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PATOLOGIE TUMORALI ENDOCANALARI U.O. Neuroradiologia Istituto Neurologico IRCCS Fondazione C. Mondino, Pavia Dott.ssa Anna Pichiecchio.

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Presentation on theme: "PATOLOGIE TUMORALI ENDOCANALARI U.O. Neuroradiologia Istituto Neurologico IRCCS Fondazione C. Mondino, Pavia Dott.ssa Anna Pichiecchio."— Presentation transcript:

1 PATOLOGIE TUMORALI ENDOCANALARI U.O. Neuroradiologia Istituto Neurologico IRCCS Fondazione C. Mondino, Pavia Dott.ssa Anna Pichiecchio

2 SPINAL TUMORS Uncommon lesions Classification based on their location EXTRADURAL (60% of all spinal tumors) INTRAMEDULLARY (5%-10% of all spinal tumors) INTRADURAL- EXTRAMEDULLARY (30% of all spinal tumors) gliomas Meningiomas and neurinoma Leptomeningeal dissemination Metastasis Extension of primary bone tumors

3 MRI gold standard! TRTEFOVMatrix Sag T2-w X225 Sag T1-w X225 Sag T2 STIR 2500 (TI=170) X190 Ax T2-w X200 Ax T1-w X212 Sag T1-w fat suppression post contrast X212 Ax T1-w post contrast X212

4 EPIDURAL FAT SUBDURAL SPACE EPIDURAL FAT SEPTUM POSTICUM DURA MATER ARACHNOID DURAL NERVE ROOT SLEEVE DENTICULATE LIGAMENT SPINAL CORD AND PIA JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM 1. INTRAMEDULLARY TUMORS

5 Summary Three general characteristics: 1)they tend to enlarge the cord either focally or diffusely 2) on T2-w they produce high signal intensity 3) They enhance

6 1.a. SPINAL CORD ASTROCYTOMA From astrocytes Most WHO I-II Most common in CHILDREN 80-90% low grade Pilocitic Fibrillary Association with abnormalities of chromosome 17p (TP53 gene) 20% intraspinal neoplasms 60% primary spinal cord tumors subarachnoid dissemination may occur!

7 BEST DIAGNOSTIC CLUE Enhancing infiltrating cord mass in child No capsule or cleavage LOCATIONThoracic >Cervical > Lumbar SIZEUsually 1-3 cm, less than 4 segments MORPHOLOGYfusiform expansion of cord, eccentric, posterior General features Risk in patients with Neurofibromatosis (NF1 and NF2) Demographic features: A) Age: two peaks: ys B) Gender: M > F (1,3:1); no gender difference in children!

8 b) 40% cysts and syringohydromyelia c) Solid portion (hypo-isointense) CORD EXPANSION MR Findings Usually < 4 segments T1-w: a) Cord expansion Occasionally multisegmental (holocord more common with pilocytic astrocytomas) From Rossi et al 2007

9 MR Findings T2-w: a) Hyperintense b) Not as hyperintense if cysts/syrinx a)Rarely hemorrhagic T2* GRE: HYPERINTENSE LESION CYSTS From Rossi et al 2007

10 RARELY HEMORRAGE CYSTS

11 MODERATE C.E. ALWAYS!! From Rossi et al 2007 T1-w post-contrast: a) enhancement

12 From Baker et al 1999 DIFFERENTIAL DIAGNOSIS SARCOIDOSIS INTRAMEDULLARY EPENDYMOMA INTRAMEDULLARY HEMANGIOBLASTOMA

13 SYRINGOMYELIA ARNOLD-CHIARI I MALFORMATION

14 1.b. SPINAL CORD EPENDYMOMA Myxopapillary ependymomas (from ependymal cells of filum terminale) Cellular ependymomas (lining spinal cord central canal)

15 Neoplasm of ependyma lining spinal cord central canal Most common in ADULT (60%) in lower spine [ependymoma: 4% of all primary CNS tumors] 2 nd most common in CHILDREN Associated with: ESA Superficial siderosis NF2 deletion or traslocation chr 22 CELLULAR EPENDYMOMA

16 BEST DIAGNOSTIC CLUE Circumscribed, enhancing cord mass with hemorrhage LOCATIONConus> Cervico-Thoracic SIZEMultisegmental (typically 3-4 segments) MORPHOLOGY Well-circumscribed, symmetric cord expansion, occasional exophytic component General features Demographic features: A) Age: 40 yrs B) Gender: M:F=3:1 C) Ethnicity: non racial predilection

17 Radiological features MR Findings T1-w: a)Iso- or slightly hypointense to spinal cord b)Hemorrhage ISO- HYPOINTENSE LESION

18 Radiological features MR Findings T2-w: c) Syrinx d) Focal hypointensity e) Surrounding cord oedema Hemosiderin “Cap sign” a)Hyperintense b) Polar (rostral or caudal) or intratumoral cysts (50-90%) HEMOSIDERIN “CAP SIGN”

19 MR Findings STIR: a) Hyperintense T1-w post-contrast: a) Intense,well- delineated homogeneous c.e. (50%) b) Nodular, peripheral, heterogeneous c.e. c) Minimal or no c.e. rare Radiological features C.E. HEMOSIDERIN “CAP SIGN”

20 ASTROCYTOMA AstrocytomaEpendymoma cervicalconus Eccentric posteriorcentral -hemorragic hyercellularity Infiltrative (poor borders) Pseudocapsule (plane) EPENDYMOMA

21 from ependymal cells of filum terminale MYXOPAPILLARY EPENDYMOMA 27-30% of all ependymomas 90% of all filum terminale tumors

22 Radiological features MR Findings T1-w:a)Usually Isointense with cord b)Hyperintensity (accumulation of mucin!) T2-w: a)Hyperintense b)Hypointensity at tumor margins (hemosiderin) STIR:a) Hyperintense T1-w post-contrast:a)Intense c.e. From Rossi et al 2007

23 INTENSE C.E.

24 ARTERO-VENOUS FISTOLA DIFFERENTIAL DIAGNOSIS

25 From Rossi et al 2007 SPINAL MENINGIOMA Isointense with cord on T1-w and T2-w More common in thoracic and cervical spine (conus and filum location unusual) Hemorrhage uncommon Bony changes rare

26 1.c. SPINAL CORD HEMANGIOBLASTOMA Capillary rich neoplasms 1-5% of all spinal cord neoplasms: 75% sporadic 25% associated with von Hippel-Lindau (VHL) Autosomal dominant (chromosome 3p) Cerebellar hemangioblastomas, retinal angiomas, pheochromocytoma, renal cell carcinoma, angiomatous or cystic lesions of kidneys, pancreas and epididymis WHO I

27 BEST DIAGNOSTIC CLUE Intramedullary mass with serpentine “flow voids” LOCATION Thoracic > Cervical Subpial (posterior, rarely anterior) often associated with intraspinal cysts SIZE Few mm to several cm MORPHOLOGYRound, well-defined margins General features Demographic features: A) Age: mean age at presentation 30 ys B) Gender: M = F

28 Radiological features MR Findings T1-w: a)Isointense b)Cyst!! (> 50%) Small:Large: a)hypo- isointense b)“flow voids” (lesion > 2,5 cm) ISO- HYPOINTENSE LESION + SYRINX

29 Radiological features MR Findings T2-w: a)Uniformly hyperintense (small lesions) mixed hyperintense (hemorrhage common) a)+/- peritumoral oedema b)Syrinx fluid HYPERINTENSE LESION + CYST

30 Radiological features a)Subpial nodule Well-demarcated, intense, homogeneous C.E. (often on surface of dorsal cord) Cyst/ Syrinx: no c.e. MR Findings T1-w post contrast: SUBPIAL NODULE ON THE DORSAL SURFACE

31

32 ARTERIOVENOUS MALFORMATION (AVM) CAVERNOUS MALFORMATION Cord often normal/small, gliotic focal nodule absent, dorsal veins prominent M y insidious onset of lower extremities weakness Pattern of prior hemorrhage, hemosiderin rim Minimal c.e. From Chabert E et al. J Neuroradiol 1999; 26:

33 Ependymoma Astrocytoma metastasis mass centrally located not hypervascular; peritumoral oedema common Crowley, Neurosurgery 2008 Renal cell carcinoma

34 1)they tend to enlarge the cord either focally or diffusely 2) on T2-w they produce high signal intensity 3) They enhance

35 Demylinating diseasesInfectionsInflammation Multiple Sclerosis ADEM Cord swelling from extramedullary infectious process (as meningitis producing vascular compromise) AIDS Sarcoid LES SyringohydromyeliaVascular lesionsCauses of subacute necrotizing myelopahty Hemorrage Acute infarction Venous hypertension Cavernous angioma Arterovenous malformation ADEM Devic, MS HZV,Rubeola, Mononucleosis, mumps Toxo, TBC Lupus Spinal dural AVM Venous hypertension Symptoms include pain, weakness and muscle atrophy

36 EPIDURAL FAT SUBDURAL SPACE EPIDURAL FAT SEPTUM POSTICUM DURA MATER ARACHNOID DURAL NERVE ROOT SLEEVE DENTICULATE LIGAMENT SPINAL CORD AND PIA JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM 2. INTRADURAL EXTRAMEDULLARY TUMORS

37 Schwannoma, Neurinoma Neurofibroma Arise from single nerve, from one side Typically dorsal root Schwann cells Do NOT envelope the adiacent nerve root Lobulated Single Schwann cells and fibroblasts between dispersed nerve fibers, mps matrix Spreads apart axons DO envelope the adiacent nerve root Fusiform Multiple

38 2.a. SCHWANNOMA Neoplasm of nerve sheath in PNS Most common intradural extramedullary mass 30% primary spinal tumors Mostly sporadic (inactivation of NF2 gene) Association with NF2, bilateral multiple WHO grade I

39 BEST DIAGNOSTIC CLUE Well-circumscribed, “dumbbell” shaped, enhancing spinal mass LOCATION Thoracic > Cervical = Lumbar 70-75% intradural extramedullary 15% completely extradural 15% “dumbbell” (both intra- and extradural) SIZE Few mm Giant schwannoma: > 2 vertebral segments MORPHOLOGY Round, lobulated General features Demographic features: A) Age: 40 ys B) Gender: M = F C) Ethnicity: no racial predilection

40 Radiological features T1-w: Isointense T2-w: a) hyperintense b)45%cyst 10% hemorrage c)“Target sign” HYPERINTENSE LESION WITH TARGET SIGN ISOINTENSE LESION

41 Radiological features T1-w post-contrast: a)Intense c.e. (uniform or peripheral) C.E.

42 2.b. NEUROFIBROMA Localized, diffuse or plexiform neoplasm of nerve sheath WHO grade I WHO grade III/IV 5% of all benign soft tissue tumors Association with neurofibromatosis 1 (NF1) 13-65% have spinal neurofibromas

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44 ISOINTENSE LESION HYPERINTENSE LESION + HYPOINTENSE SEPTATIONS C.E.

45 DIFFERENTIAL DIAGNOSIS CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY (CIDP)

46 2.c. MENINGIOMA Origin from arachnoid Attached to the dura mater for infiltration SECOND MOST COMMON INTRADURAL EXTRAMEDULLARY TUMOR > 25% WHO I Solitary Genetic predisposition in women! Almost all have chromosome 22 abnormalities Association with neurofibromatosis 2 (NF2) Meningothelial Fibroblastic Psammomatous angiomatous

47 BEST DIAGNOSTIC CLUE Enhancing intradural extramedullary mass with “dural tail” LOCATION Thoracic (80%)>> Cervical (16%) > Lumbar (4%) Typical intradural extramedullary Posterolateral (anterior cervical) SIZE Variable MORPHOLOGY Typically round with dural attachment, Ca ++ < 5% General features Demographic features: A)Age: yrs B) Gender: F:M=4:1 (>70-80% female!)

48 Radiological features T2-w: a)Isointense b)Iso- hyperintense c)Hypointense (calcification) MR Findings ISOINTENSE LESION WITH CALCIFICATION T1-w:

49 Radiological features T1-w post-contrast: a)Prominent c.e. b)May see enhancing “dural tail” C.E.

50 NEURINOMA More anterior Very hyperintense on T2-w with Target sign Cystic change, hemorrhage more common No dural attachment more frequent enlargment of neural foramen Differential diagnosis

51 DROP METASTASIS

52 EPIDURAL FAT SUBDURAL SPACE EPIDURAL FAT SEPTUM POSTICUM DURA MATER ARACHNOID DURAL NERVE ROOT SLEEVE DENTICULATE LIGAMENT SPINAL CORD AND PIA JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM 3. EXTRADURAL TUMORS

53 LYMPHOMA From Thurner et al. METASTASIS Female (breast and lung) Male (prostate and lung) Thoracic (70%)> lumbar (20%) > cervical (10%)

54 DROP METASTASIS

55 DIFFERENTIAL DIAGNOSIS ANGIOMIOLIPOMA

56 DIFFERENTIAL DIAGNOSIS GRANULOMATOSIS

57 INTRADURAL ARACHNOID CYSTEPIDURAL EMATOMA

58 Grazie per l’attenzione


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