Top 3 Spinal Tumors of Each Compartment

, Joon Woo Lee1 and Eugene Lee2



(1)
Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea

(2)
Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea

 



4.1 Intraosseous Tumors

4.1.1 Hemangioma

4.1.2 Metastasis

4.1.3 Multiple Myeloma

4.2 Extradural Non-osseous Tumors or Tumorlike Lesions

4.2.1 Schwannoma

4.2.2 Neurofibroma

4.2.3 Herniated Intervertebral Disc (HIVD) (Sequestration)

4.3 Intradural Extramedullary (IDEM) Tumors

4.3.1 Schwannoma

4.3.2 Meningioma

4.3.3 Myxopapillary Ependymoma

4.4 Intramedullary (IM) Tumors

4.4.1 Ependymoma

4.4.2 Astrocytoma

4.4.3 Hemangioblastoma

4.5 Multi-compartment Tumors

4.5.1 Lymphoma

4.5.2 Leukemia

4.5.3 Hemangioma

4.6 Infant/Childhood Spinal Tumors

4.6.1 Sacrococcygeal Teratoma

4.6.2 Langerhans Cell Histiocytosis

4.6.3 Ewing’s Sarcoma

Bibliography



4.1 Intraosseous Tumors



4.1.1 Hemangioma





  1. 1.


    Epidemiology



    • Peak incidence: 30–50 years old, tendency to increase in size with age


    • Asymptomatic: M = F


    • Symptomatic: M < F

     

  2. 2.


    Location



    • Thoracic spine (60%) > lumbar spine (29%) > cervical spine (6%) > sacrum (5%)


    • Vertebral body >> posterior elements

     

  3. 3.


    Characteristic imaging findings



    • Well-defined round or lobular intraosseous masses


    • Thickened trabeculation on X-ray, CT, MR


    • High signal on T1-weighted and T2-weighted images


    • Avid enhancement

     

  4. 4.


    Spectrum of imaging findings



    • Low signal on T1-weighted images in vascular (aggressive, symptomatic) hemangioma


    • Poor enhancement in sclerosing hemangioma


    • Both epidural and vertebral body involvement

     

  5. 5.


    Differential diagnosis



    • Benign notochordal cell tumor



      • Sclerosis on CT


      • Low signal on T1-weighted images


      • No enhancement


    • Metastasis



      • Cortical destruction


      • Low signal on T1-weighted images


    • Focal fat



      • Irregular shape


      • No enhancement

     


4.1.1.1 Illustrations: Hemangioma




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Fig. 4.1
Hemangioma of the T12 vertebra in a 76-year-old woman. Axial CT scan of the lumbar spine (a) shows small osteolytic lesion in the right posterior corner of the vertebral body. T1-weighted sagittal MR image (b) shows subtle low signal intensity with a hyperintense rim (white arrow). T2-weighted sagittal MR image (c) shows high signal intensity with preserved internal trabeculation (black arrow). Contrast-enhanced T1-weighted sagittal MR image (d) shows enhancement


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Fig. 4.2
Hemangioma of the L1 vertebra in a 78-year-old woman. Axial CT scan of the lumbar spine (a) shows an osteolytic lesion involving the entire vertebral body with internal dot-like trabeculation. T1-weighted sagittal (b) and T2-weighted sagittal (c) MR images show a heterogeneous low signal intensity lesion with preserved coarse trabeculations (white arrows). Contrast-enhanced T1-weighted sagittal MR image (d) shows avid enhancement


4.1.2 Metastasis





  1. 1.


    Epidemiology



    • Middle age and elderly (can be seen in all ages)


    • Men: from prostate cancer, lung cancer


    • Women: from breast cancer, lung cancer

     

  2. 2.


    Location



    • Thoracic spine (70%), lumbar spine (20%), cervical spine (10%)


    • Common in vertebral body

     

  3. 3.


    Characteristic imaging findings



    • Osteolytic (70%), osteoblastic (9%), mixed (21%) pattern


    • Osteolytic masses



      • With cortical destruction and paravertebral extension


      • Malignant compression fracture: complete replacement of the bone marrow


      • Different signal characteristics and aggressiveness depending on primary tumors


    • Osteoblastic mass with peripheral enhancement



      • Common in breast cancer and prostate cancer


      • Irregular sclerotic mass on X-ray and CT with endplate depression


      • Hypointense signal on T1-weighted and T2-weighted MR images


      • Peripheral enhancement


    • Mixed pattern



      • Osteolytic and osteoblastic masses in the spine

     

  4. 4.


    Spectrum of imaging findings



    • Malignant compression fracture.



      • Complete replacement of the bone marrow signal in the vertebral body


      • Convex posterior margin of vertebral body


      • Hypointense signal on T1-weighted images


      • Strong enhancement or internal irregular non-enhancing areas


      • Epidural mass with biconcavity due to midline septum


    • Single lesion can be possible.


    • Sclerotic rim around the tumors can be seen.


    • Slow-growing metastases in thyroid cancer.


    • Direct invasion from retroperitoneal or mediastinal metastasis.

     

  5. 5.


    Differential diagnosis



    • Aggressive hemangioma



      • Thickened trabeculation


    • Red marrow hyperplasia/red marrow reconversion



      • Isointense or hyperintense signal than intervertebral disc on T1-weighted images


      • Patchy enhancement


    • Schmorl’s node (intravertebral disc herniation)



      • Cortical depression on T1-weighted image or CT


      • Same signal as intervertebral disc


    • Multiple myeloma



      • Diffuse or variegated involvement


      • Benign osteoporotic pattern of compression fracture


    • Lymphoma



      • Multi-compartment without definable cortical breakage


      • Homogeneous signal character


      • Younger age


    • Tuberculosis



      • Subligamentous extension


      • Intraosseous rim-like enhancement


    • Polyostotic fibrous dysplasia



      • Ground glass opacity


      • Bony overgrowth or remodeling


    • Lymphangiomatosis



      • Cystic nature


      • No interval change

     


4.1.2.1 Illustrations: Metastasis




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Fig. 4.3
Metastasis of C7 in a 76-year-old woman with underlying pancreatic adenocarcinoma. Sagittal CT scan of cervical spine (a) shows an ill-defined osteolytic lesion involving the entire vertebral body. T2-weighted sagittal (b) and axial (c) MR images show a heterogeneous high signal intensity lesion with paravertebral and epidural extension (black arrows). T1-weighted sagittal MR image (d) shows low signal intensity involving the whole vertebral body, of relatively lower signal intensity than that of the intervertebral disc. Contrast-enhanced T1-weighted sagittal MR image (e) shows faint enhancement with avid paravertebral and epidural soft tissue enhancement


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Fig. 4.4
Metastases of the L2, L3, and L4 vertebrae in a 35-year-old woman with breast cancer. Coronal CT scan of the lumbar spine (a) shows an osteoblastic L2 vertebral body lesion. T1-weighted sagittal MR image (b) shows heterogeneous low signal intensity foci involving the L2, L3, and L4 vertebral bodies (white arrows). T2-weighted sagittal MR image (c) shows heterogeneous low signal intensity areas. Contrast-enhanced T1-weighted sagittal MR image (d) shows heterogeneous enhancement


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Fig. 4.5
Metastasis of the T8 vertebra in a 48-year-old woman with renal cell carcinoma. Coronal CT scan of the thoracic spine (a) shows an osteolytic lesion in the left side of the T8 vertebral body with decreased vertebral height (white arrows). T1-weighted sagittal MR image (b) shows diffuse low signal intensity involving the entire T8 vertebral body in keeping with a pathologic compression fracture, of relatively lower signal intensity than the intervertebral disc. Contrast-enhanced T1-weighted sagittal (c) and axial (d) MR images show diffuse homogeneous enhancement with paravertebral and epidural extension


4.1.3 Multiple Myeloma





  1. 1.


    Epidemiology



    • 50–60 years old


    • M > F

     

  2. 2.


    Location



    • Diffuse involvement


    • Compression fracture: 87% in T6 ~ L4

     

  3. 3.


    Characteristic imaging findings



    • Variegated pattern



      • Salt-and-pepper appearance


      • Tiny, innumerous T1-hypointense nodules in the whole spine: strong enhancement even within tiny nodules


    • Diffuse pattern



      • Diffuse T1-hypointensity of the bone marrow involving the whole spine


      • Lower signal than intervertebral disc on T1-weighted image


    • Multinodular pattern



      • Similar character as multiple metastases


    • Benign osteoporotic pattern of compression fractures

     

  4. 4.


    Spectrum of imaging findings



    • Sclerotic mass in the vertebral body.


    • One of the features in POEMS syndrome (M-spike = multiple myeloma).


    • Normal bone marrow pattern is possible.


    • Single lesion: plasmacytoma.

     

  5. 5.


    Differential diagnosis



    • Red marrow hyperplasia/red marrow reconversion



      • Isointense or hyperintense signal to intervertebral disc on T1-weighted images


      • Patchy enhancement


    • Lymphoma



      • Multi-compartment: bone, epidural, leptomeningeal


      • Homogeneous signal


      • Stronger enhancement


    • Metastases



      • Multiple nodular masses


      • Heterogeneous enhancement


      • Cortical destruction


    • Osteoporosis in elderly



      • Patchy areas of marrow inhomogeneity due to fatty deposition and red marrow hyperplasia


      • Low signal area of bone marrow



        • Irregular shape


        • Same or higher signal than intervertebral disc

     


4.1.3.1 Illustrations: Multiple Myeloma




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Fig. 4.6
Spine involvement from multiple myeloma in a 43-year-old man. T1-weighted sagittal MR image (a) of the thoracic spine shows multiple small low signal intensity nodules. T2-weighted sagittal MR image (b) shows high signal intensity foci. Contrast-enhanced T1-weighted sagittal MR image (c) shows strong enhancement of these nodules


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Fig. 4.7
Spine involvement from multiple myeloma in a 47-year-old man. T1-weighted sagittal (a) and T2-weighted (b) MR images of the lumbar spine show tiny, innumerous hypointense nodules throughout the whole spine. Contrast-enhanced T1-weighted sagittal MR image (c) shows strong enhancement of these tiny nodules


4.2 Extradural Non-osseous Tumors or Tumorlike Lesions



4.2.1 Schwannoma





  1. 1.


    Epidemiology



    • 30–60 years old


    • M = F

     

  2. 2.


    Location



    • Thoracic > lumbar, cervical

     

  3. 3.


    Characteristic imaging findings



    • Well-defined, lobular contoured, extradural mass


    • Foraminal widening, bony scalloping


    • High signal on T2-weighted image, homogeneous or peripheral irregular enhancement

     

  4. 4.


    Spectrum of imaging findings



    • Intradural extension (dumbbell shape)


    • Cystic degeneration: peripheral irregular enhancement, central bright T2-hyperintensity

     

  5. 5.


    Differential diagnosis



    • Neurofibroma



      • Fusiform shape


      • Target sign: peripheral high signal + central low signal on T2-weighted images


    • Herniated disc (sequestration)



      • Low signal on T2-weighted images


      • No enhancement/peripheral enhancement with central T2-hypointensity


      • Protrusion at the base of the adjacent intervertebral disc


    • Abscess



      • Thin peripheral enhancement


      • Bone marrow edema of the adjacent vertebral body


    • Angiolipoma



      • T1-hyperintensity


    • Epidural hemangioma



      • Cystic or solid mass with homogeneous enhancement


      • Lobular shape


    • Epidural hematoma



      • No enhancement, foci of T1-hyperintensity or T2-hypointensity

     


4.2.1.1 Illustrations: Schwannoma




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Fig. 4.8
Extradural schwannoma in a 50-year-old man. T2-weighted axial MR image (a) shows a heterogeneous signal intensity extradural soft tissue mass involving the right T8/T9 neural foramen. Marked compression and left-sided deviation of the spinal cord is noted. Contrast-enhanced T1-weighted axial MR image (b) shows homogeneous enhancement


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Fig. 4.9
Extradural schwannoma in a 53-year-old woman. T2-weighted axial MR image (a) shows a high signal intensity left anterolateral extradural mass extending through the C1/C2 left neural foramen. Compression and right-sided deviation of the spinal cord is noted. Contrast-enhanced T1-weighted axial MR image (b) shows heterogeneous enhancement


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Fig. 4.10
Extradural schwannoma in a 65-year-old man. T2-weighted axial MR image (a) shows a high signal intensity right-sided extradural mass at L4/L5 level. Contrast-enhanced T1-weighted axial MR image (b) shows peripheral enhancement (white arrows)


4.2.2 Neurofibroma





  1. 1.


    Epidemiology



    • 30–60 years old


    • M = F

     

  2. 2.


    Location



    • Thoracic > lumbar, cervical

     

  3. 3.


    Characteristic imaging findings



    • Peripheral high signal (myxoid material) + central low signal (nerve tissue) on T2-weighted images


    • Fusiform shape in the neural foramen, swollen nerve rootlike shape

     

  4. 4.


    Spectrum of imaging findings



    • Plexiform neurofibromas



      • Multiple neurofibromas in the brachial or lumbar plexus


      • Neurofibromatosis type I


    • Diffuse neurofibroma



      • Ill-defined diffuse infiltration in the muscle and subcutaneous fat layer


      • Neurofibromatosis type 1

     

  5. 5.


    Differential diagnosis



    • Schwannoma



      • Similar imaging findings


      • Rare target sign


    • Malignant peripheral nerve sheath tumors (MPNST)



      • Large mass, more than 5 cm

     


4.2.2.1 Illustrations: Neurofibroma




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Fig. 4.11
Extradural neurofibroma in a 33-year-old man. T2-weighted axial MR image (a) shows a dumbbell-shaped heterogeneous high signal intensity extradural mass extending through the left L1/L2 neural foramen. Contrast-enhanced T1-weighted axial MR image (b) shows peripheral enhancement


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Fig. 4.12
Neurofibroma in a 35-year-old woman. T2-weighted coronal MR image (a) shows a high signal intensity lobulated paravertebral mass. Contrast-enhanced T1-weighted coronal (b) and axial (c) MR images show a peripheral enhancing mass extending through the right C6/C7 neural foramen (white arrow)


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Fig. 4.13
Extradural neurofibroma in a 25-year-old woman. T2-weighted axial (a) and sagittal (b) MR images show a high signal intensity lobulated extradural mass extending through the enlarged right T4/T5 neural foramen. Spinal cord compression and left-sided deviation is noted. Contrast-enhanced T1-weighted axial MR image (c) shows a peripheral enhancing mass


4.2.3 Herniated Intervertebral Disc (HIVD) (Sequestration)





  1. 1.


    Epidemiology



    • All age


    • M = F

     

  2. 2.


    Location



    • Lumbar

     

  3. 3.


    Characteristic imaging findings



    • Low signal on T2-weighted images


    • No enhancement/peripheral enhancement with central T2-hypointensity


    • Protrusion at the base of the adjacent intervertebral disc

     

  4. 4.


    Spectrum of imaging findings



    • Rare intradural disc herniation


    • Thick peripheral enhancement

     

  5. 5.


    Differential diagnosis



    • Schwannomas


    • Neurofibromas


    • Abscess


    • Hematoma

     


4.2.3.1 Illustrations: HIVD (Sequestration)




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Fig. 4.14
Disc sequestration at T12/L1 level in a 65-year-old woman. T2-weighted axial MR image (a) shows a right epidural lesion with peripheral high signal intensity and inner low signal intensity area (white arrow). The lesion causes cord compression and displacement to the left side. Contrast-enhanced T1-weighted axial MR image (b) shows peripheral enhancement


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Fig. 4.15
Disc sequestration at L2/L3 level in a 57-year-old woman. T2-weighted axial MR image (a) shows a high signal intensity lesion extending from the ventral and left lateral epidural space into the left neural foramen (white arrows). Contrast-enhanced T1-weighted axial MR image (b) shows peripheral enhancement


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Fig. 4.16
Disc sequestration at L3/L4 level in a 61-year-old man. T2-weighted axial MR image (a) shows a high signal intensity lobulated left lateral and posterior epidural lesion (white arrows). The lesion causes left L4 nerve root compression and central canal compromise. Contrast-enhanced T1-weighted axial MR image (b) shows peripheral enhancement


4.3 Intradural Extramedullary (IDEM) Tumors


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Oct 13, 2017 | Posted by in GENERAL RADIOLOGY | Comments Off on Top 3 Spinal Tumors of Each Compartment

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