Primary

y bone
e tumors
s off the
e spine Primary bone tumors of the spine
Learning Objectives
HOSPITAL DE TRAUMATOLOGÍA
1. To review the imaging diagnosis of primary bone
VIRGEN DE LAS NIEVES
GRANADA
tumors of the spine.

2.. Identify the typical find

findings of benign and malign
primary bone tumors.

Fernando Ruiz Santiago

Primary bone tumors of the spine Benign bone tumors of the spine

SCLEROTIC
DIA
DIAGNOSTIC CRITERIA 1.-
1.
.-Enostoma
11.-
1.
..-Clinical
Cllinical features
C featu
2..--P
2. Patient
atient age OSTEOLYTIC
3.- T
3. Topographic featuress off the
tth
he tumor 2.-
2.
2 .- HHemangioma
4.--Lesion pattern as seen
4. n on Radiography, CT and MRI 3..--G
3. Giant cell tumor
4...--A
4 Aneurysmal bone cyst
5.--Eosinophilic
5. sinophilic granuloma
OSTEOLYTIC W WITH REACTIVE SCLEROSIS
Primary tumors of the spine are infrequent lesions, representing less than 6.-
6.
6 ..-Osteoid
Osteoid osteoma
O
5% of all bone tumors
Imaging features of the primary spinal lesions are often nonspecific
7.--Osteoblastoma
7.
BONE EXOSTOSIS
BO
8.-
8. .-Osteochondroma

1.-
1.
.-Enostoma
a (Bone island) 1..-Enostoma
1.- a (Bone island)
loc
location
ocation
a Radiography
Rad diograph
d ogrra
aphhy-
hy
h y-CT
CT
C
1..--D
1. Dorsolumbar
orsolumbar spine 1..--Sl
1. Slerotic
Sllerotic lesions with irregular spiculated margin
2.--Close to the endosteal surface of the cortex
2. 2 - Some of them may show uptake on scintigraphy
2.

1.-Any age 1.-Male = female

2.-No pain. Asymptomatic lesions discovered incidentally 2.-14% in cadaver studies
 1.-
1.
.-Enostoma
a (Bone island) 1.-
1.
.-Enostoma
a (Bone island)
MRI
Low
ow signal on T1 and T2 weighted images with no
enhancement after contrast injection

T1 T1+C T2 STIR

These signs help us to differentiate enostoma for a more sinister condition Biopsy should be considered if the lesion increases in diameter by more than
25% within 6 months or 50% within 1 year.

Osteopoikilosis
s (Bone island) 2.-
2.
.-Haemangioma
Sclerosing
clerosing dysplasia of bone characterized by the Radiography
Rad diograph
d hy-
h y-ray
ray
ra
ay-
a y-CT
C
CT
presence of numerous bone islands in the skeleton. 1..--Co
1. Corduroy
Corduroy pattern on sagittal images
2.- P
2. Polka dot sign on axial images seco
secondary to the
remaining thickened trabeculae.

1.-Vertebral haemangioma account for 75% of all haemangiomas

Pain is not a dominant feature of OPK but in 15%–20% of patients, slight 2.-They are multiple in up to 30% of all patients.
joint pain and effusion have been reported.

Typicall Hemangioma Atypicall Haemangioma

MRI
MR RII MRI
MR RII
1.--H
1. Hyperintense on T1 and T2 weighted images due to 1.--H
1. Hypointense on T1 and hy
hyperintense on T2
2 WI and
d fat
high fatty contain, suppressed on STIR or fat sat suppression
s
suuppression sequences.
iimages
im
mages 2.-- Variable contrast enhancement
2.
2.-
2.
.- Hyperint
Hyperintensity is greater on T2 because of water
H
contain

T1 T2 STIR T1 T2 STIR
1.-Generally non symptomatic 1.-May be symptomatic
2.-Predominates the fat contain 2.-Predominates the vascular contain
Aggressive
e Hemangioma Aggressive
e Hemangioma
MRI
MR RII
1..--IInvolvement
1. nvolvement of the entire verteb
n vertebral body;
2...--e
2 extension
xtension into the ne
x neural arch
3..--c
3. cortical
co
ortical expansion
4...--tth
4 thoracic
horacic location (T
h (T3
3– T
T9)
9)
5..--A
5. An irr
irregular
rrre
egular honey
honeycomb pattern
6 - Soft
6. ft-
ft
t-tissue mass

T1 T2 STIR 1.-The polka dot sign may not be so evident

3 or more findings associated with pain suggest the diagnosis. 2.-May require biopsy for final diagnosis.

3.-
3.
.-Giantt Cell Tumor 3.-
3.
.-Giantt Cell Tumor
MR
MRIRI
Radiograph
Radiographyhy-
h y-ray
ray
ra
ay-
a y-CT
C
CT -HHeterogeneous sig
signal
gn
nal intensity with low signal
Osteolytic lesion, without mineralized matrix intensity on T2
2-WI due to fibrous components and
hemosiderin
-
-There is enhancement after intravenous contrast

location T2 T1+C
1.-The majority are in the sacrum
1.-Spinal GCTs correspond to 7% of all GCTs
2.-In other spinal locations typically involves the vertebral
2.-Malignant GCTs occur in 5–10% of cases and are usually related to
body and can extend to posterior elements previous irradiation

4.-
4.
.-Aneurysmall Bone Cyst 4..-Aneurysmall Bone Cyst
4.-
ABCs consist of arteriovenous fistulae and can be primary, with no underlying Radiog
Radiography
diog
iog
graph
g ra
aph
aph
hy-
y-CT
C
CT
neoplasm, or secondary to neoplasm. The majority of ABCs are considered
primary lesions
Well
Wel
ll-
lll
l-d
defined,
efined, radiolucent, and occasionally trabeculated
trabecu
expansile lesion surrounded by a thin sclerotic
margin.

winking owl sign

-ABC usually occurs in <20 years patients
-GCT in patients 20-40 years old 1.-The posterior vertebral elements are usually affected
2.-Sacrum involvement is rare
 4.-
4.
.-Aneurysmall Bone Cyst 5..-Eosinophilic
5.- c Granuloma
MR
MRI
RI Compression
ompression
pre
esssion fracture off a ve
ssi
ssio vertebral body
b
body, resulting in
-So
Soft
oft tissue exte
extension
ension
n is
s usual wedging and later vertebra plana
-lobulated
obulated or
o r se
septated
eptated
dmmass surrounded by a thinin
nrri
rim
im of
low signal intensity, containing mu
multiple fluid
d–fluid
levels indicating hematic content.

T2 T1 T1+C
19-3-2016 4-4-2016
After intravenous contrast injection, the septations and rim generally
enhance
-It usually occurs in <20 years patients

5..-Eosinophilic
5.- c Granuloma 5.-
5.
.-Eosinophilic
c Granuloma
1.-
1.
.-lytic
lytic
ly tic destruction
d
des
destr of the
e vertebral
ver body,
body often
o is
associated with a paravertebral soft tissue mass
a mass.
2.-
2.
2..--A
After contrast
contras administration, there is marked
enhancement
31-3-2016

24-5-2016 27-5-2019

T2 T1 T1+C
With healing, a reconstruction of the vertebra occurs and reestablishes an
almost normal appearance
1.-It is the localized form of Langerhans cell histiocytosis

6..-Osteoid
6.- d osteoma 6..-Osteoid
6.- d osteoma
Young individuals
id
d l with
ith painful
i f l scoliosis
li i are 1.-
1.
.-On
On radiographs
O ograap
ph and CT,
phs CT
T, osteoma
os osteoid
osteo appears as
important and should alert to the possibility of osteoid an oval or rounded osteolytic area less than 2 cm in
osteoma
steoma in the spine, particularly becau
because idiopathic diameter, representing tthe nidus, with variable
scoliosis are usually asymptomatic surrounding
s
suurrounding sclerosis.
2.-
2.
.--Central calcification may be present

Most cases of osteoid osteomas in the spine affect the posterior osseous arc Most cases of osteoid osteomas in the spine affect the posterior osseous arc
accounting for 75% of the cases, while only 7% occurs in the vertebral body accounting for 75% of the cases, while only 7% occurs in the vertebral body
 6.-
6.
.-Osteoid
d osteoma 6.-
6.
.-Osteoid
d osteoma
1.-
11.
..-MR
MR images, the
M h b best clue
l ffor the
h diagnostic
di is
extensive osseous or surrounding soft tissue edem
edema in
young
oung individu
individuals with no evidence of trauma or
infection.

6.-
6.
.-Osteoid
d osteoma 6.-
6.
.-Osteoid
d osteoma
2.-
2.
..-The
The nidus h
Th has markedly
k dl enhanced
h d after
f intrav
intravenous
paramagnetic injection, which can be more
conspicuous if compared to the MRI before contrast

T1 stir

T1 T1+C

7..-Osteoblastoma
7.- 7..-Osteoblastoma
7.-
1.-
1.
.-Osteoblastoma
Osteoblastoma
O asto
om
ma and
a osteoid osteoma are variants o of 3.-
3.
..-Peritumoral
Peritumoral
ora
all ed
edema in bone marrow and soft tissues,
ede
tthe same benign process with similar histology
histology. reflecting
r
reeflecting inflammatory reaction
2--O
2 Only the size is used as a differential criterion. 4.-
4...--Sh
Showsmarked
Showsmarked enhancem
enhancement after intravenous
lesions > 2 cm are classified as osteoblastomas. paramagnetic injection

T1 T1+C
1.-It is a rare benign tumor with osteoid matrix 3.-Osteoblastoma frequently originates from the posterior arc (85% of
2.- Spinal osteoblastoma accounts for approximately 40% of all lesions)
osteoblastoma, and occurs with equal distribution in the spinal segments
 7.-
7.
.-Osteoblastoma 7.-
7.
.-Osteoblastoma

It is
s a lytic
c ex
expansile
xpansile lesion with a prominent
promine sclerotic
rim and multiple small calcifications.

More aggressive than osteoid osteomas, with a higher recurrence rate,

4.-When feasible ablation is a therapy of choice ranging from 10 to 50% lesion

7..-Osteoblastoma
7.- 8.-
8.
.-Osteochondromas
It is an expansile
ans
siile le
lesion
esion with a promin
prominent sclerotic rim
and multiple small calcifications. 1.-
1.
.-The
The pathologic and radiologic hallmark of this entity
Th
is the continuity of the lesion wi
with the marrow and
cortex of the underlying bone.

1.-accounts for 5% of solitary osteochondromas and present in 10%

of the patients with hereditary multiple exostoses
1.-Osteoblastoma frequently originates from the posterior arc (85% of
2.-No growth potential after physeal closure
lesions) and may invade the vertebral body

Osteochondromas Primary malignantt bone tumors of the spine

1.-
1.
.-The
The cartilage cap
Th app exhibits low to intermediate signal 1.-
11.
..-Chordoma
Ch
Chordoma
d
intensity
inte
nte
ten
nsity on T
T1-
T11-weighted and high signal intensity on 2.- C
2. Chondrosarcoma
Chondrosarcom
T2
2-weighted.
w 3..--E
3. Ewing
wing sarcoma
w
MRI is the best modality to assess the cartilage cap. 4.--Osteosarcoma
4.

Thickening of the cartilage cap larger than 2 cm is suspicious of malignant

transformation to chondrosarcoma
 1..-Chordoma
1.- 1.-
1.
.-Chordoma
They
hey are
e al
almost
lmost
mo
os
st exclusively
ex
e seen in the midline,
accounting approx
approximately 50% to the sacrum and Radiograph
Radiography
hy-
h y-CT
C
CT
35% to the clivus The
he bone destructionn pr
predominates,
redomina with
h intratumoral
calcification seen commonly

1.-is the most common non-lymphoproliferative primary malignant neoplasm

of the spine in adults.
2.-It commonly affects middle-age individuals and has a peak incidence in the It arises from the embryonic remnants of the notochord that extend from
fifth decade Rathke’s pouch to the coccyx

1.-
1.
.-Chordoma 1.-
1.
.-Chordoma
MRI
characterized
haracterized
d by
y low to intermediate sig
signal
ign
nal on T
T1-
T11
weighted and very high signal on T22 -w
weighted MR
images. Contrast enhancement is usuall
usually in a thick
peripheral nodular and septal pattern

T2 T1 T1+C
The location and thus resectability of the lesion usually determines the
Paraspinal soft tissues and spinal canal involvement are frequent patient’s prognosis, with high rate of recurrence

Chordoma versus benign notochordal tumor 2.-

2.
.-Chondrosarcoma
1.-
11.
..-Contained
Co
Contained
Contained inside the bone CT
2..--T
2. Tend
end to be smaller (< 3 cm) chondroid matrix calcification:
3..--U
3. Usually sclerotic Rings, punctate, and arcs calcification
4...--H
4 Hypointense on T1 and Hyperi
Hyperintense on T2 WI
5.--Minimal or no enhancement
5.
STIR

1.-is the second most common non-lymphoproliferative primary malignant

T1 T1+C neoplasm of the spine in adults.
2.-The mean age of presentation is 45 years
 Chondrosarcma
2.-
2.
.-Chondrosarcoma 3.-
3.
.-Ewing
g Sarcoma and Primitive Neuroectodermal Tumor
MRI
RI
Low
w si
signal
ignal on T1
T1-
T 11-WI
WI and high signal on T
W T22-WI
2-WI
W The most common location for primary lesions is
and frequently reveal a peripheral nodular and septal the
he sacrococcygeal region, followed by the lumbar and
enhancement pattern the thoracic spi
spine, with rarely involvement of the
cervical spine

T2 T1 T1+C

They represent the most common nonlymphoproliferative primary malignant

The spine represents the primary site in 3–12% of chondrosarcomas tumors of the spine in children and adolescents.

3.-
3.
.-Ewing
g Sarcoma and Primitive Neuroectodermal Tumor 3.-
3.
.-Ewing
g Sarcoma and Primitive Neuroectodermal Tumor
MRI
CT
intermediate
ntermediate signal intensity o on T1 intermediate to high
Subtle
ubtle or
r permeative
p e ly
lytic
ytic
c le
lesions,
esions, and extensive
e
signal
siggnnal intensity on T2 WI.
paraspinal soft tissue components.
post
osst-
st
s t-co
contrast
c ontrast images show ma
marked enhancement with
central areas of necrosis.

T2 T1 T1+C
Lesions affecting the spine account less than 10% of all primary sites of Secondary involvement of the spine from other foci of primary Ewing
Ewing sarcoma/PNET sarcoma/PNET is much more common than primary lesions

4..-Osteosarcoma
4.- 4.-
4.
.-Osteosarcoma
Radiograph
Radiography
hy-
h y-CT
CT
CT MR
MRI
RI
osteosclerotic
osteoscleroti
ic,
iic
c, m
mixe
mixed,
ixe
ed, or purely osteolytic lesion with Het
eterogeneous
terogeneous
s si
signal
ignal intensity on T1
T1-- and T2-
T2
2-WI and
extensive
ive
e osseous s de
destruction
estruction heterogeneous enhancement
Osteoid
d matrix calcification is like a dense cloud

T2 T1 T1+C

Osteosarcoma of the spine is rare, representing less than 3% of all Spinal osteosarcomas may be associated with Paget’s disease or previous
osteosarcomas and 5% of all primary malignant tumors of the spine. irradiation
 TAKE HOME MESSAGES

1.-Primary bone tumours of the spine are infrequent lesions

THANKS
2.-Haemangioma is one of the most frequent benign bone tumours and three
types (typical, atypical and aggressive) can be characterized by their imaging
appearance.

3.-Enostoma is usually subcortical and shows a spiculated margin

4- Osteoid osteoma and osteoblastoma are only differentiated by their size.

5.-GCT is preferentially located at the sacrum in adults and ABC in the posterior
elements in young people. Fluid-fluid levels are more frequent in ABC.

6.-Chordoma is more frequent at sacrum and clivus. Its more aggressive

appearance and extension to the soft tissue allows differentiation from benign
tumour of notochordal cells.
BIBLIOGRAPHY
7.-Consider Ewing sarcoma in children with permeative lesions with soft tissue Garcia, D.A.L., et al. Diagnostic Imaging of Primary Bone Tumors of the Spine. Curr
components Radiol Rep 5, 30 (2017)
Orguc S, et al. Primary tumors of the spine. Semin Musculoskelet Radiol. 2014;
8.-Chodroid matrix and osteoid matrix identify chondrosarcoma and 18:280–99.
osteosarcoma, respectively