Paravertebral Soft Tissue Mass Research Articles

MRI imaging pattern of metastasis and tuberculous spondylitis in the spine: serial case report

Background: Tuberculous spondylitis and spinal metastasis manifestations have a similar clinical manifestation. Spinal metastasis prevalence is high in malignant process while tuberculosis is frequent in endemic areas. Back pain, paresthesia, and paralysis are commonly caused by vertebral fractures, soft tissue mass, and spinal canal involvement. The magnetic resonance imaging (MRI) is a useful modality in the pattern differentiation of these diseases. This case series aimed to provide a differentiation between those two diseases using MRI. Case report: In the first case, we presented a 24-year-old female complained of hip pain without history of tuberculosis infection or malignancy. Whole spine MRI showed kyphotic deformity, compression of T9 vertebral body, erosion of anterior aspect T8 and T10 vertebral body, and subligamentous abscess at T7-T12 vertebrae level. Tuberculous infection was proven. The second case was a 39-year-old female complained of leg weakness without complaint of cough or breathing difficulty. Whole spine MRI showed kyphotic thoracic vertebrae, compression T10 vertebral body, destruction of inferior endplate T9 vertebrae, bone marrow changes on thoracic vertebral body, and paravertebral soft tissue mass on anterior T6 to T11 vertebral body. Tuberculosis etiology was proven. The third case was a 51-year-old female that came to the hospital due to waist pain with no history of tuberculosis infection or malignancy. Whole spine MRI revealed T8 and T9 vertebral body compression and bone marrow replacement on cervical, thoracic, and lumbar vertebrae, spinous process of thoracic and lumbar, bilateral posterior rib T4-T5, and soft tissue mass at the posterior T9 vertebrae. In the last case, we presented a 58-year-old male that complianed pain in the back and both legs. Lumbosacral MRI showed compression fracture with signal intensity change on L3 vertebral body, bone marrow replacement on thoracic, lumbar, and sacral vertebrae, expanding to epidural and cause spinal canal stenosis. CT-scan thorax showed lung malignancy proven to be non-small cell lung carcinoma. A spinal biopsy revealed malignant infiltration. Conclusion: Tuberculous spondylitis and metastasis differentiation can be a challenge. Early complaints mostly are back pain, paresthesia, and paralysis. Spine MRI can differentiate the pattern of both diseases and identify the possible etiology.

A Curious Case of IgG4-Related Disease Masquerading As an Occult Abdominal Malignancy

Introduction IgG4-related disease is an autoimmune, fibroinflammatory disorder involving multiple organ systems in the body. Diagnosis is often suggested by strong IgG4-positive stain on tissue biopsy. Patients respond well to steroids; and in cases of relapse, steroid-sparing agents like rituximab, azathioprine or cyclosporine can be used. Case Presentation Here we present the case of a 77 year-old African-American female with a past medical history significant for cerebrovascular accident, chronic hepatitis C infection status post treatment with antivirals, left chronic dacryoadenitis and chronic iron-deficiency anemia. She presented to the hematology office for a follow-up visit for chronic anemia and complained of new onset right upper quadrant pain and unexplained weight loss. Subsequent abdominal and pelvic imaging showed hypoechoic lesion in pancreatic head along with multiple epigastric, omental and gastro-hepatic nodules/lymph nodes suspicious for malignancy. This was followed by esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) which revealed gastric body/antral erosions along with multiple enlarged abdominal lymph nodes and heterogeneous, hypoechoic irregular mass in the pancreatic head/neck, all of which were biopsied. While awaiting biopsy results, due to high suspicion for malignancy, PET-FDG was performed which showed hypermetabolic lesions corresponding to the EUS findings and a FDG-avid right paravertebral mid thoracic soft tissue mass favored to represent a neurogenic tumor, unrelated to abdominal disease. Laboratory work-up was significant for elevated IgG levels with particularly high titres of IgG subclass 4. Biopsy results from EUS showed no evidence of malignant cells, no clonal proliferation on flow cytometry in either the lymph nodes or pancreatic tissue. Cytology of pancreatic tissue biopsy revealed lymphoid infiltration, extensive edema and fibrosis with no malignant cells. Immunohistochemistry studies revealed strong positive stain for IgG4 suggestive of IgG4-related disease. Of note, the patient had been following up with ophthalmology for a few years for chronic inflammatory dacryoadenitis of the left eye, which can likely be attributed to IgG4-related disease. After shared-decision making with the patient regarding treatment options, treatment was initiated with a plan of rituximab for 4 cycles along with corticosteroid. As of this abstract submission, the patient received one dose of rituximab, pending assessment of response to treatment. Discussion Heterogeneous pancreatic masses on abdominal imaging should be considered malignant until otherwise proven. In cases where these masses are associated with diffuse abdominal and pelvic lymphadenopathy, definitive diagnosis is made through obtaining biopsies from the easily accessible sites. A benign, auto-immune, fibroinflammatory condition which mimics this presentation is IgG4-related disease, whose treatment is far less complicated than a metastatic carcinoma. It often involves lacrimal glands. A high index of suspicion backed by the biopsy results showing strong stain affinity to IgG4 and elevated blood IgG4 levels are required. Treatment involves initiation of steroids followed by steroid-sparing agents like azathioprine, cyclosporine or rituximab in cases of relapse after steroid induction. However, as in our case, combination therapy of simultaneous use of steroids with rituximab can be used after shared decision making with patients.

Multiple Langerhans cell histiocytosis with spinal involvement.

The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS). We included 28 patients with multiple LCH involving the spine treated between January 2009 and August 2021. Kaplan-Meier methods were applied to estimate overall survival (OS) and PFS. Univariate Cox regression analysis was used to identify variables associated with PFS. Patients with multiple LCH involving the spine accounted for 15.4% (28/182 cases) of all cases of spinal LCH: their lesions primarily involved the thoracic and lumbar spines. The most common symptom was pain, followed by neurological dysfunction. All patients presented with osteolytic bone destruction, and 23 cases were accompanied by a paravertebral soft-tissue mass. The incidence of vertebra plana was low, whereas the oversleeve-like sign was a more common finding. The alkaline phosphatase was significantly higher in patients with single-system multifocal bone LCH than in patients with multisystem LCH. At final follow-up, one patient had been lost to follow-up, two patients had died, three patients had local recurrence, six patients had distant involvement, and 17 patients were alive with disease. The median PFS and OS were 50.5 months (interquartile range (IQR) 23.5 to 63.1) and 60.5 months (IQR 38.0 to 73.3), respectively. Stage (hazard ratio (HR) 4.324; p < 0.001) and chemotherapy (HR 0.203; p < 0.001) were prognostic factors for PFS. Pain is primarily due to segmental instability of the spine from its destruction by LCH. Chemotherapy can significantly improve PFS, and radiotherapy has achieved good results in local control. The LCH lesions in some patients will continue to progress. It may initially appear as an isolated or single-system LCH, but will gradually involve multiple sites or systems. Therefore, long-term follow-up and timely intervention are important for patients with spinal LCH.

Clinical Significance of Preoperative CT and MR Imaging Findings in the Prediction of Postoperative Recurrence of Spinal Giant Cell Tumor of Bone.

ObjectivesTo explore the predictive value of preoperative imaging in patients with spinal giant cell tumor of bone (GCTB) for postoperative recurrence and risk stratification.MethodsClinical data for 62 cases of spinal GCTB diagnosed and treated at our hospital from 2008 to 2018 were identified. All patients were followed up for more than 2 years according to the clinical guidelines after surgery. Medical history data including baseline demographic and clinical characteristics, computed tomography (CT) and magnetic resonance imaging (MRI) findings of recurrent and non‐recurrent patients were compared. Two musculoskeletal radiologists read the images and were blinded to the clinical data. The imaging features associated with postoperative recurrence were analyzed by multivariate logistic regression, and receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cutoff value of the largest lesion diameter predicting recurrence after surgery.ResultsAccording to whether the disease recurred within the follow‐up period, patients were divided into the recurrence group and the non‐recurrence group. Of 62 patients (29 males and 33 females), 17 had recurrence and 45 did not. The recurrence rate was 27.4%. The mean follow‐up time was 73.66 (± 32.92) months. The three major treatments were total en bloc spondylectomy (n = 26), intralesional spondylectomy (n = 20), and curettage(n = 16). A total of 16 CT and MRI features were analyzed. A univariate analysis showed no significant difference in age, sex, treatment, multi‐vertebral body involvement, location, boundary, expansile mass, residual bone crest, paravertebral soft tissue mass, CT value, and MRI signal on T1‐weighted imaging (WI), T2‐WI, and T2‐WI fat suppression (FS) sequences (P > 0.05). The largest lesion diameter [(4.68 ± 1.79) vs (5.92 ± 2.17) cm, t = 2.287, P = 0.026] and the vertebral compression fracture (51% vs 82%, χ 2 = 5.005, P = 0.025) were significantly different between the non‐recurrence and recurrence groups. Logistic regression analysis showed that both largest lesion diameter (odds ratio [OR], 1.584; 95% confidence interval [CI], 1.108–2.264; P = 0.012) and compression fracture (OR, 8.073; 95%CI, 1.481–11.003; P = 0.016) were independent predictors of postoperative recurrence. When we set the cutoff value for the largest lesion diameter at 4.2 cm, the sensitivity and specificity for distinguishing the recurrence and non‐recurrence of GCTB were 94.1% and 42.2%, respectively, and the area under the curve (AUC) was 0.671. The combined model achieved a sensitivity, specificity and accuracy of 47.1%, 97.8% and 83.9%, respectively.ConclusionsIn spinal GCTB, maximum lesion diameter and the vertebral compression fracture are associated with tumor recurrence after surgery, which may provide helpful information for planning personalized treatment.

Giant cell tumour of the tendon sheath of the spine: clinical features and imaging findings

ObjectivesTo review the clinical and imaging data of spinal giant cell tumour of the tendon sheath (GCTTS) to improve our understanding of the disease.MethodsThe imaging findings, clinicopathological features and clinical outcomes of 14 patients with pathologically confirmed spinal GCTTS were analysed retrospectively.ResultsAll 14 patients had a single spinal lesion, including ten cervical vertebra lesions and four thoracic vertebra lesions. CT scan findings: The lesions showed osteolytic bone destruction and were centred on the facet joint, eroding the surrounding bone with a paravertebral soft tissue mass. MRI scan findings: all the lesions manifested predominantly as isointense or hypointense on T1-weighted imaging (T1WI). On T2-weighted imaging (T2WI), eight lesions were hypointense, and four were isointense. The remaining two lesions showed slight hyperintensity. The enhanced scans of eight lesions showed moderate to marked homogeneous or heterogeneous enhancement. PET/CT findings: Among the five patients who underwent PET/CT, three presented lesions with well-defined, sclerotic borders, and the uptake of 18F-FDG was markedly increased. One lesion showed an ill-defined border and an uneven increase in 18F-FDG uptake with an SUVmax value of 8.9. A recurrent lesion was only found on PET/CT 45 months after surgery and the SUVmax was 5.1.ConclusionsSpinal GCTTS is extremely rare. Osteolytic bone destruction in the area of the facet joint with a soft tissue mass and hypointensity on T2WI images are indicative of the spinal GCTTS. GCTTS shows high uptake of 18F-FDG, and PET/CT is helpful in detecting recurrent lesions.

2157 A Novel Case of Plasma Cell Leukemia Diagnosed by Endoscopic Ultrasound With Fine-Needle Biopsy

INTRODUCTION: There are numerous reports of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) used to diagnose plasmacytoma of the GI tract but, to our knowledge, this is the first report of plasma cell leukemia diagnosed by EUS with fine needle biopsy (FNB). CASE DESCRIPTION/METHODS: A 78 year old woman presented with exertional chest pain, dyspnea, and unquantified unintentional weight loss. CT chest showed bilateral pleural effusions, left pleural soft tissue masses, and multiple paravertebral soft tissue masses. Thoracentesis was non-diagnostic. She re-presented a month later with the same symptoms. Repeat imaging revealed enlargement of the lesions and the decision was made to pursue EUS-FNB to obtain tissue for diagnosis. On endoscopy, the patient was found to have gastric erosions and two non-bleeding, ulcerated nodules in the fundus. Biopsies resulted in chronic gastritis and h.pylori. EUS described one enlarged lymph node visualized in the middle para-esophageal mediastinum, surrounded by hyperechoic hazy soft tissue. The lymph node measured 30.6 mm by 18.5 mm, with irregular, poorly defined margins. A second lymph node was found in the peri-pancreatic region, measuring 19.4 mm × 15 mm. FNB was performed. The pathology report from both nodes identified sheets of atypical plasma cell proliferation which stained positive for CD138 and CD56. Flow cytometry revealed a proportion of 40% IgG Lambda-restricted plasma cell population. These findings, taken in the context of a known M-spike and circulating atypical IgG lambda-restricted plasma cells on peripheral blood smear, established the diagnosis of plasma cell leukemia with soft tissue component. Unfortunately, it was felt that the patient would not be able to tolerate chemotherapy and she was sent home with hospice. DISCUSSION: While EUS-FNA is used frequently to evaluate lesions in the upper GI tract, this is the first reported case, to our knowledge, of EUS-FNB used to diagnose a plasma cell leukemia. In this case, the diagnosis was confirmed, not on peripheral smear or with cytology from pleural fluid, but from the biopsies we obtained. This is a good example of how EUS-FNB can often be the safest and easiest way to obtain adequate tissue samples from intrathoracic or intraabdominal lesions to facilitate diagnosis.

Intense PSMA-expression using 68Ga-PSMA PET/CT in a paravertebral schwannoma mimicking prostate cancer metastasis

The prostate-specific membrane antigen (PSMA) is highly expressed in prostate cancer (PC) cells. The recently introduced PSMA-PET/CT has evolved as a powerful imaging tool for staging of PC [1–3]. Albeit the high specificity of PSMAtracers, there are reports of high PSMA-expression in nonprostatic malignant (e.g., renal cell carcinoma, bronchial carcinoma, and glioblastoma) and benign (schwannomas) lesions [4]. These reports raise concerns over the specificity of PSMA-PET imaging indicating the need for thorough review of accompanying morphological images besides exclusive interpretation of and reliance on PSMA-expression in PET. A 69-year-old patient with PC (Gleason 6 [3+3],iPSA 11.3 ng/ml) underwent Ga-PSMA-PET/CT for primary staging. Ga-PSMA-PET/CT showed intense PSMA-expression in the prostate representing the histological proven primary PC (A: MIP). Intense PSMA-expression was also observed in projection on a right paravertebral soft-tissue mass (B-D). Due to pain in the thoracic spine the patient had undergone MRI one month before. Images revealed typical features of a schwannoma showing a slightly hyperintense signal in T2w (E) and dumbbell configuration in coronal T2w stir with pathognomonic growth along the neuroforamen (F). In addition, T1w images showed a native hypointense lesion with inhomogeneous contrast enhancement (G,H). Thus, the patient was diagnosed with local PC without metastatic spread. This case advises caution particularly in patients with solitary Blesions^ as the interpretation of PSMA-PET/CT scans might directly influence therapy guidance (curative surgical vs. palliative medical treatment). In this case, typical MRI features (localization relative to the nerve, typical configuration) [5] as well as a former report of possible positive PSMAexpression in schwannomas [4] led to the diagnosis of this benign lesion.

Kesesuaian MRI 1,0 Tesla untuk Membedakan Spondilitis dan Metastasis Vertebra dengan Konfirmasi Hasil Histopatologi

Background: Magnetic Resonance Imaging (MRI) is the most accurate modality imaging to evaluate vertebral abnormality. Infection and metastatic in musculoskeletal is most commonly found in the vertebra. It is often difcult to di?erentiate between spondylitis and metastatic, both clinically and radiographically, mainly on atypical case.Objective: To analyze the precision of MRI 1,0 Tesla in di?erentiation of radiological imaging between spondylitis and vertebral metastatic with histopathological confrmation.Materials and methods: This is an analytic observational study, with cross-sectional research design. Statistical analysis was performed with Mc Neemar test. Samples were selected by consecutive sampling with 35 patients (15 men, 20 women), 22samples of spondylitis and 13 of samples metastatic which were confrmed by histopathological examination.Result: From 22 samples of spondylitis confrmed by histopathology, only 86% (19 samples) were diagnosed as having spondylitis on MRI, whereas 13 metastatic samples 100% was correctly diagnosed on MRI.Conclusion: Statistically there was no signifcant di?erences between radiology diagnostic using 1,0 Tesla MRI with histopathological diagnosis, p=0,250 (p&gt; 0,05), with tendency MRI 1,0 Tesla is more precise in diagnosing metastatic. MR imagesshow typical fndings in spondylitis such as anterior component corpus vertebral and discus intervertebralis involvement, disk signal abnormalities, paravertebral abscesses and involvement of multiple vertebral bodies sequentially. MR images show typical fndings in metastasis such as anterior and posterior corpus vertebral involvement, paravertebral soft tissue mass and skip lesion.

Lipomatous ganglioneuroma of the retroperitoneum

Lipomatous ganglioneuroma (LG) is a rare variant of ganglioneuroma that is histologically characterized by a mature adipocytic component admixed with a conventional ganglioneuroma. We report the clinicopathological and immunohistochemical features of an LG in a 44-year-old Chinese male; additionally, we review the literature regarding this type of tumor. Magnetic resonance imaging revealed a left paravertebral soft-tissue mass at the T11-L3 levels. Grossly, the encapsulated neoplasm had a white to yellowish cut surface and rubbery consistency. Microscopic evaluation revealed an encapsulated lesion that consisted of areas of ganglioneuroma admixed with areas of mature fat. By immunohistochemistry, the ganglion cells were positive for chromogranin and synaptophysin, whereas the Schwann cells were positive for vimentin, S-100 protein, and glial fibrillary acidic protein (GFAP). This is the second known report of a retroperitoneal LG. The patient was well and without evidence of disease at 2 years' follow-up.

Multiple myeloma in a liver transplant recipient: Diagnostic value of MR imaging

Multiple myeloma is a rare complication in a liver transplant patient. In this case report, we present a 54-year-old man who received an orthotopic liver transplantation for HCC in HBV/HDV-related cirrhosis; about ten months after liver transplant, patient was admitted to our hospital complaining of asthenia and low grade fever with an accompanying costal, dorsal and lumbar pain. MRI of thoracic and lumbar spine was performed; T1-, T2-weighted fast spin-echo and short time inversion recovery (STIR) images showed scattered focal lesions diffusely involving vertebral bodies and an expansive mass at the level of T10–T12 right paravertebral soft tissues. The excisional biopsy of the paravertebral soft tissue mass leaded to the final diagnosis of multiple myeloma. The presented case shows that the multiple myeloma can represent a rare complication in liver transplant recipient as part of the spectrum of post-transplant lympho-proliferative disease. Although the biopsy is necessary to make the definitive diagnosis of multiple myeloma, in our opinion MRI is the best technique to determine the exact location, size and local compressive effects of the focal lesions.

Idiopathic pulmonary arterial hypertension in a patient with pyruvate kinase deficiency and paravertebral extramedullary hematopoiesis

Dear Editor, Pulmonary arterial hypertension (PAH) is defined as a sustained elevation of pulmonary arterial pressure to more than 25 mmHg at rest or to more than 30 mmHg during exercise, with a mean pulmonary–capillary wedge pressure and left ventricular end-diastolic pressure of less than 15 mmHg, leading to right ventricular dysfunction, congestive heart failure, and death [1]. PAH is a well-known complication in patients with hemoglobinopathies such as sickle cell disease and thalassemia. PAH is closely related to the hemolytic anemia. Nonhepatosplenic extramedullary hematopoiesis has been described in association with a wide variety of myeloproliferative diseases and hemoglobinopathies such as sickle cell disease and thalassemia [2]. It is due to increased renal excretion of erythropoietin secondary to anemia or hypoxia and can involve any organs and tissues, including the mediastinum, pleura, lungs, and heart. In most cases, the diagnosis is fortuitous, and rarely, the lesions are symptomatic, displaying neurological signs, pleural effusion, cardiac tamponade, and dyspnea [2]. Pyruvate kinase (PK) deficiency is the most common cause of hereditary nonspherocytic hemolytic anemia, transmitted as an autosomal recessive condition, with classical features ranging from mild anemia to a transfusion-dependant disease [3]. We report in this paper a case of dyspnea indicating idiopathic PAH associated with paravertebral hematopoiesis in a patient with PK deficiency. A 47-year-old man, current smoker, with PK deficiency diagnosed at birth requiring splenectomy at age 5 years and who denied any drug intake, was hospitalized in July 2007 for dyspnea on exertion [New York Heart Association (NYHA) class III] present for 1 month. On examination, he appeared healthy. A grade 3/6 systolic murmur was heard best in the pulmonary area. Mucocutaneous jaundice was found. The findings on laboratory testing of renal function, liver test function, and C-reactive protein, search for antinuclear antibodies and anti-extractable nuclear antibodies, and HIV testing were normal or negative. Hepatitis B virus serology was consistent with past immunization, and hepatitis C virus serology was positive, with a negative viral load. Other laboratory test results are indicated in Table 1. Arterial blood gas analysis showed pO2 73 mmHg, pCO2 34 mmHg, pH 7.43, SaO2 93% while breathing ambient air. Chest X-ray (Fig. 1) and computed tomography (CT) scan demonstrated paravertebral soft tissue masses extending from T1 to T10, with heterogeneous enhancement after contrast administration and main pulmonary artery enlargement at 43 mm without signs of thrombotic or embolic disease concordant with the ventilation-perfusion lung scan. Magnetic resonance imaging (MRI) displayed the paravertebral masses isointense on T1-weighted sequences, Ann Hematol (2009) 88:603–605 DOI 10.1007/s00277-008-0644-z

MRI features of lymphoma in spinal area

Objective To analyze MR imaging manifestations of spinal area lymphoma in order to improve the recognition and understanding of the disease. Methods A group of 45 patients with pathologically or clinically proven spinal area lymphoma were reviewed. Five cases were primary NHL,40 cases were secondary with 9 HL and 31 NHL (27 B-cell type NHL and 4 T-cell type NHL). MR Imaging findings were analyzed and correlated with clinical and pathologic findings. Results (1) Location of lesions: 13 cases were focal type and 32 cases were multifocal type. All of the 5 patients with primary lymphoma were focal type, while 32 of 40 cases of secondary lymphoma were multifocal type. (2) Type oflesions: ①Vertebral destruction: 27 cases manifested as bone destruction with 23 of them had soft tissuemass and the extent of soft tissue masses were larger than that of bone destruction in 18 cases.②Soft tissuemasses: 6 cases manifested as soft masses without obvious bone destruction, of which 5 cases had soft tissuemasses imbedded vertebrae and communicated paravertebral and epidural spaces through intervertebralforamen.③Bone marrow infiltration: 9 cases of secondary spinal lympboma had signal intensity changes ofbone marrow without obvious cortical bone destruction and soft tissue mass. ④ Spinal cord infiltration:3 cases of secondary spinal lymphoma had spinal cord swelling and signal intensity changes. (3) MRIfindings: all lesions of bone destruction and marrow infiltration manifested as hypointense on T1-weightedimages, hypointense, isointense or hyperintense on T2-weighted images and hyperintense on T2-weightedimages with fat-suppression technique. All soft tissue masses were homogeneous hypointense on T1-weightedimages and hyperintense on T2-weighted images. After intravenous injection of contrast media, the lesions ofthe bone and the soft tissue showed mild or moderate enhancement without remarkable cystic degenerationand necrosis. Conclusions Most of the spinal area lymphoma is the secondary B type NHL with complexMRI manifestation. Osteolytic lesion with contiguous paravertebral soft tissue mass imbedded vertebrae whichcommunicated paravertebral and epidural spaces through intervertebral foramen with a mild or moderateenhancement may suggest the diagnosis of this rare disease. Key words: Lymphoma; Bone neoplasms; Spinae; Magnetic resonance imaging

Squamous Cell Carcinoma Arising in a Pediatric Intra- and Paravertebral Teratoma

A 7-year-old boy presented with a 1-year history of back pain radiating to his left scapula and arm, with tenderness to palpation over the area. Laboratory studies were unremarkable. Computed tomographic scan showed a mixed lytic and sclerotic process at the T5-T6 level of the vertebral column in continuity with an adjacent paravertebral soft tissue mass. Nuclear medicine scan demonstrated increased uptake in the T5 vertebral body. Histology revealed invasive squamous cell carcinoma infiltrating mature, gliotic neural tissue, with areas of necrosis and prominent perivascular space involvement. Associated vertebral fragments showed bone destruction, reactive bone formation, and fibrosis. By immunohistochemistry, the carcinoma cells were positive for cytokeratin AE1/AE3, cytokeratin 5/6, EMA, and MIC-2 (membranous staining). The mature neural tissue was positive for GFAP; immature neural elements were not identified. Based on morphologic, immunohistochemical, and clinical features, this lesion was diagnosed as invasive squamous cell carcinoma arising within an intravertebral and paravertebral teratoma.

Spinal tuberculosis: CT and MRI features

BACKGROUNDSpinal tuberculosis (TB) is perhaps the most clinically important extrapulmonary form of the disease. Early recognition is therefore necessary to minimize residual spinal deformity and/or permanent neurological deficit. We defined the CT and MRI image morphology of spinal TB and correlated the imaging features of these two modalities.METHODSCT (29 patients) and MRI (11 patients) images were retrospectively analyzed in 30 patients with proved spinal TB. CT and MRI findings were compared in cases with both imaging tests (10 cases). The parameters assessed were the type and extent of bone and soft tissue involvement.RESULTSThe majority of the 30 patients were males (n=18) in the 30–49 year age group (43%). The most common clinical presentation was backache (73.3%) followed by fever (63.3%) and malaise (36.6%). The lumbar spine was the commonest site of the disease (43.3%) followed by the thoracic region (36.6%). A fragmentary type of bone destruction was the most frequent CT feature of the disease (48.2%) followed by the lytic type (24.1%). Intervertebral disc destruction (72%) and paravertebral mass/abscess (65.5%) were other features. Of the 11 patients who had an MRI, contiguous vertebral disease with disc destruction was seen in 10 cases. In 4 patients, there was distant vertebral disease in addition to the disease at the symptomatic site.CONCLUSIONSMRI offers excellent visualization of the bone and soft tissue components of spinal tuberculosis and helps to identify disease at distant asymptomatic sites. CT is useful in assessing bone destruction, but is less accurate in defining the epidural extension of the disease and therefore its effect on neural structures. MR imaging clearly demonstrated the extent of soft tissue disease and its effect on the theca/cord and foramen in cases with doubtful CT findings.

MRI of spinal epidural lymphoma

We reviewed the MRI features in eight patients with spinal epidural lymphoma (clinically primary in 4 patients); one patient had multiple lesions. The cervical spine was involved in one patient, the thoracolumbar spine in 5 and the sacrum in two. Mean longitudinal extension of the epidural lesion was 2.6 vertebral segments. The tumours were homogeneously isointense with the spinal cord on T1-weighted images and isointense or hyperintense on proton-density and T2-weighted images. The spinal cord was compressed in four patients but showed signal changes in only one. In five patients the lesions communicated through the intervertebral foramina with paravertebral soft tissue masses. In all but one of the patients diffuse signal changes in the vertebral body marrow consistent with osteolytic or osteoblastic changes were identified adjacent to or at distance from the epidural lesion. Vertebral collapse was observed in two patients.

Computer tomography of vertebral tuberculosis: Patterns of bone destruction

A retrospective analysis was performed of CT scans of 30 consecutive patients with a clinical suspicion or diagnosis of spinal tuberculosis. Four patterns of bone destruction were noted, namely, fragmentary, osteolytic, subperiosteal and well-defined lytic with sclerotic margins. The fragmentary type was most common (47%). Intervertebral disc destruction was always associated with contiguous vertebral body destruction. Associated paravertebral soft-tissue masses were seen in all patients. Epidural extension of disease was seen in 66% and showed a very good correlation with neurological signs on clinical evaluation. Bone fragments were detected in the epidural soft-tissue mass in 65% of patients with epidural extension of disease. CT appearances of bone destruction are highly suggestive of tuberculous osteomyelitis in about half the patients.

CT findings in tuberculous spondylitis.

The computed tomographic (CT) features of ten documented cases of spinal tuberculosis were analyzed. All cases showed evidence of vertebral body destruction, with paravertebral soft tissue masses. Four cases revealed extension of involvement into the neural arches. Calcification within the paraspinal soft tissue was found in only two cases. Two of four cases who received intravenous contrast medium demonstrated evidence of rim enhancement around multilocuated fluid collections. Compared to conventional roentgenography, CT better delineated the extent of bony destruction, involvement of the spinal canal and existence of paraspinal soft tissue masses.

Magnetic resonance imaging in suspected metastatic spinal cord compression

This study describes high field magnetic resonance imaging (MRI), in 55 patients with suspected metastatic spinal cord compression. MRI, principally using T1-weighted sagittal surface coil images, showed evidence of cord compression in 29 patients, and intramedullary masses in three patients. MRI clearly showed the site, nature and extent of the cord compression and gave useful additional information about the presence of bone marrow metastases and paravertebral soft-tissue masses. Comparison with conventional myelography was possible in 21 patients and MRI was superior or equivalent to myelography in 18 patients and inferior in three patients. MRI is the method of choice for the investigation of patients with suspected metastatic spinal cord compression.

Thoracic chordoma with unusual radiographic features

A case of chordoma involving the thoracic spine (T12) is reported. The plain film findings included lytic obstruction and partial collapse of a single vertebral body. Noncontrast CT and CT following Metrizamide myelography revealed vertebral body destruction with paravertebral and intraspinal soft tissue masses. Unusual findings in the case included a photon deficient area on nuclear medicine corresponding to the lesion and normal vascularity on spinal angiography. We know of no previous report describing chordoma as a “cold” defect on bone scanning.

Surgical treatment of spinal cord compression in patients with lung cancer.

We analyzed the clinical features, radiological findings, and results of surgical treatment in a series of 25 patients with lung cancer and invasion of the spine. In 12 of the 25 (40%) patients, involvement of the spine was present at the time of initial presentation of malignancy. Computed tomography revealed the presence of a large paravertebral soft tissue mass with destruction of adjacent ribs in the majority. The surgical approach consisted of an anterolateral exposure through a formal thoracotomy in 22 patients and a thoracoabdominal flank approach in the 3 patients with lumbar lesions. All gross tumor was resected from the involved paravertebral tissues, vertebral body, and epidural space. Immediate stabilization of the spine was then achieved with methyl methacrylate. Local brachytherapy (iridium-192 implants) was used in 19 patients. After treatment, 87% were ambulatory, and 67% maintained ambulation for more than 6 months. Our data suggest that compression of the spinal cord in many patients with lung cancer results from direct extension of tumor through the chest wall. Because the majority of such patients often have localized disease involving the spine, aggressive surgical treatment is indicated.