MRI appearances of a destructive giant cell tumor and aneurysmal bone cysts of the lumbosacral spine

Abstract

CASE REPORT We report a case of a 35­year­old man who was hospitalized on January 23, 2008 who complained of experiencing weakness on both legs for six months prior to his hospital admission. The weakness started on his left leg after he played badminton and lasted for three months. Two weeks later, he felt weakness in his right leg. He also felt cramps and pain on his lower back, and it spread down to the lower leg. The pain was aggravated by coughing and sneezing. He could not normally urinate and defecate. There was no history of trauma, fever, chronic cough, diabetes and cardiac disease. Based on neurologic physical examination, movement on the lower limb had decreased. Additionally, pathological reflex at the lower limb, the muscle tone and the physiological reflex decreased as well. Sensory functions were anesthetized from acral until S1 dermatome and hypoesthesia from the S1 dermatome until L3 dermatome in both sides. Routine and blood chemistry analyses revealed the following results: white blood cell 8.43/mm3, red blood cell 4.21x106/mm3, hemoglobin 12.7 g/dL, hematocrit 38%; platelet 310x103/mm3, blood sedimentation rate 1 hr – 11 mm and 2 hr – 30 mm (normal value for males below 10 mm/1st hr glucose (random) 95 mg/dL, total cholesterol 194 mg/dL, HDL 46 mg/dL, LDL 70 mg/dL, triglyceride 146 mg/dL, uric acid 4.6mg/dL, urea 29mg/dL, creatinine 0.73 mg/dL, SGOT 15 mg/dL, SGPT 11 mg/dL, alpha­ fetoprotein 1.59 mg/mL (Normal value <12.5 mg/mL), anti TB IgG ­ negative and prostate­specific antigen (PSA) 2.73 mg/mL (normal value <4 mg/mL). The perspiration test showed no color change from acral up to the knee (spinal cord dermatome L3). An anterior posterior (AP)/lateral view of lumbosacral X­ray showed that alignment of lumbosacral vertebrae was changed; destruction of posterior part of lumbar 4–5 vertebrae corpus and destruction of right lumbar 4 pedicles and bilateral lumbar 5 pedicles; narrowing in the vertebral discus of L4–5; bone mineralization in normal range and soft tissue was normal limit suggesting metastatic tumor to the vertebra corpus. An magnetic resonance imaging (MRI) examination was performed with and without administration of intravenous Gadolinium (Gd­DOTA). The result revealed an extradural mass with mix­intensity (iso, hypo and hyperintense) in sagittal T1­weighted images of the lumbosacral region (Figure 1) and extradural mass with mix­intensity (iso and hyperintense) in sagittal T2­weighted images of the lumbosacral region (Figure 2). Sequential sagittal T2­weighted images Fat­ Sat with MR­myelography revealed a clear border, lobulated side with the solid component of the mass, cyst containing blood (level fluid appearance) in the large areas that were spreading to the anterior and posterior regions and also damaging the surrounding bones, and compressing thecal sac and nerve roots bilaterally, that cause stenosis canalis spinalis at that level (Figure 3). These findings suggested destructive giant­cell tumor and aneurysmal bone cysts in the lumbosacral spine of vertebrae corpus L3–S2 level. The patient was recommended neurosurgical operation. The tumor was biopsied and revealed the histopathology as carcinoma metastases at the vertebrae (it was very CLINICAL IMAGES OPEN ACCESS