Spinal tumors lecture

2. Spinal tumors Tumors of the spine are easily classified as extradural, intradural/extramedullary, and intramedullary. Regarding spinal tumors in general, extradural lesions occur most commonly and most are metastatic. Of the intradural lesions (which are rare), 84% are extramedullary, the majority being nerve sheath tumors or meningiomas. Approximately 16% of intradural tumors are intramedullary, the most common being ependymoma followed by astrocytoma. A primary spinal tumor means it comes from cells within or near the spine. They can involve the spinal cord, nerve roots, and/or the vertebrae (bones of the spine) and pelvis. They can be benign (non-cancerous) or malignant (cancerous). In general, benign tumors do not invade other tissues. Malignant tumors may invade other tissues and organs in the body. Although primary spinal tumors often contain a number of abnormal genes their cause remains unknown. In some cases the tumors run in families. Tumors in the spine become a problem when they compress the spinal cord or nerves. This can lead to serious complications such as paralysis and loss of bladder and bowel control. Others can destroy the vertebral bone that supports the spinal cord making it unstable. A secondary spinal tumor is more common. This means that the tumor traveled there from cancer somewhere else in the body. These secondary or metastasized tumors are always cancerous. These cancer cells travel and cause tumors that usually involve the vertebrae or bony portion of the spine. They may come from melanoma (skin cancer), cancer in the lung, breast, prostate, kidney, or thyroid gland for example

3. Spinal tumors

6. Surgery Complete surgical removal is the treatment of choice for most spinal tumors. This can be accomplished in almost all cases by means of a standard posterior laminectomy. A laminectomy is the removal of the back part of the bony spine to gain access to the spinal canal. Decompression refers to removing bone around the spinal cord or spinal nerves in order to take pressure off these structures. Neurological damage during surgery has been improved with the use of newer techniques. These techniques include ultrasonic aspirators, and microsurgery. Ultrasonic aspirators use sound waves to destroy the tumor. It also sucks up the pieces of tumor. Microsurgery uses a microscope for a better view of the operation site. This helps to minimize any damage to surrounding healthy tissue. If the spine needs to be stabilized or fused as a result of removing a tumor in bone, metal hardware may be required. Metal plates, cages, rods, or screws may be used. The bone may be additionally supported by bone graft or bone cement. Recurrences are rare if total removal has been achieved. Some tumors may not be possible for complete excision and radiotherapy may be necessary. Radio- and Chemo-therapy Malignant tumors may require additional treatment with radiation or chemotherapy. Referrals will be made to the oncologist and therapeutic radiologist for evaluation based on histology results after surgery. Spinal tumors-Treatment

8. Malignant spinal tumors-Osteosarcoma Osteosarcoma occurs most often in children, adolescents, and young adults. Males are more likely to be affected than females. Treatment usually consists of removal of the tumor when possible as well as chemotherapy. Radiation therapy is not effective. Older persons with Paget's disease or who have had radiation therapy may develop this type of tumor.

9. Malignant spinal-Chondrosarcoma Chondrosarcoma usually occurs in adults. They usually are noticed because they cause pain and swelling. Surgery is performed to remove the tumor and any tumors that have spread, usually to the lung. In most cases, chemotherapy is not effective.

10. Malignant spinal-Astrocytomas Astrocytomas are tumors that involve nerve cells within the spinal cord. They most commonly occur in children and adolescents. Neurological symptoms such as weakness and/or sensory changes may be the cause for seeking treatment. They tend to spread throughout the spinal cord and brain. Astrocytomas in the spine can usually be removed surgically. However, they are difficult to completely remove. Radiation therapy may be necessary following surgery to slow the spread of the tumor. Spinal cord astrocytoma

11. Multiple Myeloma Myeloma is the most common primary malignant tumor of bone. It typically affects adults greater than 40 years of age. It tends to be generalized, involving multiple bones, but back pain and involvement of the spine is the most common presenting complaint. Treatment is palliative; meaning that disease can be controlled, but not completely cured. Chemotherapy is used to control the pain and slow the progression of the disease. Surgery may be required if pathological fractures develop or there is compression of the spinal cord. Cancer in the bone marrow is called multiple myeloma. Bone tissue is destroyed by excessive growth of plasma cells in the bone marrow. When X-rayed it appears that holes have been taken out of the bone. These are called osteolytic lesions. Plasma cells are part of the immune system and in multiple myeloma they grow uncontrolled forming tumors in the bone marrow. The spine is the most common site of involvement with multiple myeloma. Extradural compressive lesions are a well known complication of this disease. Sagittal 3-dimensional CT reconstruction of the lumbar spine in a patient with multiple myeloma. The central portions of the vertebral bodies (yellow arrows) have been replaced by the nonossified tumor. Malignant spinal-Multiple Myeloma

12. Malignant spinal-Multiple Myeloma

13. Spinal involvement is not uncommon with lymphoma. This can arise secondarily from extension of disease involving paravertebral lymph nodes into the vertebral body or through foramina into the epidural space. The tumor may also primarily infiltrate the vertebral body or epidural space. Primary spinal cord lymphoma is rare. L1 vertebral mass biopsy showing diffuse sclerotic large B-cell lymphoma. Malignant spinal-Lymphoma

15. Benign Spinal tumors-osteoma Osteoid osteoma is the most common of the benign tumors involving the bone of the spine. It is usually found during adolescence. It may be discovered because of scoliosis or curvature of the spine. It may cause pain that does not ease up, and is worse at night. Anti-inflammatory medications are used for treatment. Sometimes removal of the tumor by surgery is necessary. A newer, less invasive treatment is called radio-frequency ablation . These tumors rarely recur.

16. Osteoblastomas are larger versions of osteoid osteomas. They tend to be found in people under the age of 30. They may cause scoliosis or curvature of the spine. Osteoblastomas tend to be more aggressive and require surgery to remove the tumor. There is a 10% chance that the tumor may recur. MRI T1 Osteoblastoma Benign Spinal tumors-Osteoblastomas

17. Enchondromas are tumors involving cartilage. They may grow into the spinal canal or press on the spinal nerve roots. When they cause paralysis, bowel or bladder incontinence, or other neurological symptoms they are surgically removed. They rarely can become chondrosarcomas, which are malignant tumors that can spread to other parts of the body. Osteochondroma is a slow growing tumor of the cartilage usually affecting adolescents. It is uncommon and is usually found in the posterior (rear) spine. Benign Spinal tumors-Enchondromas&Osteochondroma Osteochondroma

18. Giant cell tumors are very rare. Giant Cell Tumor is known to affect children, adolescents and young adults. These tumors can be found at the cervical, thoracic, or lumbar segments of the spine, but are more common in the sacrum. They to affect the vertebral body of a spinal segment. Benign Spinal tumors-Giant cell tumors Giant cell tumor

19. Aneurysmal Bone Cysts (ABCs) typically cause pain and swelling usually affecting children and adolescents. These tumors can be large and quite vascular. Benign Spinal tumors-Aneurysmal Bone Cysts

20. Schwannomas are encapsulated, solitary tumors that derive from Schwann cells . They arise adjacent to, and displace the involved nerve root. Schwannomas and neurofibromas typically involve the dorsal sensory nerve roots. Depending upon their site of origin, they can be intradural, extradural, or both, forming a “dumbbell” or hour-glass shaped mass. MRI T1 ,precontrast [left, middle] and postcontrast [right] showing a spinal schwannoma, notice the T1 hypointensity and the dense contrast enhancement Benign Spinal tumors-Schwannomas

21. Benign Spinal tumors-Schwannomas

22. Meningioma is the most common spinal cord tumor. Spinal meningiomas predominate after the fourth decade and show a striking female predominance. They arise from meningothelial cells that are clustered around the spinal nerve roots . Dural based mass lesion in upper thoracic spine with same signal intensity as that of spinal cord with displacment of cord to the right.Homogenous enhancement with contrast. Benign Spinal tumors-Spinal meningioma

23. A and B: Sagittal T1-weighted MR images of the thoracic spine before (A) and after (B) Gd administration demonstrating an intradural extramedullary, isointense meningioma at T-2 that homogenously enhances. C: Axial image revealing that the mass severely compresses and displaces the spinal cord (arrowhead) to the left. Benign Spinal tumors-Spinal meningioma

24. Ependymoma is a tumor involving the cells lining the canal in the center of the spinal cord. It is important to attempt to distinguish an ependymoma from an astrocytoma preoperatively as the neurosurgeon will attempt complete extirpation of ependymoma, whereas the infiltrative astrocytoma will not be completely resectable. Spinal cord ependymoma Benign Spinal tumors-Ependymoma

25. Hemangiomas are tumors involving blood vessels that affect the vertebral body of a spinal segment. They are most commonly found in the thoracic or lumbar portion of the spine. They occur more frequently during mid-life. They are found more often in women than men. They can be a source of pain but often do not cause pain. They may be large enough to cause collapse of the vertebral body which could affect the spinal cord or nerve roots. Vertebral haemangioma Benign Spinal tumors-Hemangioma

26. Eosinophilic Granuloma is usually seen in the vertebral bodies of children and adolescents. When this tumor is systemic it is termed Histiocytosis X. Rarely do these tumors lead to vertebral collapse and paraparesis. On occasion, they may heal spontaneously. Eosinophilic Granuloma Benign Spinal tumors-Eosinophilic Granuloma

27. Chordoma is usually seen in adults frequently (50%) involving the sacrum, although it can affect other parts of the spine such as the occipito-cervical junction (where the head joins the neck). Because they can aggressively grow, they can cause compression of the spinal cord or nerve roots causing neurological problems. These tumors often require aggressive medical therapy. Benign Spinal tumors-Chordoma

28. Plasmacytoma is a single tumor involving the bone of a spinal segment. These tumors are common in the pedicle and vertebral body and may cause paraparesis. It can have characteristic punched out holes in the bone on X-ray. It can cause a compression fracture of the vertebral body. This can cause neurological symptoms. Plasmacytoma presents in middle aged and older adults. Benign Spinal tumors-Chordoma

29. Benign Spinal tumors-Chordoma Plasmacytoma X-ray

30. Acknowledgements That’s all folks!