Spinal Tumors

Prof. Dr. E. Turgut TALI

Executive Vice Dean and Director Division of Neuroradiology Department of Radiology Gazi University School of Medicine turgut.tali@gazi.edu.tr

Classification of Spinal Tumors by Location

Extradural
Osseous spine Epidural space Paraspinous soft tissues

Intradural extramedullary
(inside dura, outside cord)

Intramedullary
(spinal cord)

Pain

Clinical Features

Neurologic deficits

Persistent Intermittent Relieves by rest Relieves with medication

Root compression Spinal cord compression Altered stabilization

Laboratory findings
Serum protein electrophoresis = Multiple myeloma Acid phosphatase = Prostate ca. mets. Urinary VMA = Neuroblastoma mets. Alkaline phosphatase = Osteosarcoma CBC = Lymphoma

Neuroradiology
Diagnose
Lesion detection Lesion delineation Lesion characterization Image guided biopsy

Imaging
Plain films CT - MDCT Nuc. med. MRI
(sens. , spec. ) ) (specificity

(sens.

, spec.

(sensitive & specific)

Molecular imaging ?

Advanced MRI technics ?

Detailed morphology Shows

Active areas Extensions Marrow infiltration Compressions

MRI

Differentiates compression fractures

Low signal

MRI findings
T1WI

High signal

Children / Chronic Diseases / Sclerotic / degenerative changes!!

(Fat Sat FSE / STIR)

T2WI

Heterogeneous High signal

High signal Low signal

Malignant C F Osteoporotic C F

T1-T2WI DWI&ADC

Contrast
Variable enhancement Helpful in
Fat Sat T1WI

Differentiating tumor / N marrow Indicating active tumor for bx Characterizing epidural involvement Outlining cord compression Suggesting response to treatment

Tracing the labelled cells by MRI

Integrity of the neuronal tracts (Bilgen)
Tx monitoring & effectiveness (neuronal transplantation, etc) (Lee)

Neuroradiology
Treatment planning Treatment:
Tumor embolization (Intraarterial / percutaneous) Vertebroplasty Pain management

Interventional procedures

Treatment monitoring

Nonneoplastic masses Neoplasms

Extradural Spinal Mass Lesion

nonneoplastic >> neoplasms

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

Common

Benign Tumors

Uncommon

Vertebral hemangioma

Giant cell tumor Osteoid ssteoma Osteoblastoma Osteochondroma

VERTEBRAL HEMANGIOMA

Prevalence 12% 25-35% multiple Slow growing w age, 5. decade, women Location

in

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 sclerotic

MRI findings

T1WI: Iso-Hyperintense T2WI: Hyperintense Moderate enhancement Extraosseous H. signal on T1

MULTIPLE HEMANGIOMAS

Differential Diagnosis
Focal fatty marrow ABC (vs cavernous type) Paget Osteopenia Metastases

ANEURYSMAL BONE CYST

12 - 30% spinal > 2.decade (80%), female>male Primary > Secondary (32-50%)
Rapid expansion obliterate underlying abnormality (GCT, chondroblastoma, fibrous dysplasia, chondromyxoid fibroma, nonossifying fibroma)

Location

Lumbosacral > thoracic > cervical Posterior elements (neural arch) (60%) > vertebral body (40%) Pass through the intervertebral disc Extension into paraspinal soft tissue

Lytic, expansile Thinned cortex Collapse / vertebra plana

Plain film findings

Septation Lobulation Fluid-fluid levels

CT findings

Solid & vascular / cystic / hemorrhagic Fluid-fluid levels Extension into soft tissue Heterogeneous High signal on T2WI Septal enhancement

MRI findings

Differential Diagnosis Osteoblastoma Giant cell tumor Telengiectatic osteosarcoma

OSTEOID OSTEOMA

1-2 (13%) 1.-3. decade, male Relieves w salicylates Focal tenderness Confined & self-limited Location

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

Differential Diagnosis
Osteomyelitis (Brodies abscess Lymphoma Enostosis

Malignant Extradural Tumors

(common)

Secondary neoplasms

Primary neoplasms
Multiple myeloma Chordoma Lymphoma Chondrosarcoma Osteosarcoma

MULTIPLE MYELOMA

Solitary Plasmositoma Diffuse MM (34%) Amyloidosis 10% 5. decade, male Location

Thoracal > Lumbar Vertebral body

Plain Film & CT findings

Generalized reduction in bone density w thickening of trabeculae (osteopenia) Multiple round lytic lesions w/o reactive sclerosis Destruction Pathologic fracture (s) Ivory vertebrae

MRI findings
Hypointense on T1WI Hyperintense (+/- fat sat) on T2WI Cortical disruption & infiltration into adjacent soft tissue Heterogeneous enhancement

CHORDOMA

1-4% of primary bone tumors Arises notochord remnants Slow growing, locally invasive
(More than one segment) (Vertebral malignant)

Invades (metastasize less often) Rarely associated with

MMT / eosinophilic granuloma / sarcoma

5.- 6. decade, male Location

2:1

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

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%)

Often lobulated Surrounding capsule Internal septations (70%) Hemorrhage - cyst(s) T1WI : Isointense to cord (hypo 25%) T2WI: Hyperintense Marked enhancement

MRI findings

Differential Diagnosis
Neurofibroma Plasma cell myeloma Lymphoma Chondrosarcoma Giant cell tumor Metastasis Infection

METASTATIC TUMORS

Most common malignant extradural tumors (adult) Spinal metastases occur in 15 - 45% of disseminated cancers 5. decade Location
Thoracic (68%) > lumbal > sacral > cervical Single vertebra / multiple involvement

Adult osteophylic tms

Lung Breast Prostate Kidney Thyroid Lymphoma Uterus Testis

Prostate Breast Kidney Treated mets

Osteoblastic

Thyroid Kidney Colon

Osteolytic

Plain film findings

Osteolytic / osteoblastic Destruction (40-50%) (Pedicle) Indistinct cortex Pathologic fracture(s)

MRI findings
T1WI: Hypointense T2WI: Heterogeneous STIR: Hyperintense Variable enhancement
Hyperintense on DWI&ADC
Contrast mandatory to delineate the extensions!

Pediatric osteophylic tms

Neuroblastoma Ewing sarcoma Rhabdomyosarcoma Retinoblastoma Germ cell tumors
Spinal canal invasion

Differential Diagnosis
Bone loss of aortic aneurysm pressure Infections Inflammations Degenerative changes Neurologic sequelas

Hemangioma Giant cell tumor Lymphoma Osteosarcoma Chondrosarcoma Metastases Osteoid Osteoma Osteoblastoma Aneurysmal Bone Cyst

Take

Try to detect even a minor signal change Try to delineate the extensions Try to biopsy active area of the tumor

Take

Most frequent bone tumors

Metastases (malignant) Hemangioma (benign)

Take

T1 STIR F. S. T2 CE - T1WI w F. S. DAG & ADC

MRI for vertebrae tms

EPIDURAL TUMORS

Primary Tumors

Secondary Tumors
Lymphoma Metastases

Lipoma /epidural lipomatosis Angiomyolipoma

EPIDURAL LIPOMATOSIS LIPOMA

Unencapsulated fat

Male Well-shaped lipoma Th > L > Cerv ?

(exogenous /endogenous hypercortisolemia, Cushing's dis)

Imaging findings
Increased epidural fat Diminished subarachnoid space Tethered nerve roots

Metastases

Extradural

Classification of Spinal Tumors by Location

Intradural extramedullary ntramedullary

(spinal cord)

Vertebrae Epidural space Paraspinal soft tissues

(intradural, outside of spinal cord)

Benign >> malignant tms Well defined, round Nerve sheet tms or meningioma (80 90%) Others (10 20%)
Myxopapillary ependymoma Paraganglioma Dermoid tms Epidermoid cysts

NERVE SHEET TUMORS

Most frequent Schwannoma, neurofibroma 5th decade Back pain

(mimics HNP)

Location

Multiple lesions (NF1, NF2)

Intradural extramedullary (70-75%) Extradural (15%) Intramedullary (< 1%) Dumbbell (15%)

SCHWANNOMA

Schwannomas most frequent Encapsulated Eccentric Cystic degeneration Hemorrhage Fatty degenerations

Imaging

Ipsilateral subarachnoid space enlargement Displacemet of the cord Meniscus sign (well-defined border) Dumbbell pedicul erosion & foraminal enlargement Marked enhancement

Differential diagnosis
Neurofibroma Meningioma Myxopapillary ependymoma Meningocele Extrude disk hernia

MENINGIOMA

Benign Second frequent Solitary / Multiple Middle aged female (rare in children) Location
Thoracal 75% Cervical 15%

Imaging

Bone erosion Ca++ rare Nodular / wide dural base T1: isointense to cord T2: high signal Enhancement
Dural tail +/-

Differential diagnosis
Schvannoma Metastases Lymphoma Other tms

MYXOPAPILLARY EPENDYMOMA

Myxopapillary Ependymoma
Generally / always filum/conus 90% cauda equina tms 2-3. Decade Back pain, frequently SAH Round / sausage shape-ekilli vascular mass

Grows slowly Focal necrosis, frequent hemorrhage Metastases (14-43% multiple)

MRI findings
T1- T2: Heterogeneous signal
Hemorrhage
(intraspinal masses with hemorrhage)

70% = ependymoma!!

Long segment (mean 4 segments)

Mild enhancement

Canal widening, vertebral scalloping Extension to the neural foramina

Differential diagnosis
Nerve sheet tms Intradural metastases Acquired epidermoid tm Meningioma Paraganglioma

Malignant Intradural Extramedullary Tms

Leptomeningeal metastases
CNS Systemic (Non Hodgkin lymphoma, leukemia) Malign degeneration of NF-1 2-12%

Neurofibrosarcoma

Spinal Leptomeningeal Metastases

Imaging findings
Diffuse
Sheet-like thickening Rope-like thickened nerve roots

Nodular Focal mass Enhancement

Take

MRI is the modality of choice for intradural extramedullary tms Contrast mandatory Contrast media

Dot hunting

Higher molar Higher relaksivity

Extradural

Classification of Spinal Tumors by Location

Intradural extramedullary
(intradural, extra spinal cord)

Vertebrae Epidural space Paraspinal soft tissues

ntramedullary
(spinal cord)

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 / ventriculus terminalis 3-6. decade Multisegmental Slow growing CSF dissemination Location

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

Imaging

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

Astrocytoma Hemangioblastoma Demyelinating diseases Ischemia - infarct Inflammatory transverse myelitis

DDX

ASTROCYTOMA

Low grade Frequent in children 21y (3-4. decade) Slow growing Multisegmental (holocord) Location
Cervical cord (50%) Thoracal cord (50%)

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

Ependymoma Other tms Ischemia infarct Syringomyelia Otoimmune inflammatory myelitis

DDX

INTRAMEDULLARY METASTASES

DDX
Demyelinating diseases Primary cord tms AVM Inflammatory myelitis Granuloma

Take

Intramedullary tms
Contrast mandatory DWI DTI helps High sensitivity Low specificity

Take

CT - MDCT bone texture

For sensitivity & specificity MRI

Prefer CSE T2 / Fat Sat FSE / STIR Postcontrast imaging Fat Sat T1WI DWI & ADC (quantitative eval.)

Thank you for your attention and patience!