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
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Classification of Spinal
Tumors by LocationExtradural•Osseous spine•
Epidural space• Paraspinous soft tissues
Intradural extramedullary(inside dura, outside cord)
Intramedullary(spinal cord)
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Clinical Features
Pain•Persistent•Intermittent•Relieves by rest•Relieves with medication
Neurologic deficits•Root compression•Spinal cord compression•Altered stabilization
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Laboratory findings
Serum protein electrophoresis =Multiple myelomaAcid phosphatase =
Prostate ca. mets.Urinary VMA =
Neuroblastoma mets.
Alkaline phosphatase =Osteosarcoma
CBC =L m homa
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Neuroradiology
•Diagnose•Lesion detection
•Lesion delineation•Lesion characterization
•Image guided biopsy
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Imaging•Plain films (sens. , spec. )
•
CT - MDCT (specificity )
•Nuc. med. (sens. , spec. )
•
MRI (sensitive & specific)•Advanced MRI technics ?
•
Molecular imaging ?
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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
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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
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Tracing the labelled
cells by MRIIntegrity of the neuronal
tracts (Bilgen)Tx monitoring &
effectiveness (neuronaltransplantation, etc) (Lee)
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Neuroradiology
•Treatment planning•Treatment:
Interventional procedures•Tumor embolization
(Intraarterial / percutaneous)•Vertebroplasty•Pain management
•Treatment monitoring
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Extradural Spinal
Mass LesionNonneoplastic massesnonneoplastic >> neoplasms
Neoplasms•Benign tumors << malign tumors•Benign tumors > young people•Malignant tumors > adults
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Benign TumorsCommon•Vertebral hemangioma
Uncommon•Giant cell tumor•
Osteoid ssteoma•Osteoblastoma•
Osteochondroma
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VERTEBRAL
HEMANGIOMA
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Prevalence 12%25-35% multipleSlow growing
w age, 5. decade, inwomenLocation•Lower thoracal (60%) > lumbar(30%) > cervical & sacrum
•Vertebral body > posterior
elements (10%)
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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
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MULTIPLEHEMANGIOMAS
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Focal fatty marrow
ABC (vs cavernous type)Paget
OsteopeniaMetastases
Differential Diagnosis
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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
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Plain film findings•
Lytic, expansile•Thinned cortex•Collapse / vertebra plana
CT findings•
Septation•Lobulation•
Fluid-fluid levels
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MRI findings•Solid & vascular / cystic /hemorrhagic
•Fluid-fluid levels•Extension into soft tissue•
Heterogeneous•High signal on T2WI•
Septal enhancement
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OsteoblastomaGiant cell tumor
Telengiectaticosteosarcoma
Differential Diagnosis
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OSTEOID OSTEOMA
%
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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
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Plain films & CT findings
•Lucent nidus (<1.5 cm)
(75%)w small amount of calcium
•
Surrounding bony sclerosis
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MRI findings
•Low signal on
T1- & T2WI (Bony sclerosis)
•High signal on T2WI
(noncalcified portion of nidus)
•Marked enhancement of nidus
•Paraosseous reactive mass
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Osteomyelitis (Brodie’sabscessLymphoma
Enostosis
Differential Diagnosis
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S d l
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Secondary neoplasms
(common)Primary neoplasms•
Multiple myeloma•Chordoma•
Lymphoma•Chondrosarcoma•
Osteosarcoma
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MULTIPLEMYELOMA
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Solitary Plasmositoma
Diffuse MM (34%)Amyloidosis 10%
5. decade, maleLocation•Thoracal > Lumbar•Vertebral body
Pl i Film & CT fi di
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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
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MRI findings
•Hypointense on T1WI•Hyperintense (+/- fat sat)on T2WI•Cortical disruption &
infiltration into adjacentsoft tissue•
Heterogeneous enhancement
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CHORDOMA
1 4% of primary bone tumors
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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
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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
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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
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NeurofibromaPlasma cell myeloma
LymphomaChondrosarcoma
Giant cell tumorMetastasis
Infection
Differential Diagnosis
METASTATIC
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METASTATIC
TUMORS
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d l h l
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Adult osteophylic tms•
Lung•Breast•Prostate•Kidney•Thyroid•Lymphoma
•Uterus•
Testis
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Osteoblastic•Prostate•
Breast•Kidney•Treated mets
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Osteolytic•
Thyroid•Kidney•Colon
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Plain film findings
•Osteolytic / osteoblastic•
Destruction (40-50%)(Pedicle)•
Indistinct cortex•Pathologic fracture(s)
MRI fi di
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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
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Pediatric osteophylic
tmsSpinal canal invasion
•
Neuroblastoma•Ewing sarcoma•
Rhabdomyosarcoma•Retinoblastoma•
Germ cell tumors
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Bone loss of aorticaneurysm pressure
Infections
Inflammations
Degenerative changes
Neurologic sequelas
Differential Diagnosis
H i
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Hemangioma
Giant cell tumor
Lymphoma
Osteosarcoma
ChondrosarcomaMetastases
Osteoid OsteomaOsteoblastoma
Aneurysmal Bone Cyst
T k
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Try to detect even aminor signal changeTry to delineate theextensionsTry to biopsy active
area of the tumor
Take
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T k
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MRI for vertebraetms
•T1•STIR – F. S. T2•CE - T1WI w F. S.•
DAG & ADC
Take
EPIDURAL
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EPIDURAL
TUMORS
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Primary Tumors•Lipoma /epidurallipomatosis•AngiomyolipomaSecondary Tumors•Lymphoma•Metastases
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EPIDURAL
LIPOMATOSIS
LIPOMA
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Unencapsulated fat(exogenous /endogenoushypercortisolemia,
Cushing's dis)Male
Well-shaped lipoma
Th > L > Cerv ?
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Imaging findings•Increased epidural fat•Diminished subarachnoidspace•Tethered nerve roots
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Metastases
Classification of Spinal
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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
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Benign >> malignant tms
Well defined, roundNerve sheet tms ormeningioma (80 – 90%)
Others (10 – 20%)•Myxopapillary ependymoma
•
Paraganglioma•Dermoid tms
•Epidermoid cysts
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NERVE SHEETTUMORS
Most frequent
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Most frequent
Schwannoma, neurofibroma
5th decadeBack pain
(mimics HNP)
Location• Intradural extramedullary (70-75%)
•Extradural (15%)
• Intramedullary (< 1%)
• “Dumbbell” (15%)
Multiple lesions (NF1 NF2)
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SCHWANNOMA
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Schwannomas mostfrequentEncapsulated
EccentricCystic degeneration
HemorrhageFatty degenerations
Imaging
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Imaging•Ipsilateral subarachnoidspace enlargement
•Displacemet of the cord
•Meniscus sign (well-definedborder)
•
Dumbbell pedicul erosion& foraminal enlargement
•Marked enhancement
Diff ti l di i
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NeurofibromaMeningioma
Myxopapillary ependymoma
Meningocele
Extrude disk hernia
Differential diagnosis
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MENINGIOMA
Benign
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Benign
Second frequentSolitary / Multiple
Middle aged female(rare in children)
Location•Thoracal 75%
•
Cervical 15%
I i
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Imaging•Bone erosion
•Ca++ rare
•
Nodular / wide dural base•T1: isointense to cord
T2: high signal•Enhancement
•Dural “tail” +/-
Diff ti l di i
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Schvannoma
MetastasesLymphoma
Other tms
Differential diagnosis
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MYXOPAPILLARYEPENDYMOMA
M x p pill Ep nd m m
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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
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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
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Nerve sheet tmsIntradural metastases
Acquired epidermoid tm
Meningioma
Paraganglioma
Differential diagnosis
Malignant Intradural
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Malignant Intradural
Extramedullary TmsLeptomeningeal metastases•
CNS•Systemic (Non Hodgkin lymphoma,leukemia)
NeurofibrosarcomaMalign degeneration of NF-1
2-12%
Spinal Leptomeningeal
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Imaging findings•Diffuse
• Sheet-like thickening
• Rope-like thickened nerve roots
•Nodular•Focal mass
•Enhancement
Spinal Leptomeningeal
Metastases
Take
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MRI is the modality ofchoice for intraduralextramedullary tms
•Contrast mandatory•Contrast media
•Higher molar•Higher relaksivity
•
Dot hunting
Take
Classification of Spinal
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Extradural•Vertebrae•
Epidural space•Paraspinal soft tissues
Intradural extramedullary(intradural, extra spinal cord)İntramedullary(spinal cord)
Classification of SpinalTumors by Location
Adult
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•Glioma 95%
(ependymoma > astrocytoma)•Others 5-10%
•Hemangioblastoma•Metastases
Children•Astrocytoma 60%•
Ependymoma 28%•Others
•Teratoma•Dermoid / epidermoid tms
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EPENDYMOMA
Ependyma of central canal /
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Ep n yma f c ntra cana /ventriculus terminalis
3-6. decadeMultisegmental
Slow growingCSF dissemination
Location•Cervical (60%) > thoracal (28%) >filar (16%)
Imaging
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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
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AstrocytomaHemangioblastoma
Demyelinating diseasesIschemia - infarct
Inflammatorytransverse myelitis
DDX
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ASTROCYTOMA
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Imaging
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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
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EpendymomaOther tms
Ischemia – infarctSyringomyelia
Otoimmune –inflammatory myelitis
DDX
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DDX
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Demyelinating diseases
Primary cord tms
AVM
Inflammatory myelitisGranuloma
DDX
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Take
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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
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Thank you
for your
attention
andpatience!