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Spinal neoplasms
- 1. SPINAL NEOPLASMS Presented by: Dr Fahad Shafi PG 3RD YEAR
- 2. • Tumors ofthe spine are important due to their potentially devastating clinical effects and challenging radiographic appearance. • In establishing the differential diagnosis for a spinal lesion, location is the most important feature, but the clinical presentation and the patient’s age and gender are also important. • Magnetic resonance (MR) imaging plays a central role in the imaging of spinal tumors, allowing tumors to be classified as extradural, intradural-extramedullary or intramedullary, which is very useful in tumor characterization
- 3. CLASSIFICATION OF LESIONS •Spinal tumors are subdivided according to their point of origin: Intramedullary, intradural-extramedullary and extradural. • Although this classification occasionally may not be appropriate owing to the propensity for some spinal tumors to traverse compartments, it a convenient and meaningful framework by which to approach the majority of spine tumors
- 4. Intramedullary Tumors • Single:Ependymoma, myxopapillary ependymoma, astrocytoma, ganglioglioma, hemangioblastoma, subependymoma, paraganglioma. • Multiple: Hemangioblastomas, metastases, lymphoma
- 5. Intradural-extramedullary Tumors • Single:Meningiomas, nerve sheath tumors, intradural metastases, lymphoma/leukemia, paraganglioma. • Multiple: Any of the preceding except paraganglioma
- 6. Extradural Tumors • Single:Aneurysmal bone cyst, giant cell tumor, osteoblastoma, osteochondromas, chordoma, chondrosarcoma, chondroblastoma, metastasis, hemangioma, solitary plasmacytoma, lymphoma • Multiple: Metastatic disease, hemangiomas, multiple myeloma, lymphoma • Epidural Lesions: Angiolipoma and angiomyolipoma, epidural lipomatosis, lymphoma
- 7. INTRAMEDULLARY TUMORS • accountingfor about 4-10 percent of all central nervous system tumors. • Intramedullary tumors include gliomas (ependymomas, astrocytomas and gangliogliomas) and nonglial tumors (such as hemangioblastomas, lymphoma and metastases). • Exact histologic diagnosis of the two most common tumors, ependymoma and astrocytoma, remains elusive but there are some suggestive imaging characteristics
- 8. Ependymomas • Most commonintramedullary neoplasm in adults and usually occur in the cervical region. • Slightly more common in women of 40 to 50 years of age. There is an increased incidence of these tumors in patients with NF-2.
- 9. • symptoms arechronic and consist mainly of pain, myelopathy and radiculopathies. • Occasionally, these ependymomas may bleed and produce subarachnoid hemorrhage or hematomyelia and hence acute symptoms
- 10. • These lesionsarise from ependymal cells that line the central canal and therefore tend to be central in location with respect to the spinal cord. Are low grade, classified as either grade I or grade II by the World Health Organization (WHO);malignant ependymomas are quite rare. • Characterized by slow growth they compress rather than infiltrate adjacent spinal cord tissue.
- 11. • On MRI,ependymomas are generally iso- to hypointense on T1WI and hyperintense on T2WI. • Ependymomas tend to produce symmetric spinal cord expansion and usually have solid and cystic components. • Cysts can be intratumoral, located within the solid tumor, or peritumoral (polar), occurring at the cranial or caudal aspects of the tumor. These cysts are not specific for ependymomas and can be seen with astrocytomas, hemangioblastomas and gangliogliomas.
- 12. • The solidcomponents of ependymomas usually enhance avidly, although the degree of enhancement may vary considerably. • In addition, ependymomas can hemorrhage, resulting in the “cap sign”, a hypointense rim at the periphery of the tumor on T2-weighted imaging that is related to hemosiderin deposition from prior hemorrhage.
- 13. T1WI and T2show extensive cord enlargement from medulla to C6 level. The lesion has heterogeneous signal intensity on T1WI and T2WI with suggestion of hemorrhagic and cystic area. Following Gd, the tumor shows enhancing nodule at medulla-C2 level and enhancement of wall of tumor cyst.
- 14. • Clear tumormargins, more uniform enhancement and central locations can help differentiate ependymomas from other intramedullary spinal cord tumors. • Spinal cord ependymomas may result in metastases in the subarachnoid space.
- 15. Myxopapillary Ependymoma • Representthe most frequent type of ependymomas found at the conus medullaris- cauda equina-terminal filum level. • Mainly observed during the fourth decade of life cases have been rarely described at an age range of 10 to 13 years. • usually manifest with lower back, leg, or sacral pain and weakness or sphincter dysfunction.
- 16. • thought toarise from the ependymal glia of the filum terminale. Occasionally, they occur in the extradural space, probably arising from the coccygeal medullary vestige at the distal portion of the neural tube with multiple lesions in 14 – 43%
- 17. • Myxopapillary ependymomasare characteristically lobulated, soft, sausage- shaped masses that are often encapsulated. • Myxopapillary ependymomas have a nonspecific radiologic appearance and are typically isointense relative to the spinal cord on T1WI and hyperintense on T2WI
- 18. Sagittal T1WI showsan intradural lesion extending from conus till sacral spinal canal, causing canal expansion with scalloping of posterior margins of vertebral bodies. The mass is of mixed intensity on T2WI and shows intense heterogeneous enhancement
- 19. • Hyperintensity onboth T1 and T2WI may be noted occasionally, a finding that reflects mucin content or hemorrhage. • Superficial siderosis may be seen but is not specific, as it has been noted in association with other highly vascular tumors
- 20. Subependymoma • Subependymomas representa variant of CNS ependymomas that may also occur in the spinal cord. • Originally thought to arise from the pluripotential cells of the subependymal plate, these tumors are now believed to have their origin from tanycytes, cells that bridge the pial and ependymal layers
- 21. • At MRimaging, they manifest with fusiform dilatation of the spinal cord with well-defined borders. Unlike other ependymomas, they are eccentrically located. • MR imaging findings are not sufficiently unique to enable the differentiation of ependymomas from subependymomas. A spinal subependymoma may manifest as an extramedullary lesion within the subarachnoid space, perhaps secondary to leptomeningeal heterotopic glial cells
- 22. Astrocytomas • Astrocytomas accountfor approximately 30 percent of spinal cord tumors. • They are the most common childhood intramedullary neoplasms of the spinal cord and are second only to ependymomas in adults. • Clinical presentation varies from nonspecific backpain to sensory and motor deficits, according to the size and location.
- 23. • The vastmajority of spinal cord astrocytomas in adults are of low malignancy, classified either as pilocytic (grade I) or low-grade astrocytomas (grade II), although anaplastic astrocytomas and glioblastomas rarely occur. • In contradistinction to ependymomas, astrocytomas are located eccentrically within the spinal cord & tend to infiltrate the cord and are, therefore, difficult to resect completely and have worse prognosis
- 24. Imaging features • Characterizedby enlargement of the spinal cord within a widened spinal canal involve a large portion of the cord, spanning multiple vertebral levels in length. • Cervicomedullary junction and the cervico- thoracic cord are the most common locations
- 25. • Tumors canshow areas of necrotic-cystic degeneration (60 % of cases), can have a ‘‘cyst with mural nodule’’ appearance, or can be structurally solid (about 40 % of cases). • The solid components are iso- to hypointense on T1WIs and hyperintense on T2WIs, whereas necrotic-cystic components display higher relaxation times on T1 and T2WIs
- 26. Astrocytoma. Sagittal T1WIshows expansion of the cervical spinal cord extending from C2 to C4. The affected cord is slightly hypointense relative to the unaffected cord. Sagittal T2 weighted MR image reveals an abnormal area of high signal intensity throughout the expanded region
- 27. Gangliogliomas • Gangliogliomas arecomposed of a mixture of ganglion cells and neoplastic glial elements; the majority of neoplastic glial cell types are of astrocytic subtype. • Gangliogliomas are the second most common intramedullary tumor in the pediatric age group (15 % of cases) and mostly affect children between 1 and 5 years of age, as do pilocytic astrocytomas
- 28. • Spinal cordgangliogliomas are found more often in the cervical spine, followed by the thoracic region, but also may occur in the filum terminale. • Gangliogliomas tend to be extensive on presentation, occupying an average length of 8 vertebral segments, compared with ependymomas and astrocytomas, which average 4 vertebral segments in length.
- 29. • calcification isprobably the single most suggestive feature of gangliogliomas. • mixed isohypointensity on T1WI and heterogeneous isohyperintensity on T2WI. • Gangliogliomas are perhaps the second most common tumor after astrocytomas to have a holocord distribution
- 30. Hemangioblastomas • nonglial, highlyvascular neoplasms of unknown cell origin that represent 1.6 to 6.4 percent of the spinal tumors. • most of these tumors (75%) are intramedullary, they may involve the intradural space or even be extradural. • thoracic spinal cord is most frequently involved, followed by the cervical spinal cord. • sporadically, but approximately one-third of cases occur in association with von Hippel-Lindau disease
- 31. • MR featuresof spinal hemangioblastoma depend on the size of the tumor. • Small (10 mm or less) hemangioblastomas are mostly isointense on T1WI and hyperintense on T2WI and show homogeneous enhancement, whereas larger ones tend to be hypointense or mixed hypoisointense on T1WI and heterogeneous on T2WI and tend to show heterogeneous enhancement
- 32. Sagittal MR imagesof the cervical region reveals intramedullary mass lesion at C2-C4 level which is isointense on T1-WI and heterogeneously hyperintense on T2-WI . The mass shows dense homogeneous enhancement following gadolinium administration
- 33. • A hemangioblastomalarger than 24 mm is usually accompanied by vascular flow-voids on MR images. A tumor is not likely to be a hemangioblastoma if it is 25 mm or larger and is not associated with vascular flow voids on MR images. • Spinal hemangioblastomas may be associated with syrinx that are usually more extensive than those seen with ependymomas or astrocytomas
- 34. Sagittal T2-WI and post-gadT1-WI shows cystic hemangioblastomas with enhancing mural nodules (arrow head in B) in cervicodorsal cord and mid-dorsal cord. In addition, solid enhancing hemangioblastoma (arrows in B) with multiple intradural flow-voids (arrows in A) is seen in region of conus.
- 35. Paraganglioma • Although rare,they are the third most common primary tumor to arise in the filum terminale. • Isointense relative to the spinal cord on T1WI and iso- to hyperintense on T2WI. • Hemorrhage is common (third most common after ependymoma and hemangioblastoma) and a lowsignal- intensity rim (cap sign) may be seen on T2WI
- 36. • After Gd-administration, heterogeneous and intense enhancement is virtually always seen. • Multiple punctate and serpiginous structures of signal void due to high-velocity flow may be seen
- 37. Sagittal T1-WI (A)and T2-WI (B, C) of the lumbosacral spine show intradural isointense mass at L3 vertebral level. Note multiple vascular flow-voids in the intradural space
- 38. INTRADURAL EXTRAMEDULLARY TUMORS • Intradural-extramedullarytumors include benign lesions (such as meningiomas and schwannomas) and metastatic lesions
- 39. Meningiomas • strong femalepredominance with a peak occurrence in the fifth and sixth decades. • Multiples spinal meningiomas are seen in patients with NF-2. • Most spinal meningiomas are found in the thoracic spine, followed by the craniocervical junction and the lumbar region. • thoracic and lumbar meningiomas are based on the posterior dura, craniocervical ones may be anterior or posterior in location
- 40. Imaging features • T1and T2 signal isointense with cord & display intense homogeneous enhancement following gadolinium administration. • A dural tail may be seen, reflecting tumor spread or reactive changes in the dura adjacent to the tumor. • CT may show intratumoral calcifications and this finding may aid in distinguishing between meningiomas and nerve sheath tumors,
- 41. Meningioma. Sagittal T1-WI(A) and T2-WI (B) of the dorsal spine show an isointense extramedullary intradural mass located posterior to the cord.
- 42. Nerve Sheath Tumors •nerve sheath tumors are the most common spinal tumor. • Schwannomas are most common, while neurofibromas generally occur in association with neurofibromatosis (especially NF-1). • Approximately • 50 percent of nerve sheath tumors are intradural-extradural (dumbbell-shaped) in location and 50 percent are purely extradural
- 43. • Both massesare slow growing and cause bone remodeling (e.g. expansion of neural formina) and both show low T1 and high T2 signal with homogeneous or inhomogeneous enhancement • Cystic spaces and hemorrhage, however, are more common in schwannomas than in neurofibromas
- 44. Sagittal T2WI (A)and axial T2WI (B) of the spine show an isohyperintense extramedullary intradural mass with extradural extension through left neural foramina. The mass shows heterogeneous enhancement following gad administration
- 45. EXTRADURAL TUMORS :Multiple Lesions •Metastatic Disease • Spinal metastasis is the most common tumor of the spine;develops in approximately 10 percent of all patients with cancer and are multiple in 90 percent of cases. • primary tumors are adenocarcinomas of lung, prostate and breast in adults and neuroblastoma, Ewing’s sarcoma in children.
- 46. • Most spinalmetastases are lytic and densely sclerotic metastases are typical (but not pathognomonic) for prostrate and rare cancers such as carcinoid tumors. • MRI is the imaging method of choice in these patients. • Metastases to spine generally present as T1- hypointense and T2-hyperintense lesions that replace normal marrow with pc enhancement.
- 48. Axial gadolinium-enhanced spin-echoT1-weighted magnetic resonance image from a 68-year-old man with thyroid carcinoma
- 49. Multiple Myeloma • MMis most common primary neoplasm of spine with the majority occurring in the thoracic and lumbar spine. Most patients are men, 60 years of age or older. • MRI is superior to radiography for both, focal and diffuse involvement
- 50. • Abnormalities areidentified as hypointensities on T1WI, hyperintensities on STIR images and enhancement on gadolinium-enhanced images. • In general, however, MM is suspected whenever MR images depict an expansile focal mass; multiple focal masses in the axial skeleton; diffuse marrow involvement, particularly at known sites of normal hematopoiesis; or multiple compression fractures in a patient with no known primary malignancy
- 52. Lymphoma • most oftenbetween the 5th and 7th decades of life with most patients have underlying non-Hodgkin’s lymphoma. • Spinal involvement affects mostly epidural space bone lesions also occur. • OSTEOLYSIS but mixed ivory or blastic lesions also seen.
- 53. • hypointense orbright on T2 images. The T2 signal characteristics are related to the fact that lymphomas have a high nuclear-to- cytoplasmic ratio. For similar reasons, lymphomas have restricted diffusion on DWI.
- 54. Arrows point tolymphoma causing epidural compression. Corresponding ct
- 55. Hemangioma • most commonprimary bone tumor and are found in over 10 percent of population. • majority of hemangiomas discovered incidentally in asymptomatic patients, but occasionally they may present as large and aggressive masses destroying a vertebra and producing pain and even compression of the spinal canal
- 56. • vertebral hemangiomasclassically have a coarse, vertical, trabecular pattern, with osseous reinforcement (trabecular thickening) adjacent to the vascular channels that have caused bone resorption.
- 58. • presence ofhigh signal intensity on T1 and T2WI is related to the amount of adipocytes or vessels and interstitial edema, respectively. • Fatty vertebral hemangiomas may represent inactive forms of this lesion, whereas low signal intensity at MR imaging may indicate a more active lesion with the potential to compress the spinal cord
- 59. Sagittal T1WI (A)and T2-WI (B) of the dorsal spine reveal D4 and D8 hemangiomas. The lesions are hypointense on T1WI and hyperintense on T2WI, suggesting aggressive hemangiomas. Axial T2WI (C) image shows right paravertebral and epidural soft tissue component, compressing the spinal cord.
- 60. Solitary Lesions • AneurysmalBone Cyst • 20 percent of all ABCs are located in the spine, particularly in the cervical and thoracic regions. • second decade of life with a slight female predominance. • primary (70%) or secondary. Secondary ABC may be associated with GCT, osteoblastoma, chondroblastoma,metastases and osteosarcoma
- 61. • Radiographs ofspinal ABCs generally show marked expansile remodeling of bone centered in the posterior elements, although extension into the vertebral body is frequently seen (75-90 percent of cases). A thin, outer periosteal rim and septations may be apparent
- 62. • CT andMR imaging may reveal multiple fluid- fluid levels reflecting hemorrhage with sedimentation, a characteristic feature of this tumor. • low-signal-intensity rim on CT and MR images (all pulse sequences) corresponds to an intact, thickened periosteal membrane.
- 63. Sagittal T2WI (A)and axial T2WI (B) of the cervicodorsal spine show and multicystic expansile mass involving the posterior arch, right pedicle and body of D1 vertebra. The mass contains multiple septa with fluid-fluid levels. The spinal cord is displaced posteriorly and to the left. CT scan (bone windows) shows the thin rim of bone marginating the mass
- 64. Giant Cell Tumor •Spinal lesions are more frequent in women and affect patients in the 2nd to 4th decades of life. • Most GCT of the spine occur in the sacrum. • Compared with chordomas, which are central lesions, sacral GCT are frequently eccentric and abut or extend across the sacroiliac joint
- 65. • When GCToccurs in the spine above the sacrum, it is usually located in the vertebral body with or without extension to the posterior elements. • Radiography typically shows a lytic lesion with cortical expansion
- 66. • On CTmscans,the tumor has soft-tissue attenuation with well-defined margins that may show a thin rim of sclerosis. • Being very vascular neoplasms show heterogeneous signal intensity on both T1 and T2WI because of the presence of necrosis, hemorrhage, or cystic spaces. Low signal intensity is frequently noted on T2WI and is related to the hemorrhagic and fibrotic of this tumor.
- 67. Giant cell tumorof C5 and C6. Sagittal (A) and axial (B) CT scan reveal expansile lytic lesion centered in the vertebral body with posterior element extension.
- 68. Osteoid Osteoma • commonbenign osseous lesion, involves the axial skeleton in 10 percent of cases. • Patients are usually affected between the ages of 10 and 20 years, with a male to- female distribution of 1.5:2. • symptoms include painful scoliosis, focal or radicular pain, gait disturbance and muscle atrophy. The pain is worse at night and is relieved with aspirin.
- 69. • lumbar spineis most commonly affected, followed by the cervical, thoracic and sacral segments. • The majority of axial osteoid osteomas (75%) are located in the posterior elements of the vertebra (pedicles, articular facets and laminae) and only 7 percent are in the vertebral body.
- 70. • CT showsthe nidus as a rounded hypodense lesion surrounded by a hyperdense sclerotic ring. Calcification within the nidus results in a target appearance of the lesion. • On MR imaging, nidus is generally low to intermediate signal intensity on T1WI, intermediate to high signal intensity on T2WI and enhances markedly; the surrounding osteosclerotic component results in a hypointense ring
- 72. • Osteoblastoma • Itis classically believed that osteoblastomas differ from osteoid osteomas only in size (>2 cm in diameter). • Osteoblastoma of the spine accounts for 30- 40 percent of all osteoblastomas and the lesions are equally distributed in the cervical, thoracic and lumbar segments
- 73. • The first,which consists of a central radiolucent area (with or without calcification) and surrounding osseous sclerosis, is similar to the radiographic appearance of osteoid osteoma, but the lesion is larger than 1.5 cm in diameter. • The second, an expansile lesion with multiple small calcifications and a peripheral sclerotic rim, is the most common appearance of spinal osteoblastomas . • The third pattern has a more aggressive appearance, consisting of osseous expansion, bone destruction, infiltration of surrounding soft tissue and intermixed matrix calcification
- 74. Osteoblastoma. Axial CTof the dorsal spine reveals expansile lesion of left pedicle and lamina of D6 vertebra with small foci of mineralized matrix
- 75. Chordoma • most commonnonlymphoproliferative primary malignant tumor of the spine and accounts for 2- 4 percent of malignant osseous neoplasms. • arise from notochordal rests and therefore, almost always occur in a midline or paramedian location in relation to the spine. Nearly 50 percent of all chordomas originate in the sacrococcygeal region, particularly in the fourth and fifth sacral segments
- 76. • most suggestivemanifestation is a destructive lesion of a vertebral body associated with a soft-tissue mass with a “collar button” or “mushroom” appearance and a “dumbbell” shape, spanning several segments and sparing the disks with areas of amorphous calcification.
- 77. • Most chordomasare iso-or hypointense relative to muscle on T1WI. The focal areas of hemorrhage and high protein content of the myxoid and mucinous collections may account for the high signal intensity on T1WI. • On T2WI, most chordomas have a high signal intensity due to the presence of their signature physaliphorous cells. • most tumors demonstrate moderate heterogeneous enhancement, but ring and arc enhancement and peripheral enhancement have also been described.
- 79. Chondrosarcoma • malignant cartilage-producingneoplasm. It is the second most common nonlymphoproliferative primary malignant tumor of the spine following chordoma. • Chondrosarcomas are seen at all levels of the spine, although the thoracic spine is the most common site. • Chondrosarcoma originates in the vertebral body (15 percent of cases), posterior element (40%), or both (45%) at presentation
- 80. • Characteristic chondroidmatrix mineralization (rings and arcs) may be evident on radiographs, but better evaluated with CT. Calcified matrix is detected as areas of signal void at MR imaging. • non-mineralized portion of the tumor has low attenuation on CT scans, low to intermediate signal intensity on T1WI and very high signal intensity on T2WI due to the high water content of hyaline cartilage. • An enhancement pattern of rings and arcs at gadolinium-enhanced MR imaging reflects the lobulated growth pattern of these cartilaginous tumors
- 82. EPIDURAL LESIONS • Angiolipoma •On MRI, angiolipomas are predominantly hyperintense on T1WI and inhomogeneous owing to interspersed vascular elements & are hyperintense on T2WI
- 83. Axial T1WI (A)and T2WI (B) show extradural hyperintense mass displacing the spinal cord anteriorly and left side. Axial T1-weighted fat-saturated image (C) showing diffuse, nearly homogeneous decrease in the signal intensity of mass suggestive of fatty tissue. Axial T1-weighted post-gadolinium fat-saturation image (D) showing enhancement of extradural lesion
- 84. • Epidural Lipomatosis •On sagittal MRI, the width of the normal posterior epidural fat is less than 3 to 5 mm. • typical MRI appearance of epidural lipomatosis is that of excessive bright Tl fat (>5 to 6 mm) in the posterior aspect of the canal on sagittal images