Expansile bone lesions of the vertebra

Clinical outcome in Giant cell tumor of cervico-thoracic spine: Our experience with three cases

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Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. The purpose of this study was to report on a surgical treatment for the cases of GCT (C2, D4 and C7-D1). In the cervico-dorsal spine, the incidence is extremely low and has been reported very less in the literature.

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Local recurrence is high when total resection is not achieved, especially when the tumor extends around the neural elements or adjacent vascular structures. In the upper cervical spine, the recurrence rate is slightly higher because complete excision is not always feasible.

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Giant cell tumour of cervico-dorsal spine is a rare entity and should be managed Surgically with en bloc/extralesional resection but due to risk of surrounding neurovascular structures damage they are managed by marginal resection.

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Also radiotherapy plays a pivotal role to prevent recurrence in cases where extralesional/en bloc excision is not feasible if used in controlled dosage.

Background

Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. The purpose of this study was to report on a surgical treatment for the cases of GCT (C2, T4 and C7-T1). The spine is not a common site for a Benign GCT, with a 2.5% incidence in the sacrum and 2.9% in the vertebrae above the sacrum. In the cervico-thoracic spine, the incidence is extremely low and has been reported very less in the literature.

Material and methods

This study was conducted on 3 cases of GCT of the spine and evaluated the outcome of different treatment modalities retrospectively. All the cases were treated with intralesional surgical resection but only one developed recurrence.

Results

Cord compression and neurological deficits of varying grades was observed in all the cases. All patients also presented with clinical as well as radiological instability. Overall results were satisfactory, as all patients were symptom-free postoperatively. One out of the three cases had tumour recurrence and needed repeat intervention.

Conclusion

Giant cell tumour of cervico-thoracic spine is a rare entity and should be managed Surgically with en bloc/extralesional resection but due to risk of surrounding neurovascular structures damage they are managed by marginal resection therefore since total resection is not possible there are high chances of recurrences, Hence require close monitoring and follow up for early diagnosis and appropriate management.

The clothes maketh the sign

Abstract

Pattern recognition is a key tool that enables radiologists to evoke certain diagnoses based on a radiologic appearance. In Shakespeare’s Hamlet, Polonius tells his son Laertes to dress well because “apparel oft proclaims the man”; this phrase is now expressed in modern parlance as “the clothes maketh the man”. Similarly in radiology, appearances are everything, and in the case of radiologic signs, occasionally “the clothes maketh the sign”. The radiologic signs described in this pictorial review resemble items of clothing, fabric types, headwear, or accessories and are found in the musculoskeletal, pulmonary, gastrointestinal, and genitourinary systems. These “clothing signs” serve as a useful visual trigger to help radiologists to identify particular disease entities.

Teaching Points

• Pattern recognition enables radiologists to evoke a diagnosis based on radiologic appearance.

• The radiologic signs described in this review resemble clothing, fabric, or accessories.

• These “clothing signs” serve as visual triggers that evoke particular disease entities.

The rare case of giant cell tumor occuring in the axial skeleton after 15 years of follow-up: Case report

The majority of giant cell tumors (GCTs) occur in the ends of the long bones. The presence of more than one GCT in the axial skeleton is rare. A GCT is capable of remaining clinically latent following treatment and becoming active a number of years later. We report an extremely rare case of GCT occurring in the axial skeleton, involving the sacrum, thoracic spine and parieto-occipital skull in more than 15 years of follow-up.

Primary telangiectatic osteosarcoma of the cervical spine

Telangiectatic osteosarcoma (TOS) is one of the 8 subtypes of osteosarcoma that infrequently affects the spine. The radiopathological features of TOS overlap with those of more benign entities, most commonly the aneurysmal bone cyst), and therefore is a significant diagnostic challenge. It is a rare but well-described entity in the thoracolumbar and sacral spine, and to the authors' knowledge has not been previously reported in the cervical spine. The authors report the case of a 15-year-old boy who presented with a 6-month history of neck pain and torticollis. He underwent preoperative glue embolization followed by a staged subtotal C-5 spondylectomy and posterior fusion for a C-5 vertebral body lytic expansile lesion. Histopathological examination showed the lesion to be TOS. The surgery was followed by adjuvant radiation and chemotherapy with a favorable outcome at the 1-year follow-up. This report reiterates that TOS is an important differential diagnosis for aneurysmal bone cyst and giant-cell tumor of the spine, as its biological behavior and clinical outcome differ from those of these more benign lesions, which it mimics.

CT and MRI of fibrous dysplasia of the spine

OBJECTIVES

The purpose of this study was to present the CT and MRI findings of patients with fibrous dysplasia (FD) of the spine.

METHODS

Among the patients with pathologically proven skeletal FD, 12 (8 males and 4 females; mean age, 43 years) who were evaluated with either spine CT or MRI were included. The number and location of the involved vertebral segments, the presence of lytic lesions, ground-glass opacity (GGO), an expansile nature, cortical disruption, a sclerotic rim, a decrease in body height and contour deformity were examined on CT scans (n=12), while signal intensity, enhancement patterns and the presence of a dark signal rim on the lesion were examined using MRI (n=9).

RESULTS

Nine patients had polyostotic FD, including one with an isolated spinal localisation, while three had monostotic FD. An expansile nature (n=3) and osteolytic lesions with GGO (n=3) were seen. On CT images, GGO was noted in all patients. An expansile nature (n=11) and presence of lytic lesions (n=11) were noted. A decrease in body height (n=9) and sclerotic rim formation (n=9) were indicated. Contour deformities were visible in six patients. The MRI findings were non-specific. Dark signal rims were visible on MRI in seven patients.

CONCLUSION

Typical imaging findings of extraspinal FD were noted on spine CT scans. These characteristic CT imaging findings of spinal FD may be helpful in differentiating FD from other common spine diseases.

Primary tumors of the osseous spine

Primary tumors of the spine are less frequent than metastatic disease, multiple myeloma, and lymphoma. MR imaging is commonly used to evaluate the spine in patients presenting with pain and can further characterize lesions that may be encountered on other imaging studies, such as radiographs, bone scintigraphy, or CT. This article guides radiologists in identifying these lesions and referring physicians to the appropriate patient evaluation. It also offers directions for avoiding all-encompassing broad differential diagnosis lists in situations where the clinical scenario or specific imaging features can significantly limit the diagnostic possibilities.

MRI findings of giant cell tumors of the spine

OBJECTIVE

The purpose of this article is to describe the MRI features of giant cell tumors of the spine in 10 patients.

CONCLUSION

One of the tumors was located in C7. The other nine tumors were located in the thoracic spine, lumbar spine, and sacrum, three in each site. The characteristic findings included an expansile mass with heterogeneous low to intermediate signal intensity on the T2-weighted images (10/10), a curvilinear area of signal void on T1- and T2-weighted images (9/10), and cystic changes within the mass (4/10). Although no imaging feature was pathognomonic, MRI was found to be valuable in identifying the tumor, revealing its extent, and defining its relationship with the intraspinal structures.

Cervical schwannoma presenting as an expansile vertebral body lesion: report of two cases with a technical note on the surgical management

BACKGROUND

Schwannoma causing invasion and osteolytic expansion of the vertebral body has been uncommonly noted in lumbar and thoracic regions, but has not been yet reported in the cervical spine. Our purpose is to discuss the surgically relevant anatomical features of cervical schwannomas associated with vertebral invasion, to review their imaging findings and briefly discuss the surgical strategies in managing these challenging lesions.

CASE DESCRIPTION

Clinical and radiological follow-up in two patients is presented. Both tumors were successfully resected using an anterior approach with lateral extension. Pathology was diagnostic for a benign schwannoma, and at 1-year follow-up, both patients were asymptomatic with no recurrence.

CONCLUSION

In conclusion, schwannoma should be included in the differential diagnosis of large, extradural mass causing expansion and destruction of the spine, especially with characteristic imaging findings such as neural foraminal widening and vertebral body scalloping. Aggressive surgical management with skeletonization of the vertebral artery may provide good technical and clinical outcome.

Imaging and differential diagnosis of primary bone tumors and tumor-like lesions of the spine

Primary bone tumors and tumor-like lesions of the spine and sacrum are rare. A wide variety of benign and malignant lesions can arise in the spine and sacrum. Specific diagnosis is based on the location, matrix appearance and patient's age at time of presentation. In this location CT is often necessary for matrix characterization, particularly, detection of mineralization. MRI can be helpful for further characterization and radiological differential diagnosis. An overview of age distribution and imaging features including pattern for differential diagnosis is presented for the most frequent primary spinal bone tumors and tumor-like lesions.

C-1 root schwannoma with aggressive lateral mass invasion

Schwannomas are relatively common, benign tumors that are thought to arise from the nerve sheath cell. Schwannomas of the C1 root are extremely rare and seldom invade lateral masses because they gradually increase in size and can extend through the wide space behind the lateral mass instead of the intervertebral foramen. We present here an unusual case of a benign schwannoma that aggressively invaded the lateral mass of C-1.

Villonodular synovitis (PVNS) of the spine

OBJECTIVE

To describe the imaging features of spinal pigmented villonodular synovitis (PVNS).

DESIGN AND PATIENTS

We retrospectively reviewed 15 cases of pathologically proven spinal PVNS. Patient demographics and clinical presentation were reviewed. Radiologic studies were evaluated by consensus of two musculoskeletal radiologists for spinal location, spinal segments affected, lesion center, detection of facet origin and intrinsic characteristics on radiography (n=11), myelography (n=7), CT (n=6) and MR imaging (n=6).

RESULTS

Women (64%) were more commonly affected than men (36%) with an average age of 28 years. Clinical symptoms were pain (45%), neurologic (9%) or both (36%). Lesions most frequently affected the cervical spine (53%) followed by the thoracic (27%) and lumbar regions (20%). The majority of lesions (93%) were centered in the posterior elements with frequent involvement of the pedicle (67%), neural foramina (73%), lamina (67%) and facets (93%). No lesions showed calcification. Determination of a facet origin by imaging was dependent on imaging modality and lesion size. A facet origin could be determined in 45% of cases by radiography vs 67% of patients by CT (n=6) and MR (n=6). Large lesions (greater than 3 cm in at least one dimension) obscured the facet origin in all cases with CT and/or MR imaging (44%,n=4). Small lesions (less than 3 cm in any dimension) demonstrated an obvious facet origin in all cases by CT and/or MR imaging (56%,n=5). Low-to-intermediate signal intensity was seen in all cases on T2-weighted MR images resulting from hemosiderin deposition with "blooming effect" in one case with gradient echo MR images.

CONCLUSIONS

PVNS of the spine is rare. Large lesions obscure the facet origin and simulate an aggressive intraosseous neoplasm. Patient age, a solitary noncystic lesion centered in the posterior elements, lack of mineralization and low-to-intermediate signal intensity on all MR pulse sequences may suggest the diagnosis in these cases. Small lesions demonstrate a facet origin on CT or MR imaging. This limits differential considerations to synovial-based lesions and additional features of a solitary focus, lack of underlying disease or systemic arthropathy, no calcification as well as low-to-intermediate signal intensity on all MR images should allow spinal PVNS to be suggested as the likely diagnosis.

From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation

The radiologic features of giant cell tumor (GCT) and giant cell reparative granuloma (GCRG) of bone often strongly suggest the diagnosis and reflect their pathologic appearance. At radiography, GCT often demonstrates a metaepiphyseal location with extension to subchondral bone. GCRG has a similar appearance but most commonly affects the mandible, maxilla, hands, or feet. Computed tomography and magnetic resonance (MR) imaging are helpful in staging lesions, particularly in delineating soft-tissue extension. Cystic (secondary aneurysmal bone cyst) components are reported in 14% of GCTs. However, biopsy must be directed at the solid regions, which harbor diagnostic tissue. These solid components demonstrate low to intermediate signal intensity at T2-weighted MR imaging, a feature that can be helpful in diagnosis. Multiple GCTs, although rare, do occur and may be associated with Paget disease. Malignant GCT accounts for 5%-10% of all GCTs and is usually secondary to previous irradiation of benign GCT. Treatment of GCT usually consists of surgical resection. Recurrence is seen in 2%-25% of cases, and imaging is vital for early detection. Recognition of the spectrum of radiologic appearances of GCT and GCRG is important in allowing prospective diagnosis, guiding therapy, and facilitating early detection of recurrence.

Vertebral tumors and pseudotumors

This article discusses lesions that may present as vertebral tumors at radiologic examination. Conditions are discussed in order of decreasing frequency: pseudotumoral lesions, vertebral metastases, bone marrow diseases, and primary vertebral tumors, which are relatively uncommon. The differential diagnosis between nontraumatic benign and malignant vertebral collapses is also discussed.

CT and MRI of the normal and diseased perivertebral space

The perivertebral space is in the midline, in the deep tissues of the neck, and can be identified from the skull base above to the mediastinum below. It is a discrete space completely enclosed by the deep layer of deep cervical fascia. The fascial attachments of the perivertebral space divide it into two areas, the anterior prevertebral and posterior paraspinal portions. We made a retrospective analysis of the radiologic and clinical records of 52 patients with lesions in the perivertebral space, to identify the imaging features that mark a lesion as originating in the perivertebral space and define the spectrum of pathology which occurs in the space. Mass lesions present in the prevertebral or paraspinal portions. In the former they usually involve the vertebral body, displacing the prevertebral muscles anteriorly. Epidural extension from lesions in the perivertebral space proper is common. Masses in the paraspinal perivertebral space usually displace the paraspinal muscles away from the spine. We found 9 inflammatory lesions, 29 malignant and 6 benign tumors, and 8 miscellaneous lesions.