SPINAL TUMORS IMAGING

Rahmi Ardhini
Bag/KSM Neurologi FKUNDIP/RSUP dr. Kariadi Semarang

STRONG 3 – 8 Maret 2018

 DEFINITION
Primary spinal cord tumors (SCT)
a group of neoplasms that arise from the parenchyma of
the spinal cord or from tissues that comprise or are
contained within the surrounding spinal canal,
including meninges, nerves, fat, bone, and blood vessels.

Secondary SCT
Neoplasm that arise as metastatic deposits, within the
spinal cord parenchyma or surrounding tissues, from
a primary lesion outside of the CNS
 EPIDEMIOLOGY
• Spinal tumors account for 15% of all CNS tumors
• Incidence 0,5 – 2,5 cases / 100.000 population
• Both genders are equally affected
• 60% extradural, 40% intradural
• Metastatic tumors are most common tumors of the
spine
• 50 – 55% located in thoracal segment
Epidemiology

CBTRUS Statistical Report: NPCR and SEER, 2010-2014.

Distribution of primary spinal cord, spinal meninges and cauda equina tumors in
(A) Children and adolescents ; (B) Adults (age > 20 years)
CLASSIFICATION
SPINAL CORD TUMOR

EXTRADURAL INTRADURAL

Primary
Extramedullary Intramedullary
Hemangioma
Osteoid-osteoma
Osteoblastoma Primary
Osteochondroma Nerve sheath tumor Primary
Giant-cell tumor Meningioma Ependymoma
Chondrosarcoma Fillum terminal Astrocytoma
Ewing’s Sarcoma ependymoma
Multiple myeloma Hemangioblastoma
Paraganglioma
Ganglioneuroma Secondary
Secondary
Spinal Metastasis Intramedullary
Secondary metastasis
Extramedullary
metastasis
Historic classification of spine tumors based on
myelography

(A) Normal,
(B) Extradural
(C) Intradural extramedullary
(D) Intradural intramedullary
SPINAL TUMORS IMAGING METHODS
• Plain Radiograph (X-rays)
• Computed Tomography (CT)
o Conventional CT
o Myelo-CT
• Magnetic Resonance Imaging (MRI)
• Technetium-99m (99mTc) bone scans
• Single photon emission computed tomography
(SPECT)
• Positron Emission Tomography (PET)
• Spinal Angiography
 Plain Radiograph

 First imaging modality  explore the vertebra

 Low sensitivity and specificity
 Do not images soft tissue adequately
 40% spine metastases visualized in plain radiograph

Neoplasm of vertebra can present as :

• Osteolytic
• Osteoblastic/ sclerotic
• Mixed
 Computed Tomography (CT)

 CT and CT-myelography : greatly enhance

anatomic details superior to X-rays
 Excellent visualization of osseus structure
 Poor detection in soft-tissues lesions
 Use when MRI is contraindicated
 Magnetic Resonance Imaging (MRI)

 Diagnostic procedur of choice in spinal tumors

 Superior in detecting : bone marrow, spinal
cord, and soft-tissue
 Earlier tumor discovery
 Precise localization
 Evaluating therapeutic results
 Imaging protocol : T1W and T2W (contrast)
axial, coronal and sagital plane
 Spinal Angiography

 Rare indications for spinal lesions

 Mass with rich vascular structures (aneurysmal
bone cysts and hemangiosarcoma)
 Showing the vascularity of all feeding and
draining vessels
 Used for selective embolization of hypervascular
lesions
EXTRADURAL TUMOR
 Primary Benign Tumors of the Spine
Location MRI CT Others
Hemangioma Usually confined T1 and T2 White polka- dot Most common
to vertebral body, hyperintense; often appearance tumor of the spine-
but may extend to heterogeneous with 10-12% 25-30%
pedicle flow voids multiple
Negative bone scan
Osteoidosteoma Posterior elements Central nidus is Osteolytic lesion
<2cm; typically Intermediate with sclerotic rim
lumbar spine; soft intensity on T1 ; and
tissue mass may hypointense and
be present edematous rim on
T2
Osteoblastoma >1.5-2cm Neural Similar to osteoid Well- circumscribed Scoliosis 50-60%
arch Cervical most osteoma; T1 and T2 expansile Bone scan positive
common signals depend on Variable
degree of enhancement
calcification
Giant Cell Tumor Most frequent Low-intermediate May reveal the Locally aggressive
spinal location is signal; CT scan to destruction of sacral Bone scan positive
sacrum assess soft tissue foramina Lytic, expansile
Heterogeneous lesion
enhancement
Osteochondroma Common in C May miss a small Modality of choice
spine (C2) tumor
Primary Malignant Tumors of the Spine
 Benign spinal tumor:
Stage 1 : latent lesion
Stage 2 : active lesion
Stage 3 : aggressive
lesion

Malignant spinal tumor

:
Stage I : low grade
Stage II : high grade
Stage III : metastasis

Enneking’s staging of benign and malignant spinal tumors

 Hemangioma

Typical spotted bright signal intensity changes within the vertebral body of L1 on a
T1W and b T2W image suggesting a benign hemangioma
 Osteoid Osteoma

Small lucent lesion with a

calcified central nidus

Bone scans in osteoidosteoma Sclerosis of the surrounding bone

Osteoblastoma
 Multiple Myeloma

(a) Lateral radiograph demonstrated compression fractures at L1 and L2. (b)

Hypointense on the T1W image and (c) hyperintense signal intensity on the T2W
image.
 Metastasis

• Primary tumors : breast 73% (47-85%), prostate 68% (33-

85%), thyroid 42% (28-60%), lung 36% (30-55%), kidney 35%
(33- 40%), esophageal 6% (5-7%), and gastrointestinal 5% (3-
11%) (Maccauro et al 2011)
• Most type of bone metastasis is osteolytic, destructive and
invasive
• Imaging modality : plain radiograph, bone scans, MRI, PET
scans
• Lesions can be focal or multifocal and the diffuse involvement
of the vertebral bodies.
• MRI : T1 hypointense and T2 hyperintense
 Metastasis

“winking owl sign”

the absent of
pedicle

Compression fracture. (A) T1 hypointense

(B) T2 intermediate hyperintense

Diffuse vertebral metastasis. (A) T1

hypointense (B) T2 hyper-isointense
INTRADURAL EXTRAMEDULLARY
TUMOR
Nerve sheath tumor
SCHWANNOMA

• Most common nerve sheath tumor

• Solitary, well circumscribed, encapsulated
• Plain films and CT may demonstrate foraminal
enlargement, pedicular erosion, posterior vertebral
scalloping, thinned lamina, or a paravertebral soft
tissue mass.
• MRI : T1W isointens, T2W hyperintense ;
homogenous contrast enhancing
Schwannoma

(A) Sagital T1W + C enhance heterogenously, well-demarcated

(B) Axial T1 W + C showed dumbbell-shaped tumor extending through right neural foramen
Schwannoma

(a) T1W showing a round, well demarcated tumor with intense contrast enhance
(b) T2W + C
(c) Axial T1 contrast, showing a typical dumbbell-shape
 MENINGIOMA

 Second most common extramedullary tumor

 75% in thoracic segment
 Location : intradural (90%), 5% are both intradural and
extradural (dumb-bell), and 5% are only extradural
 Mostly in thoracic region (80%)
 Broad dural base, dural tail
 MRI : T1W iso-hypointens, T2W isointens ; strong
homogenous contrast enhancing
Meningioma. (A) Sagital T2W (B) T1W and (C) T1W + C demostrate a well-
circumscribed, homogenous enhancing intradural-extramedullary lesions
Meningioma
 LEPTOMENINGEAL
METASTASIS

• Leptomeningeal metastasis (LM) : infiltrating tumor cells into

the arachnoid and the piamater (leptomeninges)
• Diagnosed in 4% - 15% of patients with solid tumors.
• The most involved : breast (12-35%), lung (10-26%),
melanoma (5-25%), gastrointestinal (4-14%), and CUP (1-7%)
• Gold standard : CSF examination
• MRI sequence : T1W, T2W, FLAIR
• MRI findings : subarachnoid and parenchymal enhancing
nodules, diffuse or focal pial enhancement, and nerve root
enhancement
Leptomeningeal metastases in man with neuroblastoma. (A) Sagital T2W
hypointensity (B) Sagital T1W hypointensity (C) T1W+C
INTRAMEDULLARY TUMOR
MRI appearance of different intramedullary spinal tumors
 EPENDYMOMA

 Benign tumor, slow-growth

 Common location below foramen magnum
 Diffuse enlargement of spinal cord
 Associated with syrinx and cyst
 MRI
T1 isointense or slightly hiperintens ; T2 hyperintense
Enhanced with contrast
“Cap sign”  deposit of hemosiderin on cranial or caudal
margin of the tumor
 T1W + C. T2W + C. enhancing
enhancing lesion with cystic
lesion with component and
central cystic syrinx extending
rostral to caudal

DTI images show non-infiltrating mass with fiber displacement

Intramedullary ependymoma showing uniform enhancement, central location,
focal distention of spinal cord.
 ASTROCYTOMA

CT
 Low-grade : hypodense, homogeneous with minimal or absent
contrast enhancement
 High-grade tumors may show areas of more intense contrast
enhancement and internal heterogenity

MRI
 Diffuse astrocytomas : T1W hypointense – isointense ; T2W hyper-
intense
 Poorly defined margins
 Contrast enhancement is usually mild and may be focal or diffuse or
may be completely absent
Astrocytoma

(A) Sagital T2W and (B) T1W + contrast demonstrate an expanded cord with
heterogenously enhancing tumor with a cystic-necrotic degeneration.
Astrocytoma
 HEMANGIOBLASTOMA

 a benign, WHO gr.I tumor

 Common in cervical and thoracal segment
 25% associated with von Hippel-Lindau disease
 MRI : T1W isointense, and T2W hyperintense
 Spinal angiography : enlarged feeding arteries, intense
nodular stains, and early draining
Hemangioblastoma

Hemangioblastoma. (A) T2W sagital images show a heterogenous mass at T6 associated with cord edema
and hypointensity linear structure consistent with a vessel posterior to the cord. (B) T1W image show
enhancing bilobulated mass. (C) Axial T1W contrast show bilobulated mass and extramedullary “snowman”
appearance. (D) Axial T2W show hyperintensity signal with extensive holocord edema.
 INTRAMEDULLARY
METASTASIS

 Primary cancer : lung (49%), breast (15%), lymphoma (9%),

colorectal (7%), head and neck (6%), renal (6%) and
melanoma (5%) (Wilson et al, 2012)
 Commonly affects thoracic segment (57%)
58 y.o female with a history of metastatic melanoma. (A) T2W iso-
hypointense (B) T1W hyperintense
 SUMMARY
• Spinal tumors consist of primary or secondary
(metastasis)
• Classified as extradural, intradural
extramedullary, and intradural intramedullary
tumors
• Imaging procedure of choice is MRI