The hardest thing about ecchordosis physaliphora is remembering how to say and spell them. Other than that, they are hard to distinguish from chordomas. Small, indolent, asymptomatic, non-enhancing are the best clues. 

In some ways it is best to not biopsy them as the histology is also difficult to distinguish from the more aggressive chordoma. 

The patient has been followed up for over 5 years and remains well.