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Radiological evaluation of spinal tumours
- 1. RADIOLOGICAL EVALUATION OF SPINALTUMOURS PRESENTER : DR SIVA
- 2. OUTLINE 1. Introduction 2. Generalradiological features 3. Specific radiological features • Intradural, intramedullary • Intradural, extramedullary • Extradural
- 3. 1. INTRODUCTION • 15%of primary CNS tumors are intraspinal • Most primaryCNS spinal tumors are benign(unlike the case with intracranial tumors). • Most common malignantspinal tumors are 2’ metastases • Most present by compression rather than invasion.
- 4. COMPARTMENTS • Extradural (ED)(55%) • arise outside cord in vertebral bodies or epidural tissues • Intradural extramedullary (ID-EM) (40%) • arise in leptomeninges or roots. • Primarily meningiomas & neurofibromas (together; 55% of ID- EM) • intramedullary spinal cord tumors (IMSCT) (5%): • arise in SC substance. • Invade , destroy tracts and gray matter **Metastasis may be of either three but commonly extradural Greenberg MS., "Handbook of neurosurgery." 9th Ed; Thieme , 2020.
- 6. 2. GENERAL RADIOLOGICALFEATURES • Within what compartment is the lesion situated?” • Extradural • Intradural extramedullary • Intradural intramedullary • Key for approach: inspection of the edge of the lesion at its interface with subarachnoid space
- 7. EXTRADURAL • Subarachnoid space at the interface of the mass lesion and the spinal cord • tapering of the dorsal CSF column Extradural mass (lymphoma). An ovoid mass dorsal to the canal at the L1–L2 level that narrows the subarachnoid space. Note the tapering of the dorsal CSF column as it approaches the L1 mass, both superiorly and inferiorly. Vertebral marrow infiltration with smaller anterior and posterior epidural components are also noted at the L3 level Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 8. INTRADURAL EXTRAMEDULLARY • Thesubarachnoid space is widened & covering the lesion • **Except: plaquelike lesion instead of spherical • Eg: plaquelike meningioma, not necessarily widen the CSF space Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. Note the widening of the subarachnoid space as the cerebrospinal fluid enclosing the mass, indicating its intradural (subarachnoid space) location.
- 9. INTRADURAL INTRAMEDULLARY • The lesionis part of the expanded spinal cord ; inseparable • The subarachnoid space around the lesion– spinal cord complex is narrowed Intramedullary mass (Ependymoma). Demonstrate a round and mildly hyperintense lesion within the substance of the cord. There is localized cord expansion and circumferential narrowing of the subarachnoid space. Axial T2 GRE image (C) demonstrates greater contrast between the central hyperintense lesion and the peripheral rim of surrounding cord parenchyma. Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 10. LESIONS NOT FOLLOWING3 COMPARTMENTS 1. Reside in two compartments simultaneously. • The most common is neurofibroma 2. Two lesions with identical pathology may occur in different compartments. • metastases may occur in any of 3 compartments (including intramedullary space) Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 11. Fusiform cord widening Capping effect (Meniscussign) Incomp: Hourglass deformity Comp: Paintbrush effect
- 12.
- 13. • More commonin children (~40%) • 20% to 30% of primary spinal cord tumours in adults • Location: thoracic > cervical > lumbar • 80% : Gliomas • Astrocytoma : Children • Ependymoma : Adult Virdi G. Intramedullary Spinal Cord Tumours: A Review of Current Insights and FutureStrategies. iMedPub 2017
- 14. GENERAL MR CHARACTERISTICS •TI : Excellent morphologic detail ; cord widening • T2 : High signal of cord edema or surrounding tumour • STIR : More sensitive at detecting intramedullary pathology. • However, most lesions are sizeable at time of diagnosis not essential • T2-GRE: haemorrhage (Ependymoma > Astrocytoma) • T1+G: Focal masses enhanced well • Delineate & differentiate Eg: Hemangioblastomas (a/w syrinx) and metastases (a/w edema) • Area of enhancement represent active tumours , suitable areas for biopsy • Spinal gliomas mostly enhanced (regardless of grade ; unlike brain gliomas)
- 15. 1. EPENDYMOMA • Mostcommon 1’ lower spinal cord tumor, conus and filum terminale • 1/3 of ependymoma intraspinal • 1/3 Myxopapillary form — filum (2/3), conus+filum (1/3) • Arising from ependyma lining spinal cord central canal • tend to be central in location • Tend to have a delicate capsule • Better margin • 50%: cyst formation • Rarely calcified (unlike brain ependymomas)
- 16. • T1: Hypoto isointense • T2: • Iso to hyperintense • Regional hypointensity (hypercellularity) • T1+G • Intense enhancement (50% homogenous) with well defined border • Intra or peritumoural cyst are better defined • More heterogenous (vs astrocytoma) • Hemosiderin deposition on superior and inferior border of tumour • T1: hypointense, T2: markedly hypointense T1 T2 T1+G Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 17. • T1: Lowsignal intensity • T2: High signal intensity with small tumoural cysts • T1+G: Heterogenous contrast enhancement Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. T1 T2 T1+G Syrinx association
- 18. • Almost 70%of filum terminale masses are ependymomas mostly myxopapillary type. Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 19. 2. ASTROCYTOMA • Mostcommon 1’ tumor outside the filum terminale • Commonly in children • 80-90% low grade • 10-15% high grade • Thoracic cord (vs ependymoma more caudal) • Frequently eccentric in location usually posterior • T1 : Low signal lesion with cord enlargement • T2 : High signal lesion and edema • T1+G: • Contrast enhanced but poorly defined (no capsule, infiltrative) • More homogenous (vs ependymoma) Ross JS., Moore KR. Diagnostic Imaging Spine.3rd edition. Elsevier 2015
- 20. • TI: Lowsignal with central high signal, T2: high signal • T1+G: Enhancement (nearly homogenous), more over periphery • Cyst with superior enhancement (tumour cyst) – white arrow Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. T1 T2 T1+G
- 21. EPENDYMOMA VS ASTROCYTOMA EpendymomaAstrocytoma Incidence Less common Common Location Caudal: Conus, filum terminale Central (Ependymal cells) Thoracic Eccentric (commonly posterior) Hypercellularity Common (regional hypointensity on T2) Less common MRI contrast enhancement Heterogenous Homogenous Margin Well defined; encapsulated Ill-defined (infiltrative) Tendency of haemorrhage Common Less common Cyst Common Less common
- 22. 3. HEMANGIOBLASTOMA • 2-15%of IMSCT • No sex predilection; 4th decade • Low-grade, capillary-rich neoplasms of cerebellum & s. cord occur sporadically or in setting of VHL (1/3) • cerebellar hemangioblastomas (35% to 60%) • retinal angiomatosis (>50%) • renal cell carcinomas (25% to 38%) • pheochromocytoma (>10%) • spinal hemangioblastomas (less than 5%) • Tend to be well demarcated • 80% are solitary • 60% intramedullary • can also be IDEM or purely ED • 50% in thoracic region (most common) • 40% a/w cyst Graphic depicts a focal IM mass in the cervical cord with prominent feeding vessels, adjacent cysts and cord expansion with edema.
- 23. • TI: Increasedsignal with rostral and caudal cyst • T2: Decreased signal intensity (may see signal void, diffentiate with mets) • T1+G: Contrast enhanced (markedly) • Differentiate small tumour nidus from adjacent edematous s.cord / cyst • Essential for accurate removal of the tumour and cyst decompression Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. • Angio: Vascular tumour Vascular tumour nodule Artery Vein
- 24. 4. GANGLIOGLIOMA • Neoplasticastrocytes (mainly) and neural cells • Very rare; but 2nd most common Intrameduallry in paediatric • Cervical ; eccentric location (like astrocytoma) • Low malignant potential, slow growing, tend to recur • Cysts are common (compared to astrocytoma & ependymoma) • Key character: • T1: Mixed signal intensity T1+G: Patchy enhancement Cystic & solid components, heterogenous signal T1+G
- 25. 5. INTRAMEDULLARY METASTASIS •Very rare ; commonest from lung • Other common sites: Breast, melanoma, lymphoma, colon, kidney • Rapid progression (vs 1’ s.cord tumour) • T1: Low signal intensity • T2: High signal intensity (cord edema) • Edema disproportionate to lesion size • Rarely a/w syrinx – unlike hemangioblastoma • T1+G: marked homogenous enhancement • T1+G: Avidly enhancing nodule Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 26. • T1: Conusexpansion with subtle signal abnormality • T2: Decreased signal, well-circumscribed nodule against surrounding high signal edema. (Typical of cord metastasis) T1 T2 T2 L1 Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 27. 6. DERMOID ANDEPIDERMOID • Dermoid • Found throughout the CNS but rare in spinal region • Dermoid contains fat ; epidermoid doesn’t • Despite containing fat, dermoid has a non- fatty component • distinction from a lipoma • Location • Lumbosacral (60%), cauda equina (20%) • 40% intramedullary, 60% extramedullary (for both) May have posterior dysraphism. T2WI : intramedullary component contiguous with an extramedullary component following a dermal sinus tract to the skin surface
- 28. • T1: Increasedsignal • T2: Mixed/Increased signal • FST1: Fat supressed T1 T2 Fs Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 29. • Epidermoid cyst •cauda equina (35%) , lower thoracic (26%), lumbosacral (22%) • Best diagnostic clue • Lumbosacral or cauda equina CSF isointense mass • Occasionally mildly hyperintense to CSF, reflecting protein or cellular debris • T1WI C+ • minimal ring enhancement • May enhance avidly if infected Sagittal graphic shows a pearly white epidermoid cyst located within the cauda equina at the conus, a typical location for post lumbar puncture acquired epidermoid cyst. T1W Epidermoid cyst: Signal intensity is slightly hyperintense to CSF, and there is no hyperintense lipid content to indicate dermoid cyst is very unlikely
- 30. Samartzis D etal. Intramedullary Spinal Cord Tumors: Part I-Epidemiology, Pathophysiology, and Diagnosis. Global Spine J. 2015.
- 31.
- 32. • Meningeal: Meningioma •Nerve sheath tumour: • Neurofibroma, schwannoma • Spinal lipoma • Secondary tumors or leptomeningeal disease • Metastasis (4%)
- 33. 1. MENINGIOMA • Female(60-80%) • Mainly adult ; 5th -7th decade • 3-6% in children (commonly in NF2) • Location; • Thoracic (80%) , Cervical (15%) , Lumbar (5%) • Usually posterolateral • Rarely • Extradural ; tend to be malignant • Multiple ; NF2 • CT: Isodense or slightly hyperdense mass, rarely calcified , no hyperostosis • Best diagnostic clue • Intradural extramedullary mass that enhances avidly with contrast
- 34. MRI • T1WI • Isointenseto spinal cord • T2WI • Majority isointense to cord • Hypointense if calcified • Cystic degeneration in 2-4%, hyperintense on T2WI • Very vascular meningioma; prominent flow voids • T1WI C+ • Prominent, diffuse enhancement • Dural tails • Displaced cord Koeller KK., Shih RY. Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation RadioGraphics 2019 39:2, 468-490
- 35. • Saggital T1W+C: Homogeneous enhancement of the mass • Axial T1W+C : Homogeneous enhancement with significant compression of the spinal cord
- 36.
- 37. GINKGO LEAF SIGN Itis seen on axial post contrast T1 imaging, with the leaf representing the distorted spinal cord, pushed to one side of the thecal sac by the meningioma, and the stem, seen as a non-enhancing 'streak', probably representing the stretched denticulate ligament. Useful sign in distinguishing spinal meningioma from neurogenic tumor
- 38.
- 39. 2. NERVE SHEATHTUMOURS • Mainly neurofibroma and schwannoma • 16% to 30% of all intraspinal masses. • Common in 4th decade • 10-29% of intraspinal lesions in children Location % IDEM 70 Extradural 15 Intra+ Extradural (Dumbbell shaped) 15 Schwannoma Neurofibroma Envelopes adjacent nerve root No Yes (dorsal sensory commonly) Number Solitary Multiple NF NF2 NF1 Axonal relation Displace axons (Centrifugal) Engulf nerve of origin (Centripetal) Histology Antoni A > B Antoni B > A
- 40. A B Classic "biphasic" pattern ○Antoni A: Compact, elongated cells with occasional palisading ○ Antoni B: Less cellular, loosely textured, often lipidized Displace Engulf
- 41. 2.1. SCHWANNOMA • Slowgrowing, benign • 75% arise from dorsal sensory root • Early sx are often radicular • Rarely recurs after total excision • CECT • Moderate solid or peripheral enhancement • Bone CT • Bone remodeling adjacent to tumor • • Best diagnostic clue • Well-circumscribed, "dumbbell- shaped' transforaminal mass • Axial graphic ; right-sided dumbbell-shaped spinal nerve root schwannoma, enlarging the neural foramen and compressing the spinal cord. • Axial CECT hypodense transforaminal mass enlarging the right neural foramen. The intraspinal component effaces the thecal sac
- 42. • Axial T2WI:heterogeneous mass signal intensity. Canal stenosis (white arrow) • Foraminal enlargement and vertebral body scalloping (blue arrow) spinal canal + paravertebra foraminal + paravertebral paravertebra foraminal i/vertebral e/laminar & laminar invasion multidirectional
- 43. 2.2. NEUROFIBROMA • Mixturesof fibroblasts and proliferated Schwann cells between dispersed nerve fibers. • matrix spreads apart the axons • fusiform shape • Arises sporadically as a single nodule OR as multiple numerous lesions in the setting of NF1
- 44. • T1WI • Similarintensity to cord and nerve roots • T2WI • Iso- or hyperintense • Target sign suggestive but not pathognomonic for NF • Peripherally hyperintense • Central hypo- to isointense • Hypointense septations throughout plexiform NF
- 45. FASCICULAR SIGN ISA FINDING ON T2-WEIGHTED MRI IMAGES THAT SUGGESTS A LESION OF NEUROGENIC ORIGIN. IT IS CHARACTERISED BY MULTIPLE SMALL RING-LIKE STRUCTURES WITH PERIPHERAL HYPERINTENSITY REPRESENTING THE FASCICULAR BUNDLES WITHIN THE NERVES.
- 46. 3. SPINAL LIPOMA •Benign tumor of adipose tissue • A/w spinal dysraphism – 84% • Nondysraphic intradural lipoma = 4% (rare) • Become symptomatic in early adulthood, usually in the 2nd decade of life • Potential to grow with increased body fat, pregnancy
- 47. • Characteristically resemblefat on MR • T1 & T2: High signal intensity, T1+G: does not enhance • STIR: Signal loss
- 48. 4. SECONDARY TUMORSOR LEPTOMENINGEAL DISEASE • Both 1’ intracranial neoplasms & systemic tumors may spread to the CSF • More common due to primary intracranial neoplasm; especially in paediatrics. • Systemic: Breast, lung, malignant melanoma, GUT • Commonly lumbosacral ; gravity effect Primary % Medulloblastoma 48 GBM & high grade astrocytoma 14 Ependymoma 12 Oligodendroglioma 12 Other astrocytoma 7 Retinoblastoma 5 Pinealoma 3 Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 49. • MRI: • Bestseen in T1W+C • Smooth or nodular enhancement along the cord / cauda equine • 4 basic patterns • Nodular • Solitary focal mass at bottom of thecal sac or along cord surface • Multifocal discrete nodules along cord/roots • Diffuse • Thin, sheet-like coating of cord/roots "carcinomatous meningitis" • Rope-like thickening of cauda equine **CSF still is the most sensitive modality for determining leptomeningeal tumor spread Bulky nodular drop metastases from a pineal germinoma along the conus and cauda equina. Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 50. • T1+G: Linearenhancement along the entire surface of the cord and giving a characteristic “sugar-coated” appearance or “sheet-like coating” DIFFUSE Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. Mixed nodular and diffuse leptomeningeal tumor along the distal cord & conus medullaris due to drop mets from GBM
- 51. Koeller KK, ShihRY. Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation. Radiographics. 2019
- 52.
- 53. • Evaluating extradural lesionson MR: 1. Detect vertebral body lesions. • Well seen on unenhanced MRI • T1: low intensity lesions with surrounding increased intensity of the fat containing marrow • T2: high intensity lesions with surrounding less intensity of the fat containing marrow T1 T2 Complete replacement of the normal vertebral marrow signal and mild vertebral body compression deformity. Signal alteration is less visible on T2-weighted imaging Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 54. 2. Delineate possibilityof thecal sac impingement. • T1/T2 : both excellent for depiction of epidural disease • T2/GRE: Produce a myelographic effect with the CSF of high signal, and better delineate regions of impingement. T1 T2 T1: Normal marrow fat replaced with epidural extension of tumour. T2: Marrow signal is heterogeneous. Some flow void is seen (to be confirmed on axial) Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 55. • T2: Axialimages define the extent of epidural extension. Lobulated appearance in the anterior epidural space, due to limiting PLL in the midline. • Numerous flow voids seen, suggesting hypervascularity; later confirmed with angiography • Vascular metastasis from renal carcinoma T1 T2 Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 56. • 3. Differentiatebetween benign osteoporotic collapse & pathologic collapse due to neoplastic replacement. • Marrow signal • Nonneoplastic: Preserved (similar signal intensity T1) • Neoplastic: Replacement of marrow (decreased signal intensity on T1) • Margin between spared normal bone marrow signal & abnormal signal • Nonneoplastic: Regular, well defined (even band) • Neoplastic : Ill-defined, infiltrative Diffuse abnormal marrow signal in a neoplastic vertebral comp. fracture Atlas, Scott W., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017.
- 57. T1+GAD. IN EXTRADURALLESIONS • Usefulness 1. More specifically characterizing possible epidural tumor • Eg: Differentiate from non-enhancing disc material (esp. if adjacent to the narrowed disc) 2. Outlining areas of cord compression 3. Indicating regions of more active tumor for biopsy • Limitations • Enhancement is variable even in the same pt. with different lesions of metastasis • Maybe Isointense with surrounding marrow difficult to delineate Shah LM., Salzman KL.,Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Nov 2011
- 58. EXTRADURAL LESION Metastases (95%extradural) Primary Osteolytic (most) Osteoblastic Benign Lymphoma (mostly secondary) Lungs Breast Prostate Prostate Breast Osteoid osteoma Osteoblastoma Aneursymal bone cyst Vertebral hemangioma Osteochondroma Malignant Osteolytic metastases are more aggressive than osteoblastic Metastases (slower course) Chordoma Chondrosarcoma GCT of bone (osteoclastoma)
- 59. 1. VERTEBRAL HEMANGIOMA •Most common 1’ spine tumour ; benign • Usually intraosseous • may have epidural component • Infrequently extends into posterior elements • Typically, incidental lesion identified on imaging performed for unrelated reasons • Often multiple (20-30%) • Best diagnostic clue • CT: Hypodense lesion with coarse vertical trabeculae ("white polka dots") • MR: Circumscribed lesion, hyperintense on both T1 and T2WI, with hypointense vertical striations Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 60. MRI • T1WI • Typical(fatty stroma): Hyperintense • Atypical (mostly vascular soft tissue): Isointense or hypointense • Atypical hemangioma may simulate vertebral metastasis • T2WI • Usually hyperintense, due to vascular elements • • T1WI C+ • Variable ; Usually, mild enhancement T1 T2 Fine vertical striations correspond to the thickened trabecula Aggressive hemangioma ; extraosseous extension & cord compression
- 61. 2. OSTEOID OSTEOMA& OSTEOBLASTOMA • Both benign ; uncommon • Histologically identical • Tumor often called "nidus" ; distinguish it from surrounding reactive zone (host response) • Osteoid osteoma < 1.5cm (10% in spine) • Osteoblastoma > 1.5cm (40% in spine) • Imaging: CT is preferred • Radiolucent with surrounding sclerosis • Osteoblastoma: more destructive • Bone scan positive on all 3 phases of Tc-99m MDP bone scan CT: Osteoid osteoma with radiolucent lesion and surrounding sclerosis. MRI: Reactive zone Low signal on T1WI, high signal on T2WI, STIR. Enhanced. Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 62. T1W : ill-definedlesion within the posterior S1 body just anterior to the superior articular facet. There is adjacent inflammatory change in the epidural space Anteroposterior bone scan shows intense focal uptake in the left side of the S1 body Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 63. • Osteoblastoma: • usuallyinvolve the posterior elements • Margin may not be very well defined, more destructive • Lucent or ossified center CT: Osteoblastoma: Punched out lesions with surrounding thinned out cortex.
- 64. 3. ANEURSYMAL BONECYST • 1-2% of 1’ spinal tumor • Mainly <20yrs, arise de novo • Expansile lesion containing thin- walled blood-filled cavities (honeycomb) • Best diagnostic clue: Multiple fluid- fluid levels in expansile mass Aneurysmal bone cyst with an expansile, multicystic mass in the posterior vertebral body and pedicle extending into epidural space. AP X-ray : Absent pedicle sign, with bony destruction superior & inferiorly Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 65. • Expansile masscentered on posterior elements • Commonly extends into epidural space, may severely narrow spinal canal • Cortical thinning (Eggshell cortex) Contrast enhancement around the periphery of the lesion is difficult to distinguish from reactive bone (blue arrow) Axial T2WI in the same patient shows the classic appearance of multiple fluid-fluid levels in small cysts, which are separated by thin septa. Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 66. 4. OSTEOCHONDROMA • Mostcommon 1’ bone tumor ; • only 3% of solitary & 7% of multiple OC occur within the spine • Male , <20 y.o • Nearly always confined to the posterior elements • predilection for the spinous processes • Thoracolumbar • Best diagnostic clue • Sessile or pedunculated osseous "cauliflower" lesion with corticomedullary continuity with parent bone Axial graphic of the cervical spine --> typical osteochondroma (exostosis) protruding into the spinal canal, causing canal stenosis and cord compression. Axial NECT large osseous growth projecting ventrally from the right lateral mass of C2, with ossification of the cartilaginous cap
- 67. • T1WI • Centralhyperintensity (marrow) surrounded by hypointense cortex • Hypo-/isointense hyaline cartilage cap • T2WI • Central iso- to hyperintense signal (marrow) surrounded by hypointense cortex • Hyperintense hyaline cartilage cap • T1WI C+ • May see peripheral, septal enhancement in cartilage cap
- 68. 1. CHORDOMA • Rareprimary malignant bone tumour (<5%) ; but most common primary malignant spine tumor • Arises from notochord remnants • Slow growing ; Local recurrence • Sacrum (50%), clivus (35%) • CT: • Destructive, lytic lesion • Soft tissue mass usually present destruction • Intratumoral calcifications (ill-defined) • CECT: Mild to moderate enhancement, inhomogeneous (cystic necrosis, hemorrhage) Lytic lesions of the C2 and C3 vertebrae with cortical destruction posteriorly. High signal on T2W
- 69. MRI • T1WI • Heterogeneous; hypo- to isointense (compared to marrow) • T2WI • Hyperintense ; high water content • May have low signal septations • T1WI C+ • Heterogenous Sagittal T2W (A) and sagittal T1W-Gad, fat-suppressed, (B) T2 hyperintense and enhancing mass spanning the C5 to C7 vertebral bodies. Chordoma ; likely to cross the disc spaces. “mushroom” appearance
- 70. 2. CHONDROSARCOMA • Malignanttumor of connective tissue • formation of cartilage matrix by tumor cells • 7%-20% of all primary malignant bone tumors ; 3% in spine • CT: lytic destruction,with calcified matrix Sagittal graphic a large soft tissue mass centered within the sacrum; producing extensive bone destruction with presacral & epidural extension. • mixture of soft tissue, cartilage, calcification & other components heterogenous intensity on MRI (T1W)
- 71. • T2WI • Lobularhigh signal due to high water content of hyaline cartilage • Areas of low signal intensity due to calcification • T1WI C+ • Enhancing periphery and internal septa • Nonenhancing areas represent hyaline cartilage, cystic mucoid tissue, necrosis
- 72. 3. METASTASIS • 3rdmost common site for metastatic disease (after lung and liver) • The most common osseous site • 70% of patients with systemic cancer will have spinal metastasis. • Location: • ED (95%), IDEM (5-6%), IM (0.5-1.0%) • Commonly thoracic (70%), L/S & cervical 15% each • Principal process diffusion through vertebral venous plexus (Batson’s plexus) Primary % Prostate 84 Breast 72 Thyroid 50 Renal 36 Lungs 35 Pancreas 33 Shah LM., Salzman KL.,Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Nov 2011
- 73. • Plain film: •Minimum detection: >1 cm diameter mass and > 50% bone mineral loss • Often destructive & lytic • May be sclerotic (prostate ca.) • Absent pedicle signs • CT: • Superb osseous delineation & enables detection of cortical destruction / breakthrough • epidural mass ; amorphous soft tissue displacing the thecal sac or filling the neural foramen • may miss lesions that are entirely i/medullary Shah LM., Salzman KL.,Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Nov 2011
- 74. • MRI: • Multiplelesions suggestive. • Detect early bone marrow deposits • Low intensity on T1, varied on T2. • T2 : • Often (but not consistently) have a rim of bright T2 signal around them (halo sign) • Halo sign & diffuse signal hyperintensity strong indicator of mets (sensitivity, 75%; specificity, 99.5%) Shah LM., Salzman KL.,Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Nov 2011
- 75. Large sclerotic lesionnearly completely involving the L5 vertebral body. Abnormal hypointense marrow signal in not only the L5 vertebral body but also the L4 vertebral body, corresponding to blastic metastatic lesions Multiple lytic & blastic lesions in the thoracic spine with a compression fracture in the upper thoracic spine, in breast cancer. T1WI: Multiple hypointense lesions, mainly enhanced postcontrast. A mildly enhancing epidural component compresses the thecal sac. CT T1
- 76. METASTASES- LYMPHOMA • Secondary> primary involvement • Extradural > intradural > intramedullary • Multiple types with variable imaging manifestations • Epidural lymphoma: Thoracic > lumbar > cervical • Enhancing epidural mass ― vertebral involvement • Intramedullary lymphoma: Cervical > thoracic > lumbar • Poorly defined, enhancing mass • Osseous lymphoma: Long bones > spine • Bone destruction ("ivory" vertebra, rare), vertebra plana • Lymphomatous leptomeningitis • Smooth/nodular pial enhancement T2WI MR demonstrates a discrete hypointense mass in the posterior epidural space with a cap of epidural fat. The spinal cord is displaced anteriorly Ross JS., Moore KR. Diagnostic Imaging Spine. 3rd edition. Elsevier 2015
- 77. Rodallec MH etal. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 2008 Jul-Aug;28(4):1019-41.
- 78. REFERENCES • Atlas, ScottW., ed. Magnetic resonance imaging of the brain and spine. 5th Ed. Wolters Kluwer, 2017. • Ross JS., Moore KR. Diagnostic Imaging Spine.3rd edition. Elsevier 2015 • Greenberg MS., "Handbook of neurosurgery." 9th Ed; Thieme , 2020. • Takigawa et.al.Discrimination between Malignant and Benign Vertebral Fractures Using Magnetic Resonance Imaging. Asian Spine J. 2017;11(3):478-483. • Shah LM., Salzman KL.,Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. Nov 2011 • http://rad.desk.nl/en/p4bc9b15f76a78 Radiology assistant • Koeller KK, Shih RY. Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation. Radiographics. 2019 Mar- Apr;39(2) • Rodallec MH et al. Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics. 2008 Jul- Aug;28(4):1019-41. • Samartzis D et al. Intramedullary Spinal Cord Tumors: Part I-Epidemiology, Pathophysiology, and Diagnosis. Global Spine J. 2015.
Editor's Notes
- #3 Greenberg 813
- #4 Image MRI spine tumor 2008 Greenberg 813
- #6 1st question to ask
- #7 Lymphoma: can occur at all 3 component
- #11 MR myelography findings depicted 3 compartments
- #14 noncontrast MR scans generally detect lesions in the cord accurately. Help characterized certain ddx & rx. Extensive edema in mets ; use Gad to help pinpoint lesion
- #17 Syrinx
- #24 Fatty marrow replacement ſt of lower thoracic vertebral bodies from prior radiation treatment is noted.
- #27 ;Rare in cervical and upper thoracic May have posterior dysraphism; dermal sinus tract
- #32 Common
- #33 Thoracic level Cervical level
- #34 widened, covering lesion
- #40 Displace Engulf Centrifugal: move to centre Centripetal: away from centre
- #41 Not all dumbbell tumors are schwannomas, e.g. neuroblastoma
- #42 Asazuma et al18 classification system for dumbbell spinal schwannomas is shown in ▶Fig. 49.1. Type I tumors are intradural and extradural and are restricted to the spinal canal. The constriction occurs at the dura. Type II are all extradural, and are subclassified as: IIa = do not extend beyond the neural foramen, IIb = inside spinal canal + paravertebral, IIc = foraminal + paravertebral. Type IIIa are intradural and extradural foraminal, IIIb are intradural and extradural paravertebral. Type IV are extradural and intravertebral. Type V are extradural and extralaminar with laminar invasion. Type VI show multidirectional bone erosion. Craniocaudal spread: IF & TF designate the number of intervertebral foramina and transverse foramina involved, respectively (e.g. IF stage 2 = 2 foramens).
- #50 Carcinomatous meningitis
- #53 Hyperintensity due to fat-containing marrow. Before the development of MR, bone scans were considered the most sensitive means of detecting suspected tumors of the vertebral body. MR, however, has been found to be more sensitive to marrow abnormalities (2). For example, active lesions that might not be visible on a bone scan are generally detectable on MR Fatsuppressed T2-weighted imaging, on the other hand, is often useful in depicting marrow lesions. In occasional cases, uninvolved marrow appears to be low in signal, especially in young patients, in whom the vertebral body marrow does not contain much fat or in patients with anemia of chronic disease, who are hypothesized to have altered metabolism of iron. In these cases, the low-intensity lesions are not highlighted by the surrounding high-intensity marrow, and it may be difficult to detect tumor on unenhanced T1-weighted images. In these instances, T2-weighted sequences, short–inversiontime inversion recovery (STIR) sequences, or gradient-echo (GRE) sequences may help for further evaluation.
- #54 extension of a vertebral body tumor or by neoplastic growth in the epidural space itself. T1- and T2-weighted sequences are both excellent for depiction of epidural disease,
- #55 Vascular metastasis from renal carcinoma
- #56 In malignant VCFs, tumor infiltrates throughout the bone marrow and eventually the trabeculae and cortex, leading to a fracture.17 Malignant or metastatic VCFs often have total replacement of the normally high T1 bone marrow signal intensity (SI), resulting in diffuse homogeneous low SI.11,12,14⇓⇓⇓–18,24,28 This was present in up to 88% of metastatic lesions in 1 series.17 Meanwhile, in osteoporosis, the underlying mechanism leading to fracture is the loss of bone mineral density with preservation of the bone marrow.17 Therefore, areas of preserved normal high T1 and intermediate T2 SI within the bone marrow of a collapsed vertebral body are more often found in benign VCFs
- #57 enhancing tumor surrounding nonenhancing cord is better delineated
- #58 Greenberg 813 Mets: other than listed are rare Osteolytic bony destruction
- #59 Roose moore
- #60 Atypical hypointense, as discussed earlier Aggressive hemangioma ; extraosseous extension & cord compression
- #61 Osteoid osteoma: most common at lower limb bone Osteoid is a protein mixture secreted by osteoblasts that forms the organic matrix of bone Tc-99m-methylene diphosphonate (MDP))
- #65 Fluif-fluid - due to blood products
- #66 because osteochondromas are much more common than many other bone tumors, they actually are encountered in the spine with regularity. 75% <20y.o, male predominant
- #68 The notochord represents the earliest fetal axial skeleton, extending from the Rathke pouch to the coccyx. It is a primitive cell line from which the skull base and vertebral column develop Because the notochord, which forms the early fetal skeleton, extends from the clivus to the sacrum, chordomas can occur anywhere along the skull base and spine: 50% arise in the sacrum, 35% in the clivus, and 15% in the vertebrae. CT in showing bony destruction or calcification; MR superior in outlining epidural disease and the true extent of disease involving the bone
- #72 valveless network of veins which are important in the venous drainage of the brain and spine. However, this venous network provides an easy channel for the dissemination of infections and malignant cells Breast & lungs thoracic Prostate, GI, Renal LS
- #73 X-ray; 40% false –ve. CT: L3 due to mets focus slightly hyperdense soft tissue in the ventrolateral epidural space filling the left neural foramen (yellow arrow) and causing mass effect on the thecal sac. metastases have a predilection for involving the posterior vertebral body and pedicle https://radiopaedia.org/articles/winking-owl-sign-spine?lang=gb
- #74 High signal T2 high water content
- #75 Multiple lytic and blastic metastatic breast cancer