Rare But Interesting Spinal Tumors (in Alphabetical Order)

1.
Epidemiology
40–50 years

F>M
2.
Location
Thoracic spine

Dorsal epidural space
3.
Characteristic imaging findings
Well-defined lobular mass

Both fatty and vascular component

High signal on T1-weighted image, low density on CT due to fatty component

Strong enhancement on contrast enhancement with fat suppression due to vascular component
4.
Spectrum of imaging findings
Infiltrating angiolipoma

Can infiltrate into adjacent structure
5.
Differential diagnosis
Epidural hemangioma

No fatty component

Epidural lipomatosis

No vascular component

Hematoma

No enhancement

No fat suppression

High density on CT

6.1.1 Illustrations: Angiolipoma

Fig. 6.1

Epidural angiolipoma in a 53-year-old woman. T2-weighted sagittal and axial images of the lumbar spine (a) show a 4 cm well-defined mass in the posterior epidural space at L1–2 level. Sagittal CT scan (b) shows internal fatty component. T1-weighted sagittal MR image (c) shows heterogeneous signal intensity of the lesion indicating mixed fatty and vascular components. Contrast-enhanced T1-weighted image (d) shows strong enhancement with some areas of fat signal suppression

6.2 Atypical Teratoid/Rhabdoid Tumor (ATRT)

1.
Epidemiology
Young children and infant, 7 months~17 years (more common in less than 3 years)
2.
Location
Most commonly in the brain, very rare in the spine

Intradural extramedullary, intramedullary

Cervical, thoracic, lumbar spine
3.
Characteristic imaging findings
Large heterogeneous mass

Internal hemorrhage

Diffuse contrast enhancement

CSF seeding
4.

Spectrum of imaging findings
5.
Differential diagnosis
Myxopapillary ependymoma and malignant peripheral nerve sheath tumor in extramedullary location

PNET, ependymoma, metastasis in intramedullary location

6.2.1 Illustrations: Atypical Teratoid/Rhabdoid Tumor (ATRT)

Fig. 6.2

Atypical teratoid/rhabdoid tumor (ATRT) in a 2-year-old child. Sagittal T2- and T1-weighted images (a–c) show a large heterogeneous mass at C1-C2-C3 levels with strong contrast enhancement. There is a focal cystic portion with suspected area of hemorrhage in the anteroinferior aspect of the tumor (white arrows). T2-weighted axial MR image (d) shows intradural extramedullary location of the tumor with cord compression and extradural extension into the left C1/C2 neural foramen

6.3 Chondroblastoma

1.
Epidemiology
20 years (9–62 years)

M > F
2.
Location
Very rare in spine, anywhere in the spine (most common in the thoracic spine)

Vertebral body and posterior elements
3.
Characteristic imaging findings
Expansive

Aggressive morphologic features with bony destruction and soft tissue mass

Calcification within the mass
4.
Spectrum of imaging findings
Secondary aneurysmal bone cyst

Bone marrow edema
5.
Differential diagnosis
Chondrosarcoma

Indistinguishable

Older ages (45–55 years)

6.3.1 Illustrations: Chondroblastoma

Fig. 6.3

Chondroblastoma of the L3 vertebrae in a 25-year-old woman. T2-weighted sagittal and axial MR images (a, b) show pathologic compression fracture of the L3 vertebral body with multiple hemorrhagic fluid-fluid levels within the mass. Axial CT scan (c) shows internal fuzzy calcifications with cortical destruction at the right anterior aspect and paravertebral extension. The mass shows enhancing solid portions with adjacent bone marrow edema (d)

6.4 Epidural Hemangioma

1.
Epidemiology
Any age (mean age, 38 years; age range, 2–62 years)

M = F
2.
Location
Cavernous hemangioma: dorsal epidural space

Venous hemangioma: ventral epidural space, lumbar spine
3.
Characteristic imaging findings
Cavernous hemangioma: lobular contour, solid intense enhancement
4.
Spectrum of imaging findings
Manifested as epidural hematoma

Venous hemangioma: small cystic mass, T1-hyperintensity, ventral location
5.
Differential diagnosis
HIVD

T1-hypointensity, T2-hypointensity

Peripheral enhancement

Hematoma

No solid enhancement in acute stage

Schwannoma

Peripheral enhancement, less intense enhancement

Solid component

6.4.1 Illustrations: Epidural Hemangioma

Fig. 6.4

Epidural hemangioma in a 28-year-old woman. T2-weighted sagittal and axial MR images (a, b) show an extradural mass of high signal intensity at the left side of the T1 vertebra. T1-weighted MR image (c) shows intralesional high signal intensity suggesting internal hemorrhagic areas. T1-weighted axial MR image (d) shows mild enhancement

Fig. 6.5

Epidural hemangioma in a 30-year-old man. Lumbar spine MR images demonstrate a T2 hyperintense lesion with rim enhancement in the right anterior epidural space at the level of the upper body of L4 (a, b)

Fig. 6.6

Spontaneous epidural hematoma without any tumor in a 36-year-old woman. Cervical spine MR images show an anterior epidural mass-like lesion extending from the levels of C7 to T4 of iso signal intensity on T1-weighted (a) and intermediate to high signal intensity on T2-weighted images (b). Nodular enhancement is seen centrally in the anterior spinal epidural lesion (c, d) indicating extravasation of contrast material by leaking vessels. Hyperacute to acute hematoma was diagnosed

6.5 Epithelioid Angiosarcoma

1.
Epidemiology
An extremely rare subtype of angiosarcoma, which is characterized by large cells with an epithelioid morphology

Middle aged and older

M = F
2.
Location
Rare in the spine
3.
Characteristic imaging findings
Feature of aggressive, high-grade bone tumor: destructive osteolytic mass with paravertebral extension, central necrosis, peripheral enhancement due to hyperperfusion
4.
Spectrum of imaging findings
Multicentricity (20–50%): multiple masses in a single bone
5.
Differential diagnosis
Epithelioid hemangioendothelioma

Difficult to differentiate

Less aggressive

Metastasis

Difficult to differentiate

Less hypervascular

6.5.1 Illustrations: Epithelioid Angiosarcoma

Fig. 6.7

Epithelioid angiosarcoma in a 73-year-old man. T2 SPAIR and T1-weighted sagittal MR images (a, b) show a heterogeneous signal mass in the L1 vertebral body with extensive bone marrow edema. T2-weighted axial MR images (c, d) show internal tortuous low signal flow voids (white arrows). Pre-surgical angiography for tumor embolization (e) shows marked hypervascularity within and around the tumor

6.6 Epithelioid Hemangioendothelioma

1.
Epidemiology
Vascular tumor, intermediate between hemangiomas and conventional angiosarcomas

Very rare in the spine

Middle aged and older

M = F
2.
Location
Cervical, lumbar
3.
Characteristic imaging findings
Nonspecific vascular tumor

Osteolytic mass, hypervascularity, single or multiple
4.
Spectrum of imaging findings
Distant metastasis (20–30%)
5.
Differential diagnosis
Hemangioma

Less aggressive

Can be cystic

Epidural hematoma

Angiosarcoma

More aggressive

More bony destruction and paravertebral extension

Metastasis

Less hypervascular

6.6.1 Illustrations: Epithelioid Hemangioendothelioma

Fig. 6.8

Epithelioid hemangioendothelioma in a 55-year-old man. T2-weighted sagittal MR image (a) shows a 2 cm intramedullary mass of high signal intensity at the level of T10 vertebra. Extensive spinal cord edema is combined. Contrast-enhanced T1-weighted axial MR image (b) shows an exophytic intramedullary mass in the left side with intense homogenous enhancement. Contrast-enhanced T1-weighted sagittal MR image (c) shows a vascular pedicle in the inferior aspect of the tumor (white arrow). Hypervascular tumor staining from the left T10 spinal artery (black arrow) is demonstrated on angiography (d, e)