Commentary: Epithelioid hemangioma of spine
Abrar Ahad Wani
Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||4-Aug-2015|
Abrar Ahad Wani
Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wani AA. Commentary: Epithelioid hemangioma of spine. Neurol India 2015;63:611-2
Angiolymphoid hyperplasia with eosinophilia was a name given to a rare endothelial cell tumor which the World Health Organization later on designated as epithelioid hemangioma (EH). , The authors have drawn attention to an entity, which is relatively unheard of in neurosurgical practice. I would like to emphasize the differential diagnosis of EH about which the description provided in the manuscript is not adequate.  One has to differentiate EH from a conventional vertebral hemangioma (VH), an epithelioid hemangioendothelioma (EHE), and an angiosarcoma (AS).
Radiologically, the difference is not clear except that increasing bone destruction and soft tissue involvement is found as one moves down the spectrum from VH to EH to EHE to AS. Although some other differences are mentioned in the literature, they are not widely accepted.
In the absence of diagnostic and radiologically differentiating signs, it is histopathology supplemented with immunohistochemistry, that differentiates the entitites. VH may be of capillary or cavernous type. The cavernous type comprises multiple, large, thin-walled vascular spaces lined by flat endothelial cells. The capillary type is composed of numerous capillary channels lined by plump uniform endothelial cells and separated by a reactive fibrous tissue. The adipose tissue is variable in amount. 
In EH, the vascular structures are lined by a single layer of plump, epithelioid endothelial cells with abundant eosinophilic cytoplasm in a loose, paucicellular collagenized background. Rarely mitoses are seen, there is only mild cellular atypia, and they stain positive for CD31 and CD 34. 
In EHE, the epithelioid endothelial cells form nests or cords and lie in the loose hyalinized stroma. They have abundant eosinophilic cytoplasm and often have intracytoplasmic vacuoles. Unlike normal endothelial cells, they have abundant intermediate filaments and stain for vimentin and often to cytokeratin as well. In AS, sheets of cells with irregular vascular channels and plenty of atypia and pleomorphism are seen. The degree of vascularity is much more than seen in EH and EHE. Foci of necrosis are typical of AS. ,,,
There are no clear guidelines for this tumor and treatments ranging from wide en bloc resection, curettage, embolization, radiotherapy, and just observation have been described in literature. 
In this interesting article, the authors have nicely described the case and have managed it well. It would be interesting to know the status of tumor recurrence after some more time has lapsed, If at all the tumor recurs, there are three available options: Immediate re-operation, observation with serial imaging, or radiotherapy.
I would like to differ with authors on the extent of resection in these tumors. If surgery is indicated than in the case of a surgically accessible lesion, complete excision is desirable to prevent recurrence. The institute's experience in dealing with this type of lesion, however, must be taken into consideration for the patient's safety.
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