European Course in Neuroradiology

Cycle 16 - Module 2: Tumors

May 5 2021
Overview

Extradural Tumors • introduction

Johan Van Goethem, • imaging algorithm

Frank Ramon, Luc van den Hauwe, Paul Parizel
• examples
• metastases
• conclusion

Diagnosis Diagnosis

plasmacytoma hemangioma
plasmacytoma GCT
 Diagnosis
• monoclonal protein in urin • primary breast cance
• renal insuf cienc • bone pai
• - bone scintigraphy • + bone scintigraphy
MM mets
Primary spinal bone tumors
• solitary vertebral lesions are less common than tumors
with multiple locations
• benign lesions are usually:
• asymptomatic
• incidentals ndings
• malignant vertebral tumors usually:
• cause back pain
• sometimes manifest neurologic symptoms, especially
in children

Primary spinal bone tumors Primary spinal bone tumors

• diagnosis is based on:

• most useful imaging signs suggestive for malignant
lesions: • multiplicity
• lytic without marginal sclerosis • age of the patient
• surrounding bone edema • imaging characteristics
• invasion of neighbouring structures • location of the lesion(s)
n

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y

 • multiple myelom
•
Flow chart
metastase
LYTIC
• lymphoma
• hemangioma
part 1: age! YES

Multiple?
0-1
• eosinophilic granuloma
10-2
• osteoid osteom
• ABC

20-5
• GCT 40-6
• plasmacytom
50-7 • chordom
• M • hemangioma
mets lymphoma
• metastasis

• multiple myelom • multiple myelom

• metastase
LYTIC • metastase
LYTIC
• lymphoma • lymphoma
• hemangioma • hemangioma
• sarcoma (osteo-, chondro- , • sarcoma (osteo-, chondro- ,
YES Ewing YES Ewing
• plasmacytoma/M • plasmacytoma/M
Multiple? • lymphom LYTIC Multiple? • lymphom LYTIC
• GC • GC
NO • chordom NO • chordom
• ABC • ABC
Involvement of YES Involvement of YES

adjacent levels? adjacent levels?

plasmacytoma chordoma met hemangioma ABC

M

 • multiple myelom • multiple myelom

• metastase
LYTIC
LYTIC
• lymphoma
• hemangioma
• sarcoma (osteo-, chondro- ,
YES Ewing
• plasmacytoma/M
Multiple? • lymphom LYTIC LYTIC
• GC
NO • chordom
• ABC
Involvement of YES

adjacent levels?
• metastase
• hemangiom • metastase
• plasmacytoma/M
• eosinophilic granulom • plasmacytoma/M
• eosinophilic granulom
• chordom
• GCT • chordom
• GCT
• lymphoma • lymphoma
• osteoid osteom • osteoid osteom
• osteoblastom
• sarcoma (osteo-, • osteoblastom
• sarcoma (osteo-,
• osteochondrom
chondro- , Ewing)
• osteochondrom
chondro- , Ewing)
• GC • GC
(c) 2001 Primal Pictures Ltd.
• ABC • ABC

osteoid osteoma osteoblastoma GCT

• metastase
• hemangiom • metastase
• hemangiom
• plasmacytoma/M
• eosinophilic granulom • plasmacytoma/M
• eosinophilic granulom
• chordom
• GCT • chordom
• GCT
• lymphoma • lymphoma
• osteoid osteom • osteoid osteom
• osteoblastom
• sarcoma (osteo-, • osteoblastom
• sarcoma (osteo-,
• osteochondrom
chondro- , Ewing)
• osteochondrom
chondro- , Ewing)
• GC • GC
(c) 2001 Primal Pictures Ltd.
• ABC (c) 2001 Primal Pictures Ltd.
• ABC
T

 Example 1 - 65-year-old Example 1

0-1
• eosinophilic
granuloma

10-2
• osteoid osteom
• ABC

20-5
• GCT
40-6
• plasmacytom
50-7 • chordom
• M • hemangioma
• metastasis

Example 1 Example 2 - 20-year-old

• multiple myelom
0-1
• metastase • eosinophilic
• lymphoma granuloma
• hemangioma
10-2
• osteoid osteom
YES • ABC

Multiple? 20-5
• GCT
40-6
• plasmacytom
50-7 50-7 • chordom
• M • M • hemangioma
• metastasis • metastasis

conclusion
M

 Example 2 Example 2

10-2 10-2
• osteoid osteom • •osteoid osteom
osteoid osteom
• ABC • •osteoblastom
ABC
• osteochondrom
• GC
20-5 20-5
(c) 2001 Primal Pictures Ltd. • ABC
• GCT • GCT
Involvement of
adjacent levels?
• sarcoma (osteo-, chondro- ,
Ewing
• plasmacytoma/M
• lymphom LYTIC
• GC
• chordom
conclusion • ABC

Example 3 - 11-year-old Example 3

10-2
• osteoid osteom
• ABC
T

 Example 3 Example 4 - 48-year-old

10-2
• osteoid osteom
• ABC

(c) 2001 Primal Pictures Ltd.

• osteoid osteom
• osteoblastom
• sarcoma (osteo-,
• osteochondrom
chondro- , Ewing)
• GC
• ABC

Example 4 Example 4
T

 Example 4 Example 4
0-1
• eosinophilic
granuloma

10-2
• osteoid osteom
• ABC

20-5
• GCT
40-6
• plasmacytom
50-7 • chordom
• M • hemangioma
• metastasis

Example 4 Example 4
• hemangiom
• eosinophilic granulom
• GCT

20-5 20-5
• GCT • GCT
40-6 40-6
• plasmacytom • plasmacytom
• chordom • chordom
• hemangioma • hemangioma
M

Example 6 - 30-year-old Example 6 - 30-year-old

Example 6 - 30-year-old Example 6 - 30-year-old

Example 6 - 30-year-old
Example 6 - 30-year-old
• sclerotic bone lesions in
tuberous sclerosis complex
• in upto 90% of patients
• mainly in the posterior
vertebral elements
• awareness of these lesions in
TSC is important to avoid
misdiagnosis with osteoblastic
metastases
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Example 6 - 30-year-old
Spinal metastases
• most frequent spinal tumor is metastasis
• imaging
• screening patients with malignancies
• ‘incidental’ nding of bone metastases
• fracture, neurologic signs
• differential diagnosis of ‘multiple bone lesions’
• follow-up of bone metastases
• non-bone spinal metastases
 Spinal metastases
Spinal metastases

• spinal metastases
• originate most often from arterial seeding
• retrograde venous (mainly intra-abdominal tumors)
• direct extension (mainly from lung)

Heindel et al. 2014

Strategy Conclusion
• bone scan (SPECT) is very sensitive in the detection of
osseous metastases and is recommended as the rst • detection
imaging study in patients who are asymptomatic
• differentiating benign/incidental from malignant/signi cant
• diagnosis - owchart
• if
• age
• the bone scan is negative AND
• multiplicity
• there is a high suspicion for bone metastases AND
(symptomatic and/or purely osteolytic (NSCLC, GI, …), …) • location

• therapy will change if spinal metastases are present • imaging characteristics

• consider WB-MRI and/or PET as an add-on • screening for metastases
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