Extradural Tumors • Introduction

ECNR 15th Cycle, Module 2 - Tumors Antwerp, April 29 - May 3, 2019 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 Primary spinal bone tumors • monoclonal protein in urine • primary breast cancer • renal insufﬁciency • bone pain • solitary vertebral lesions are less common than tumors • - bone scintigraphy • + bone scintigraphy with multiple locations • benign lesions are usually: • asymptomatic • incidentals ﬁndings • malignant vertebral tumors usually: • cause back pain • sometimes manifest neurologic symptoms, especially MM mets 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)

• multiple myeloma • metastases Flow chart • lymphoma LYTIC • hemangioma

part 1: age! YES Multiple? 0-10 • eosinophilic granuloma

10-20 • osteoid osteoma • ABC

20-50 • GCT 40-60 • plasmacytoma 50-70 • chordoma • MM • hemangioma mets lymphoma • metastasis

• multiple myeloma • multiple myeloma • metastases • metastases • lymphoma LYTIC • lymphoma LYTIC • hemangioma • hemangioma • sarcoma (osteo-, chondro- , • sarcoma (osteo-, chondro- , YES Ewing) YES Ewing) • plasmacytoma/MM • plasmacytoma/MM Multiple? • lymphoma LYTIC Multiple? • lymphoma LYTIC • GCT • GCT NO • chordoma NO • chordoma • ABC • ABC Involvement of YES Involvement of YES adjacent levels? adjacent levels?

plasmacytoma chordoma met hemangioma ABC • multiple myeloma • multiple myeloma metastases metastases LYTIC • LYTIC • • lymphoma • lymphoma • hemangioma • hemangioma • sarcoma (osteo-, chondro- , • sarcoma (osteo-, chondro- , YES Ewing) YES Ewing) • plasmacytoma/MM • plasmacytoma/MM Multiple? • lymphoma LYTIC Multiple? • lymphoma LYTIC • GCT • GCT NO • chordoma NO • chordoma • ABC • ABC Involvement of YES Involvement of YES adjacent levels? adjacent levels? metastases metastases • hemangioma • hemangioma plasmacytoma/MM • plasmacytoma/MM • • eosinophilic granuloma • eosinophilic granuloma chordoma • chordoma • • GCT • GCT • lymphoma • • lymphoma • • osteoid osteoma • osteoid osteoma • osteoblastoma • osteoblastoma • sarcoma (osteo-, • sarcoma (osteo-, • osteochondroma • osteochondroma • GCT chondro- , Ewing) • GCT chondro- , Ewing) (c) 2001 Primal Pictures Ltd. • ABC (c) 2001 Primal Pictures Ltd. • ABC

osteoid osteoma osteoblastoma GCT

metastases metastases • hemangioma • hemangioma plasmacytoma/MM • plasmacytoma/MM • • eosinophilic granuloma • eosinophilic granuloma chordoma • chordoma • • GCT • GCT • lymphoma • • lymphoma • • osteoid osteoma • osteoid osteoma • osteoblastoma • osteoblastoma • sarcoma (osteo-, • sarcoma (osteo-, • osteochondroma • osteochondroma • GCT chondro- , Ewing) • GCT chondro- , Ewing) (c) 2001 Primal Pictures Ltd. • ABC (c) 2001 Primal Pictures Ltd. • ABC

Example 1 - 65-year-old Example 1

0-10 • eosinophilic granuloma

10-20 • osteoid osteoma • ABC

20-50 • GCT 40-60 • plasmacytoma 50-70 • chordoma • MM • hemangioma • metastasis Example 1 Example 2 - 20-year-old

• multiple myeloma 0-10 • metastases • eosinophilic • lymphoma granuloma • hemangioma 10-20 • osteoid osteoma YES • ABC

Multiple? 20-50 • GCT 40-60 • plasmacytoma 50-70 50-70 • chordoma • MM • MM • hemangioma • metastasis • metastasis

conclusion

Example 2 Example 2

10-20 10-20 • osteoid osteoma • •osteoidosteoid osteoma osteoma • ABC • •osteoblastomaABC • osteochondroma • GCT

Example 3 - 11-year-old Example 3

10-20 • osteoid osteoma • ABC Example 3 Example 4 - 48-year-old

10-20 • osteoid osteoma • ABC

Example 4 Example 4

0-10 • eosinophilic granuloma

10-20 • osteoid osteoma • ABC

20-50 • GCT 40-60 • plasmacytoma 50-70 • chordoma • MM • hemangioma • metastasis Example 4 Example 4

• hemangioma • eosinophilic granuloma • GCT

20-50 20-50 • GCT • GCT 40-60 40-60 • plasmacytoma • plasmacytoma • chordoma • chordoma • hemangioma • hemangioma

Example 5 - 18-year-old Example 5

• osteoid osteoma • osteoblastoma • osteochondroma • GCT • ABC

Example 5 Example 5

• osteoid osteoma • osteoid osteoma • osteoblastoma • osteoblastoma • osteochondroma • osteochondroma • GCT • GCT • ABC • ABC 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 Example 6 - 30-year-old Spinal metastases

• most frequent spinal tumor is metastasis • sclerotic bone lesions in • imaging tuberous sclerosis complex • screening patients with malignancies • in upto 90% of patients • ‘incidental’ ﬁnding of bone metastases • mainly in the posterior vertebral elements • fracture, neurologic signs • awareness of these lesions in • differential diagnosis of ‘multiple bone lesions’ TSC is important to avoid • follow-up of bone metastases misdiagnosis with osteoblastic 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 first • detection imaging study in patients who are asymptomatic • differentiating benign/incidental from malignant/significant • diagnosis - flowchart • 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