Primary bone tumours of the Spine:
Imaging and Pathology
David Ritchie
Robin Reid
Incidence: primary spinal (38) and sacral (14) tumours
SBTR (2000-09), 52 patients
Benign
21
Malignant
31
ABC
6 (1)
Chordoma
10 (4)
Osteoblastoma
6 (1)
Ewings
8 (3)
Osteoid osteoma
5
Chondrosarcoma
5 (1)
Giant Cell Tumour
1 (1)
Myeloma
3 (1)
Eosinophilic Gran
1
Plasmacytoma
2 (1)
Chondroma
1
Osteosarcoma
2 (1)
Fibrous Dysplasia
1
Haemangioendoth
1
C spine (7), D spine (21), L spine (10)
(x) Sacral tumour
Spine – Tumours - Location
ANTERIOR – Malignant
POSTERIOR - Benign
• Metastases
• Myeloma
• Lymphoma
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Exceptions
Exceptions
• Eosinophilic granuloma
• Haemangioma
• Giant cell tumour
• Sarcoma
Osteoblastoma
Osteoid osteoma
Aneurysmal bone cyst
Osteochondroma
KM, SBTR 4706
17F, 2/12 Hx of
intermittant
thoracolumbar pain
Worse at night
Aneurysmal bone cyst
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Children/ young adults
Metaphysis of long bones, spine
Sponge-like mass, blood filled spaces
Septa, fibroblasts, giant cells, osteoid
Mitoses, but normal
No endothelial lining
Recur in 25%
Aneurysmal Bone Cyst
SBTR 4278, RW
Clinical and Imaging
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80% 1st - 2nd decades
Benign expansile lesion containing thin-walled
blood filled cavities
Thin cortical shell and foci of cortical destruction
Absent matrix
Fluid-fluid levels caused by blood product
sedimentation
Differential diagnosis
•
Osteoblastoma
•
Giant cell tumour
•
Telangiectatic osteosarcoma
•
Brown tumour of hyperparathyoidism
T2W
T1W
SS, SBTR 4394
50M, Increasing LBP,
Right buttock pain radiating to knee
No bladder or bowel problems
AE1/3 and S100
Chordoma
• Neuroaxis
– Base of skull
– Sacrum
– Vertebrae
• Arises from notochord remnant
• Local recurrence and extension usual
• Metastasis in <10%
Chordoma
Clinical
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50% of 1º malignant sacral tumours
50% of chordomas arise in sacrum
4-7th decades, 2M:1F
Slow growing painful mass
Low grade but recurrence common
Metastases late (5 – 43%)
5 year survival rate 60-80%
T2W
Differential diagnosis
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Metastasis / Lymphoma / Myeloma
Chondrosarcoma
Giant cell tumour
Osteosarcoma
STIR
Recurrent / metastatic chordoma
Surgery for
Sacral Tumours
Stability of the lumbo-sacral
junction
Preservation of neurological
function
• Preserve power/sensation legs - S1 roots
• Preserve bowel / bladder function - S2 roots
• Retention of sexual function - S3 root - M, S2 - F
Raque et al. Treatment of neoplastic diseases of the sacrum.
J Surg Oncol 2001; 76: 301
DH, SBTR 4604
P,10.2841
CHI 0710726171
Chordoma LV3
PC,
SBTR 4591
31M, 2yr Hx
mid thoracic /
periscapular
pain
Scoliosis
Osteoid Osteoma
• Central nidus (<1cm) of vascular/gritty tissue
• Subperiosteal or cortical lesions provoke
intense reactive new bone formation
• Nidus: active osteoblasts forming bone
osteoclastic remodelling, very vascular
• Natural history: sometimes recur following
incomplete excision
• Rare spontaneous regression suggests
osteoid osteoma may not be neoplastic
Osteoid Osteoma
Clinical and Imaging
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Benign bone forming tumour
10% in axial skeleton
90% in 2nd – 3rd decades, 3M:1F
Night pain relieved by non-steroidal analgesia
Usually arise posterior elements
Nidus <15mm, lucent but often mineralisations
Reactive sclerosis / peri-tumoral oedema
CT best cross-sectional imaging technique
Differential diagnosis
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Chronic infection
• Bone island
28M, LBP
R sciatica
SPINE
T2W
CT
Osteoblastoma
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“Giant osteoid osteoma” 2-10cm
1% of bone tumours
Wide age range, mainly 10-30 years
Spine (posterior elements), long bones
Swelling, dull pain,nerve compression,
Histology as in osteoid osteoma
• Local recurrence after curettage
(?multifocality)
Osteoblastoma
Clinical and Imaging
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Uncommon benign bone forming tumour
Histologically similar to osteoid osteoma
90% in 2nd – 3rd decades, 2M:1F
3 imaging patterns
– Large “osteoid osteoma”
– Expansile mineralised lesion
– Occasionally aggressive
Differential diagnosis
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Osteoid osteoma
Aneurysmal bone cyst
Osteosarcoma
SR, SBTR 4623
• 72F
• Bilateral lower limb pain & loss of power
and paraesthesia both thighs
Ritchie
Chondrosarcoma –
conventional
• de novo (primary) or from a pre-existing
enchondroma or exostosis (secondary)
• Central,within the medullary canal or
peripheral on bone surface
• 10% of malignant primary bone tumours
• predominantly middle aged and elderly
• Males: females; 2:1
• axial skeleton, pelvis, ribs, shoulder girdle
proximal femur and humerus. Hands and
feet rare
Proportion of
tumours
% metastatic
rate
grade 1
64%
5%
grade 2
21%
14%
grade 3
15%
75%
Chondrosarcoma
T1W
Clinical and Imaging
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7 - 12% of primary malignant spinal tumours
4th – 6th decades
Low grade - geographic growth pattern
High grade - permeative growth pattern
CT detects mineralisation in 90%
MR – Unmineralised cartilage shows lobules of
high signal on T2W separated by low signal
septae
• Calcifications may display signal voids
Differential diagnosis
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Chordoma
Metastasis
Myeloma
Giant cell tumour
T2W
CT
SBTR 4322, CH, 18F,
4/12 Hx right buttock / thigh pain and inguinal paraesthesia
More recently bilateral thigh and buttock pain
Urinary problems and decreased perianal tone
Osteosarcoma
a malignant tumour whose cells form
osteoid or bone
CH
Osteosarcoma
Clinical and Imaging
• 5% of primary malignant spinal
tumours
• 4th decade (older than long bone)
• Associated with Paget’s, DXRT
• Mixed lytic / sclerotic appearance
• Aggressive, soft tissue extension
• Osteoid mineralisation
CT
T1W
T1W
T2W
Differential diagnosis
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Ewings
Chondrosarcoma
Metastasis
Osteoblastoma
Lymphoma