Spinal Tumors Intra-Extra ( Turgut Tali)

8/13/2019 Spinal Tumors Intra-Extra ( Turgut Tali)

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Spinal TumorsProf. Dr. E. Turgut TALI

Executive Vice Dean and DirectorDivision of NeuroradiologyDepartment of Radiology

Gazi University School of Medicine

[email protected]



Classification of Spinal

Tumors by LocationExtradural•Osseous spine•

Epidural space• Paraspinous soft tissues

Intradural extramedullary(inside dura, outside cord)

Intramedullary(spinal cord)



Clinical Features

Pain•Persistent•Intermittent•Relieves by rest•Relieves with medication

Neurologic deficits•Root compression•Spinal cord compression•Altered stabilization



Laboratory findings

Serum protein electrophoresis =Multiple myelomaAcid phosphatase =

Prostate ca. mets.Urinary VMA =

Neuroblastoma mets.

Alkaline phosphatase =Osteosarcoma

CBC =L m homa



Neuroradiology

•Diagnose•Lesion detection

•Lesion delineation•Lesion characterization

•Image guided biopsy



Imaging•Plain films (sens. , spec. )

•

CT - MDCT (specificity )

•Nuc. med. (sens. , spec. )

•

MRI (sensitive & specific)•Advanced MRI technics ?

•

Molecular imaging ?





MRI findings•

Low signal T1WIChildren / Chronic Diseases /Sclerotic / degenerative changes!!

•High signal T2WI(Fat Sat FSE / STIR)

•

Heterogeneous T1-T2WI•High signal DWI&ADCHigh signal Malignant C F

Low signal Osteoporotic C F



Helpful in•Differentiating tumor / N marrow•

Indicating active tumor for bx•Characterizing epidural involvemen•Outlining cord compression•Suggesting response to treatment

ContrastVariable enhancementFat Sat T1WI



Tracing the labelled

cells by MRIIntegrity of the neuronal

tracts (Bilgen)Tx monitoring &

effectiveness (neuronaltransplantation, etc) (Lee)



Neuroradiology

•Treatment planning•Treatment:

Interventional procedures•Tumor embolization

(Intraarterial / percutaneous)•Vertebroplasty•Pain management

•Treatment monitoring



Extradural Spinal

Mass LesionNonneoplastic massesnonneoplastic >> neoplasms

Neoplasms•Benign tumors << malign tumors•Benign tumors > young people•Malignant tumors > adults



Benign TumorsCommon•Vertebral hemangioma

Uncommon•Giant cell tumor•

Osteoid ssteoma•Osteoblastoma•

Osteochondroma



VERTEBRAL

HEMANGIOMA



Prevalence 12%25-35% multipleSlow growing

w age, 5. decade, inwomenLocation•Lower thoracal (60%) > lumbar(30%) > cervical & sacrum

•Vertebral body > posterior

elements (10%)



Plain Film & CT findings•Striated appearance

Jail bar / Honeycomb•Punctate (polka dot)•

Rarely scleroticMRI findings•T1WI: Iso-Hyperintense•T2WI: Hyperintense•Moderate enhancement•Extraosseous H. signal on T1



MULTIPLEHEMANGIOMAS



Focal fatty marrow

ABC (vs cavernous type)Paget

OsteopeniaMetastases

Differential Diagnosis





12 - 30% spinal> 2.decade (80%), female>male

Primary > Secondary (32-50%)Rapid expansion obliterate underlyingabnormality (GCT, chondroblastoma,

fibrous dysplasia, chondromyxoidfibroma, nonossifying fibroma)

Location•

Lumbosacral > thoracic > cervical• Posterior elements (neural arch)(60%) > vertebral body (40%)

• Pass through the intervertebral disc•Extension into paraspinal soft tissue



Plain film findings•

Lytic, expansile•Thinned cortex•Collapse / vertebra plana

CT findings•

Septation•Lobulation•

Fluid-fluid levels



MRI findings•Solid & vascular / cystic /hemorrhagic

•Fluid-fluid levels•Extension into soft tissue•

Heterogeneous•High signal on T2WI•

Septal enhancement



OsteoblastomaGiant cell tumor

Telengiectaticosteosarcoma




OSTEOID OSTEOMA

%



1-2 (13%)1.-3. decade, maleRelieves w salicylatesFocal tendernessConfined & self-limitedLocation•Lumbar (60%) > cervical (27%)> thoracic (12%) > sacral (2%)

•75% posterior elements,

vertebral arch, facets



Plain films & CT findings

•Lucent nidus (<1.5 cm)

(75%)w small amount of calcium

•

Surrounding bony sclerosis



MRI findings

•Low signal on

T1- & T2WI (Bony sclerosis)

•High signal on T2WI

(noncalcified portion of nidus)

•Marked enhancement of nidus

•Paraosseous reactive mass



Osteomyelitis (Brodie’sabscessLymphoma

Enostosis




S d l



Secondary neoplasms

(common)Primary neoplasms•

Multiple myeloma•Chordoma•

Lymphoma•Chondrosarcoma•

Osteosarcoma



MULTIPLEMYELOMA



Solitary Plasmositoma

Diffuse MM (34%)Amyloidosis 10%

5. decade, maleLocation•Thoracal > Lumbar•Vertebral body

Pl i Film & CT fi di



Plain Film & CT findings

•

Generalized reduction inbone density w thickeningof trabeculae (osteopenia)•Multiple round lytic lesionsw/o reactive sclerosis•Destruction•Pathologic fracture (s)

•Ivory vertebrae



MRI findings

•Hypointense on T1WI•Hyperintense (+/- fat sat)on T2WI•Cortical disruption &

infiltration into adjacentsoft tissue•

Heterogeneous enhancement



CHORDOMA

1 4% of primary bone tumors



1-4% of primary bone tumorsArises notochord remnants

Slow growing, locally invasive(More than one segment)

Invades (metastasize less often)

(Vertebral malignant)Rarely associated withMMT / eosinophilic granuloma / sarcoma

5.- 6. decade, male 2:1Location•

Sacrum 50%, Clivus 35%, Vertebrae 15%• Cervical > lumbar > thoracal

Pl i fil & CT fi di



Plain films & CT findings

•Matrix calcification (50%)•Multiple vertebra / disc / SI

joint involvement•Cortical expansion•Destruction (hallmark) w/o

sclerosis•Soft tissue & epidural mass

(90%)

MRI fi di



MRI findings•Often lobulated•Surrounding capsule•Internal septations (70%)•Hemorrhage - cyst(s)•T1WI : Isointense to

cord (hypo 25%)•T2WI: Hyperintense•

Marked enhancement

Diff ti l Di i



NeurofibromaPlasma cell myeloma

LymphomaChondrosarcoma

Giant cell tumorMetastasis

Infection


METASTATIC



METASTATIC

TUMORS



d l h l



Adult osteophylic tms•

Lung•Breast•Prostate•Kidney•Thyroid•Lymphoma

•Uterus•

Testis



Osteoblastic•Prostate•

Breast•Kidney•Treated mets



Osteolytic•

Thyroid•Kidney•Colon



Plain film findings

•Osteolytic / osteoblastic•

Destruction (40-50%)(Pedicle)•

Indistinct cortex•Pathologic fracture(s)

MRI fi di



MRI findings

•T1WI: Hypointense•T2WI: Heterogeneous

STIR: Hyperintense•Variable enhancement

Contrast mandatory todelineate the extensions!

•Hyperintense on DWI&ADC

P di t i t h li



Pediatric osteophylic

tmsSpinal canal invasion

•

Neuroblastoma•Ewing sarcoma•

Rhabdomyosarcoma•Retinoblastoma•

Germ cell tumors



Bone loss of aorticaneurysm pressure

Infections

Inflammations

Degenerative changes

Neurologic sequelas


H i



Hemangioma

Giant cell tumor

Lymphoma

Osteosarcoma

ChondrosarcomaMetastases

Osteoid OsteomaOsteoblastoma

Aneurysmal Bone Cyst

T k



Try to detect even aminor signal changeTry to delineate theextensionsTry to biopsy active

area of the tumor

Take



T k



MRI for vertebraetms

•T1•STIR – F. S. T2•CE - T1WI w F. S.•

DAG & ADC

Take

EPIDURAL



EPIDURAL

TUMORS



Primary Tumors•Lipoma /epidurallipomatosis•AngiomyolipomaSecondary Tumors•Lymphoma•Metastases



EPIDURAL

LIPOMATOSIS

LIPOMA



Unencapsulated fat(exogenous /endogenoushypercortisolemia,

Cushing's dis)Male

Well-shaped lipoma

Th > L > Cerv ?



Imaging findings•Increased epidural fat•Diminished subarachnoidspace•Tethered nerve roots



Metastases




Classification of SpinalTumors by Location

Extradural•Vertebrae•

Epidural space•Paraspinal soft tissues

Intradural extramedullary(intradural, outside of spinal cord)İntramedullary

(spinal cord)

B i >> li t t



Benign >> malignant tms

Well defined, roundNerve sheet tms ormeningioma (80 – 90%)

Others (10 – 20%)•Myxopapillary ependymoma

•

Paraganglioma•Dermoid tms

•Epidermoid cysts



NERVE SHEETTUMORS

Most frequent



Most frequent

Schwannoma, neurofibroma

5th decadeBack pain

(mimics HNP)

Location• Intradural extramedullary (70-75%)

•Extradural (15%)

• Intramedullary (< 1%)

• “Dumbbell” (15%)

Multiple lesions (NF1 NF2)



SCHWANNOMA



Schwannomas mostfrequentEncapsulated

EccentricCystic degeneration

HemorrhageFatty degenerations

Imaging



Imaging•Ipsilateral subarachnoidspace enlargement

•Displacemet of the cord

•Meniscus sign (well-definedborder)

•

Dumbbell pedicul erosion& foraminal enlargement

•Marked enhancement

Diff ti l di i



NeurofibromaMeningioma

Myxopapillary ependymoma

Meningocele

Extrude disk hernia

Differential diagnosis



MENINGIOMA

Benign



Benign

Second frequentSolitary / Multiple

Middle aged female(rare in children)

Location•Thoracal 75%

•

Cervical 15%

I i



Imaging•Bone erosion

•Ca++ rare

•

Nodular / wide dural base•T1: isointense to cord

T2: high signal•Enhancement

•Dural “tail” +/-

Diff ti l di i



Schvannoma

MetastasesLymphoma

Other tms




MYXOPAPILLARYEPENDYMOMA

M x p pill Ep nd m m



Myxopapillary Ependymoma

Generally / always filum/conus90% cauda equina tms2-3. DecadeBack pain, frequently SAHRound / sausage shape-şekillivascular mass•Grows slowly•Focal necrosis, frequent hemorrhage•Metastases (14-43% multiple)

MRI findings



MRI findings

T1- T2: Heterogeneous signal•Hemorrhage

(intraspinal masses with

hemorrhage)70% = ependymoma!!

•

Mild enhancementLong segment (mean 4 segments)•Canal widening, vertebral scalloping•Extension to the neural foramina

Diff r nti l di n sis



Nerve sheet tmsIntradural metastases

Acquired epidermoid tm

Meningioma

Paraganglioma


Malignant Intradural



Malignant Intradural

Extramedullary TmsLeptomeningeal metastases•

CNS•Systemic (Non Hodgkin lymphoma,leukemia)

NeurofibrosarcomaMalign degeneration of NF-1

2-12%

Spinal Leptomeningeal



Imaging findings•Diffuse

• Sheet-like thickening

• Rope-like thickened nerve roots

•Nodular•Focal mass

•Enhancement

Spinal Leptomeningeal

Metastases

Take



MRI is the modality ofchoice for intraduralextramedullary tms

•Contrast mandatory•Contrast media

•Higher molar•Higher relaksivity

•

Dot hunting

Take




Extradural•Vertebrae•

Epidural space•Paraspinal soft tissues

Intradural extramedullary(intradural, extra spinal cord)İntramedullary(spinal cord)

Classification of SpinalTumors by Location

Adult



•Glioma 95%

(ependymoma > astrocytoma)•Others 5-10%

•Hemangioblastoma•Metastases

Children•Astrocytoma 60%•

Ependymoma 28%•Others

•Teratoma•Dermoid / epidermoid tms



EPENDYMOMA

Ependyma of central canal /



Ep n yma f c ntra cana /ventriculus terminalis

3-6. decadeMultisegmental

Slow growingCSF dissemination

Location•Cervical (60%) > thoracal (28%) >filar (16%)

Imaging



g g•Swelling of the cord•Well defined•T1: isointens, T2: signal•Hemorrhage (“cap sign”)•Narrowing of subarachnoid space

• Posterior vertebral scalloping• Widening of spinal canal (>10%)

• Thinning of the pedicles• Increased interpeduncular distance

•Cystic changes•Marked enhancement

•DTI: shifted tracts

DDX



AstrocytomaHemangioblastoma

Demyelinating diseasesIschemia - infarct

Inflammatorytransverse myelitis

DDX



ASTROCYTOMA



Imaging



Imaging•Cord swelling•Widening of the spinal canal•Eccentric•

Infiltrative, ill-defined•Cystic•T1: Iso / hyperintense•T2: higher signal•Less / mild enhancement•

DTI: tract infiltration

DDX



EpendymomaOther tms

Ischemia – infarctSyringomyelia

Otoimmune –inflammatory myelitis

DDX



DDX



Demyelinating diseases

Primary cord tms

AVM

Inflammatory myelitisGranuloma

DDX



Take



CT - MDCT bone textureFor sensitivity & specificity

MRI•Prefer

CSE T2 / Fat Sat FSE / STIR•Postcontrast imaging

Fat Sat T1WI•

DWI & ADC (quantitative eval )

Take

Thank you



Thank you

for your

attention

andpatience!

Spinal Tumors Intra-Extra ( Turgut Tali)

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