Primary Vertebral Osteosarcoma: Imaging Findings

Sacral tumors: a comprehensive review of imaging, diagnostic challenges, and tumor mimics

The sacrum can harbor a diverse group of both benign and malignant tumors, including metastases. Primary tumors of the sacrum can arise from bone, cartilage, marrow, notochordal remnants, or surrounding nerves and vessels. Among a variety of primary tumors of the spine, chordoma, germ cell tumors and Ewing's sarcoma are recognized for their propensity to occur in the sacrum. Imaging is essential in diagnosis, pretreatment evaluation, and assessment of response to treatment. Radiography, CT and MRI are the primary modalities in assessing morphology and tumor extent whereas PET/CT is crucial in the evaluation of systemic disease in the setting of myeloma, lymphoproliferative disease, and metastasis. A definitive diagnosis is not always achievable by imaging as some tumors lack specific imaging features. However, as we detail in this comprehensive review, many entities have characteristic clinical and epidemiological factors as well as typical imaging findings that can help make either a confident diagnosis or offer a narrow list of differentials. We discuss a wide range of benign and malignant, primary, and secondary tumors that can involve the sacrum, highlighting the pertinent clinical details and typical imaging findings of these entities, enabling the reader to develop and apply a systematic approach to evaluating sacral masses on imaging. We also briefly describe non-neoplastic tumor mimics, which include developmental entities, infections, and insufficiency fractures.

Understanding a mass in the paraspinal region: an anatomical approach

The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.

Development and Validation of a Prognostic Model for Overall Survival in Patients with Primary Pelvis and Spine Osteosarcoma: A Population-Based Study and External Validation

Background: Primary pelvis and spine osteosarcoma (PSOS) is a specific type of osteosarcoma that is difficult to treat and has a poor prognosis. In recent years, the research on osteosarcoma has been increasing, but there have been few studies on PSOS; in particular, there have been a lack of analyses with a large sample size. This study aimed to construct and validate a model to predict the overall survival (OS) of PSOS patients, as currently there are no tools available for assessing their prognosis. Methods: Data including demographic information, clinical characteristics, and follow-up information on patients with PSOS were collected from the Surveillance, Epidemiology, and End Results (SEER) database, as well as from the Spine Tumor Center of Changzheng Hospital. Variable selection was achieved through a backward procedure based on the Akaike Information Criterion (AIC). Prognostic factors were identified by univariate and multivariate Cox analysis. A nomogram was further constructed for the estimation of 1-, 3-, and 5-year OS. Calibration plots, the concordance index (C-index), and the receiver operating characteristic (ROC) were used to evaluate the prediction model. Results: In total, 83 PSOS patients and 90 PSOS patients were separately collected from the SEER database and Changzheng Hospital. In the SEER cohort, liver metastasis, lung metastasis, and chemotherapy were recognized as independent prognostic factors for OS (p < 0.05) and were incorporated to construct the initial nomogram. However, the initial nomogram showed poor predictive accuracy in internal and external validation. Then, we shifted our focus to the Changzheng data. Lung metastasis involving segments, Eastern Cooperative Oncology Group (ECOG) performance score, alkaline phosphatase (ALP) level, and en bloc resection were ultimately identified as independent prognostic factors for OS (p < 0.05) and were further incorporated to construct the current nomogram, of which the bias-corrected C-index was 0.834 (0.824–0.856). The areas under the ROC curves (AUCs) of the current nomogram regarding 1-, 3-, and 5-year OS probabilities were 0.93, 0.96, and 0.92, respectively. Conclusion: We have developed a predictive model with satisfactory performance and clinical practicability, enabling effective prediction of the OS of PSOS patients and aiding clinicians in decision-making.

Case Report: Giant cell-rich osteosarcoma of the cervical spine in the pediatric age. A rare entity to consider

BACKGROUND

Although osteosarcoma is the most common primary malignant bone tumor in children, its location in the axial skeleton is rare, particularly at the cervical spine. Early diagnosis, together with multidisciplinary management, improves survival rates. Safe resection and stable reconstruction are complicated by the particular anatomy of the cervical spine, which raises the risks.

CASE PRESENTATION

A 12-year-old male patient presented with cervical pain for several months and a recent weight loss of 3 kg. The complementary workup revealed a large destructive bone lesion in C7 with vertebral body collapse, subluxation, partial involvement of C6 and T1, large associated anteroposterior soft tissue components, and spinal canal narrowing. A biopsy suggested giant cell-rich osteosarcoma (GCRO). After 10 cycles of neoadjuvant chemotherapy, surgical resection was performed through a double approach: anterior, for tumoral mass resection from C6-7 vertebral bodies and reconstruction placing a mesh cage filled with iliac crest allograft plus anterior plate fixation; and posterior, for C7 complete and C6 partial posterior arch resection, thus completing a total piecemeal spondylectomy preserving the dura intact, added to a C5-T3 posterior fusion with screws and transitional rods. Postoperative chemo and radiotherapy were administered. Clinical and radiological follow-up showed disease-free survival and no neurological involvement at 3 years.

CONCLUSION

An extensive review of the literature did not find any published cases of GCRO of the cervical spine in pediatric patients. This can be explained by the combination of three peculiar conditions: its location at the cervical spine region, the young age, and the GCRO variant.

A Radiologists' Guide to En Bloc Resection of Primary Tumors in the Spine: What Does the Surgeon Want to Know?

En bloc resection in the spine is performed for both primary and metastatic bone lesions and has been proven to lengthen disease-free survival and decrease the likelihood of local recurrence. It is a complex procedure, which requires a thorough multi-disciplinary approach. This article will discuss the role of the radiologist in characterizing the underlying tumor pathology, staging the tumor and helping to predict possible intraoperative challenges for en bloc resection of primary bone lesions. The postoperative appearances and complications following en bloc resection in the spine will be considered in subsequent articles.

Primary Tumors of the Sacrum: Imaging Findings

The diagnosis of sacral neoplasms is often delayed because they tend to remain clinically silent for a long time. Imaging is useful at all stages of managing sacral bone tumors: from the detection of the neoplasm to the long-term follow-up. Radiographs are recommended as the modality of choice to begin the imaging workup of a patient with known or suspected sacral pathology. More sensitive examinations such as computerized tomography (CT), magnetic resonance (MRI), or scintigraphy are often necessary. The morphological features of the lesions on CT and MRI help to orientate the diagnosis. Although some imaging characteristics are helpful to limit the differential diagnosis, an imaging-guided biopsy is often ultimately required to establish a specific diagnosis. Imaging is of paramount importance even in the long-term follow-up in order to assess any residual tumor when surgical resection is incomplete, to assess the efficacy of adjuvant chemotherapy and radiotherapy, and to detect recurrence.

An assessment of fluid-fluid levels on magnetic resonance imaging of spinal tumours

OBJECTIVE

To assess the degree of fluid-fluid levels on MRI in spinal tumours compared with final diagnosis, and the outcome of needle biopsy in such cases.

MATERIALS AND METHODS

Retrospective review of patients with a spinal tumour that contained fluid-fluid levels. Data collected included age, sex, spinal location, and final diagnosis. The outcome of needle biopsy was investigated.

RESULTS

Forty-two patients were included (19 males; 24 females; mean age 27.5 years, range 5-80 years), the commonest diagnoses being aneurysmal bone cyst (n = 25; 59.5%) and metastasis (n = 5; 11.9%). All patients with a malignant diagnosis were > 50 years of age apart from 2 who had metastases from a known primary cancer, while all patients apart from 1 with aneurysmal bone cyst were < 35 years of age. Needle biopsy was undertaken in 29 cases (69%) and diagnostic in 18 (62%). Patients with FFL occupying > 2/3 of the lesion were significantly more likely to have an aneurysmal bone cyst (p = 0.008) while those with FFL occupying < 2/3 of the lesion were more likely to have a malignant tumour (p = 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of > 2/3 FFLs occupying the lesion were 97.1%, 75%, 94.3%, 85.7%, and 92.9% respectively for differentiating a benign from a malignant spinal tumour.

CONCLUSIONS

Children and younger adults with spinal lesions containing > 2/3 FFLs were very unlikely to have malignancy. However, in patients > 50 years of age or those with lesions containing < 2/3 FFLs, a malignant lesion is much more likely.

An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

Sacral tumours and their mimics: pictorial review and diagnostic strategy

Sacral tumours encompass an extensive range of differential diagnosis. The clinical presentation is often non-specific, including neurological deficits and low back pain. Accurate diagnosis of sacral lesions is challenging and requires a comprehensive imaging strategy and robust knowledge on the imaging characteristics of different pathological processes. This review will provide an updated overview of the computed tomography (CT), magnetic resonance imaging (MRI), and integrated positron-emission tomography (PET)-CT features of some common and rare sacral tumours and their mimics. Several clinical scenarios with specific diagnostic considerations and treatment implications will be described.

Bone up on spinal osseous lesions: a case review series

Spinal osseous neoplasms are frequently encountered and can be challenging when present as solitary lesions. Familiarity with the range of benign and malignant spinal pathology can help the radiologist formulate a comprehensive differential diagnosis. This article focuses on the spectrum of extradural spinal tumors, accounting for the majority of primary spinal tumors, by comparing the epidemiology, pathophysiology, clinical presentation, and characteristic imaging appearance of these lesions. The discussion includes the commonly encountered benign lesions, such as vertebral venous vascular malformation and enostosis, as well as malignant lesions including metastases and lymphoma. The article also includes other less-encountered primary spinal tumors such as plasmacytoma, osteoid osteoma, osteoblastoma, giant cell tumor, eosinophilic granuloma, chordoma, chondrosarcoma, osteosarcoma, Ewing’s sarcoma, and angiosarcoma. Familiarity with the characteristic imaging features can help the radiologist reach an accurate diagnosis and obviate the need for unnecessary invasive procedures such as biopsy and surgery.

Diagnostic Challenges in Primary Sacral Tumors and the Yield of Computed Tomography-Guided Needle Biopsy in the Modern Era

OBJECTIVE

Primary sacral tumors pose unique challenges because of their complex radiographic appearances, diverse pathologic entities, and dramatically different treatment paradigms based on tumor type. Magnetic resonance imaging and computed tomography (CT) can provide valuable information; however, sacral lesions can possess unique radiographic features and pose diagnostic dilemmas. CT-guided percutaneous needle biopsy is a critical component of the diagnostic workup. However, limited data are available on its efficacy for primary sacral tumors.

METHODS

The data from patients with newly diagnosed primary sacral lesions during a 12-year period at our hospital were analyzed. The preoperative magnetic resonance imaging findings, biopsy results, and pathological data for patients who required surgery were analyzed. Unique cases in which the final pathologic result was unexpected from the preoperative imaging findings have been highlighted.

RESULTS

Of 38 patients who underwent percutaneous needle biopsy, diagnostic tissue was obtained on the first attempt for 31 (82%). Five of the remaining 7 obtained diagnostic tissue on the second attempt, yielding 95% diagnosis, with only two requiring open biopsies. In 2 patients with diagnostic tissue on CT-guided biopsy, an open biopsy was still recommended because of the clinical scenario. In both patients, the open biopsy results matched those of the CT-guided biopsy. For the 18 patients who required surgery, we found 100% correlation between the percutaneous needle biopsy findings and the final pathological diagnosis. No biopsy-induced complications or extraspinal tumor seeding occurred.

CONCLUSIONS

CT-guided biopsy is a safe and effective technique. It represents a critical component of the diagnostic algorithm, given the diverse pathological findings of primary sacral lesions and dramatic differences in treatment.

Spinal sarcomas and immunity: An undervalued relationship

Sarcomas, especially spine sarcomas, are rare yet debilitating and are underestimated types of cancer. Treatment options for spine sarcomas are limited to chemotherapy, radiotherapy and surgical intervention. Accumulating evidence suggests a complex course associated with the treatment of spine sarcomas as compared to other soft tissue sarcomas in the extremities since adjuvant therapy adds limited success to the oncological outcome. Likewise, the limitations of surgical interventions imposed by the proximity and high sensitivity of the spinal cord, leads to an increased recurrence and mortality rates associated with spine sarcomas. Finding novel treatment options to spine sarcomas as such is inevitable, necessitating a more thorough understanding of the different mechanisms of the underlying etiologies of these tumors. In this review, we discuss the most recent studies tackling the involvement of the immune system; a key player in the emergence of the different types of spine sarcomas and the promising immune-mediated targeted therapy that can be applied in these kind of rare cancers.

Diagnostic challenges and surgical management of co-existent osteoblastoma and aneurysmal bone cyst of the lumbar spine in a child: case report

Background

Osteoblastomas (OTB) with co-existent aneurysmal bone cysts (ABC) of the spine are extremely rare and more so in the lumbar spine. To the authors' knowledge, only one case of lumbar spine involvement has been reported in a paediatric patient.

Objectives

To highlight diagnostic challenges and surgical management of co-existent lumbar OTB-ACB in a child.

Methods

We present a 14-year old female with low back pain and progressive swelling of 2 months. She was evaluated by neuroimaging studies and histopathological assessment of resected tissue.

Results

X-ray showed a lytic lesion in L3 with loss of the left pedicle. Magnetic resonance imaging (MRI) revealed a fluid-filled, heterogeneously enhanced, lobulated lesion posterior to the vertebral bodies of L3, L4 and L5, which infiltrated the quadratus lumborum muscles bilaterally, and histologically diagnosed as ABC. The L3 pedicle also revealed an expanded, heterogeneously enhanced mass lesion which appeared to be different and showed no fluid-filled levels, histologically diagnosed as OTB. Surgical intervention involved tumour excision with partial spondylectomy of L3 vertebra, posterior instrumented stabilization and fusion.

Conclusion

The case highlights the diagnostic challenges of co-existent OTB-ABC and the significant role of surgical management via spinal reconstruction, stabilization and fusion after gross total tumour excision.

Novel therapeutic strategies for spinal osteosarcomas

At the dawn of the third millennium, cancer has become the bane of twenty-first century man, and remains a predominant public health burden, affecting welfare and life expectancy globally. Spinal osteogenic sarcoma, a primary spinal malignant tumor, is a rare and challenging neoplastic disease to treat. After the conventional therapeutic modalities of chemotherapy, radiation and surgery have been exhausted, there is currently no available alternative therapy in managing cases of spinal osteosarcoma. The defining signatures of tumor survival are characterised by cancer cell ability to stonewall immunogenic attrition and apoptosis by various means. Some of these biomarkers, namely immune-checkpoints, have recently been exploited as druggable targets in osteosarcoma and many other different cancers. These promising strides made by the use of reinvigorated immunotherapeutic approaches may lead to significant reduction in spinal osteosarcoma disease burden and corresponding reciprocity in increase of survival rates. In this review, we provide the background to spinal osteosarcoma, and proceed to elaborate on contribution of the complex ecology within tumor microenvironment giving arise to cancerous immune escape, which is currently receiving considerable attention. We follow this section on the tumor microenvironment by a brief history of cancer immunity. Also, we draw on the current knowledge of treatment gained from incidences of osteosarcoma at other locations of the skeleton (long bones of the extremities in close proximity to the metaphyseal growth plates) to make a case for application of immunity-based tools, such as immune-checkpoint inhibitors and vaccines, and draw attention to adverse upshots of immune-checkpoint blockers as well. Finally, we describe the novel biotechnique of CRISPR/Cas9 that will assist in treatment approaches for personalized medication.

Benign Giant Cell Lesion of C1 Lateral Mass: A Case Report and Literature Review

Primary osseous tumors of the spinal column account for approximately 1% of the total number of spinal tumors found in the pediatric patient population. The authors present a case of a C1 benign giant cell lesion that was incidentally found in a 15-year-old patient. A transoral biopsy was performed followed by treatment with denosumab, with definitive management in the form of transoral tumor resection with subsequent occiput-cervical three posterior instrumented fusion. The patient tolerated all of the procedures well, as there were no post-operative complications, discharged home neurologically intact and was eager to return to school when assessed during a follow-up visit in clinic. Osteolytic lesions affecting the cervical spine are rare in the pediatric population. It is of utmost importance to have sufficient background knowledge in order to formulate a differential diagnosis, as well as an understanding of principles underlying surgical techniques required to prevent occipital-cervical instability in this patient population. The information presented will guide surgical decision-making by identifying the patient population that would benefit from neurosurgical interventions to stabilize the atlantoaxial junction, in the context of rare osteolytic conditions affecting the cervical spine.

Spinal osteosarcoma in the paediatric age group: case series and literature review

INTRODUCTION AND OBJECTIVE

Osteosarcoma is the most frequent malignant spinal tumour in the paediatric age group. Diagnosis and early treatment of this pathology is essential for a good prognosis. The aim of this study was to present the results of treatment of paediatric patients with lumbar osteosarcoma and conduct a literature review.

MATERIAL AND METHODS

All the patients with lumbar osteosarcoma who were operated between 2012 and 2014 in the same centre were included. Demographic and radiological data (Enneking, WBB and Tomita classification), as well as anatomopathological (Broders classification) variables were analysed. All the patients were treated by surgical resection associated with adjuvant therapies (chemotherapy and radiotherapy); according to consensus with the tumour committee. The average follow-up was 62.53 months (47-70 months).

RESULTS

A total of 3 patients were studied, two girls of 9 and 11, with L5 osteosarcoma, and a 15-year-old boy with L4 osteosarcoma. Two of the cases were initially treated as an osteoblastoma, supported by radiological and anatomopathological images. None of the patients had local recurrences or metastases during follow-up.

CONCLUSIONS

Due to a lack of long series of cases of osteosarcoma in the mobile spine during childhood, the optimal treatment and prognosis in these patients is uncertain. Block resection improves local control of the disease, without demonstrating improvement in overall survival. Intralesional resection is associated with a higher rate of local recurrence. Oncological treatment is essential in the treatment of this pathology. A correct differential diagnosis of the tumour (osteosarcoma vs. osteoblastoma) is vital for its correct treatment.

Imaging of Malignant Primitive Tumors of the Spine

Primary malignant tumors of the spine are rare and mainly include chordoma, chondrosarcoma, Ewing sarcoma or primitive neuroectodermal tumor, and osteosarcoma. The final diagnosis is based on the combination of patient age, topographic and histologic features of the tumor, and lesion pattern on computed tomography (CT) and magnetic resonance (MR) imaging. Imaging evaluation includes radiography, CT, bone scintigraphy, and MR imaging. CT is more useful than radiography for evaluating location of the lesion and analyzing bone destruction and matrix, whereas MR has unmatched ability to assess soft tissue extension. This pictorial review provides an overview of the most prevalent primitive malignant tumors of spine.

Screw migration and oesophageal perforation after surgery for osteosarcoma of the cervical spine

Background

Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.

Case presentation

We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.

Conclusions

Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.

Image-guided resection of aggressive sacral tumors

OBJECTIVE The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors. METHODS The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type. RESULTS Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type. CONCLUSIONS Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

ALK positive Anaplastic Large Cell Lymphoma of the Thoracic Spine

Primary bone lymphoma (PBL) is an uncommon extra nodal disease that represents about 1-3% of lymphoma cases. Imaging findings are variable and non-specific. Computed tomography may demonstrate lytic lesions with sequestra and periosteal reaction. On magnetic resonance imaging, lesions are T1WI hypointense and T2WI hyperintense, related to peritumoral edema or bone marrow replacement. Rarely lesions may have associated fibrosis and show a more hypointense signal pattern on T2WI. After administration of contrast, PBL tends to enhance avidly. We present a case of a 24 years old African American female patient with history of back pain. Initial imaging examinations showed lesions involving the T12 and T11 vertebral bodies with initial negative biopsy results. One month later, the patient returned with worsening back pain, and the follow up studies depicted collapse of the T12 vertebral body. A diagnosis of anaplastic large cell lymphoma in T12 was made. A brief review of the literature, imaging and pathological findings, and treatment options are also discussed.

Primary osseous tumors of the pediatric spinal column: review of pathology and surgical decision making

Spinal column tumors are rare in children and young adults, accounting for only 1% of all spine and spinal cord tumors combined. They often present diagnostic and therapeutic challenges. In this article, the authors review the current management of primary osseous tumors of the pediatric spinal column and highlight diagnosis, management, and surgical decision making.

Imaging features of primary tumors of the spine: A pictorial essay

Primary tumors of spine are rare accounting for less than 5% of new bone tumors diagnosed every year. These tumors may exhibit characteristic imaging features that can help in early diagnosis and improved prognosis. Plasmacytoma/multiple myeloma and lymphoproliferative tumors are the most common malignant primary spinal tumors. Hemangioma is the most common benign tumor of the spine. Computed tomography is useful to assess tumor matrix and osseous change. Magnetic resonance is useful to study associated soft tissue extension, marrow infiltration, and intraspinal extension. Confusing one tumor with the other based on only imaging findings is not uncommon. However, radiologic manifestations of these tumors need to be correlated with the age, sex, location, and presentation to arrive at a close clinical diagnosis.

Single-Staged Multilevel Spondylectomy for En Bloc Resection of an Epithelioid Sarcoma With Intradural Extension in the Cervical Spine: Technical Case Report

BACKGROUND AND IMPORTANCE

Occurrence of spinal epithelioid sarcomas is rare, with few cases reported in the literature. Although wide local resection is the recommended treatment, this technique is challenging in the spine.

CLINICAL PRESENTATION

The case of a 17-year-old male with a recurrent epithelioid sarcoma with intradural extension in the cervical spine is presented. Because of nerve root involvement, the patient presented with right upper extremity weakness. The patient underwent a posterior C1-C4 spondylectomy to achieve an en bloc resection, followed by reconstruction from the occiput to T4. The right vertebral artery and C1-C4 nerve roots were sacrificed because of tumor involvement. After 3 years of follow-up the patient is disease-free but has persistent right deltoid weakness.

CONCLUSION

Cervical spondylectomy via a single-staged posterior approach is a challenging yet feasible procedure for the treatment of epithelioid sarcomas. To the best of the authors' knowledge, this is the first report of complete resection of an epithelioid sarcoma with intradural extension in the cervical spine. Although neurovascular structures may warrant sacrifice, this procedure may provide improved long-term prognosis.

Epithelioid Sarcoma in the Cervical Spine: A Case Report

Epithelioid sarcoma is a rare and highly malignant soft tissue neoplasm that most commonly occurs in the long bones. This uncommon tumor has a poor clinical outcome, and the modality of its treatment has not yet been fully established. The authors report an extremely rare presentation of epithelioid sarcoma in the cervical spine, along with its clinical progression, imaging, and pathology. The patient underwent three surgical procedures and adjuvant radiochemical management. He survived for 25 months with a good general condition and adapted well to his social activity. Systemic metastasis was not found, but the patient died of respiratory failure due to direct tracheal invasion of the tumor.

Paediatric acquired pathological vertebral collapse

Vertebral collapse is a significant event in the paediatric patient with a real potential for associated deformity and morbidity. While in adults the causes tend towards the malignant, particularly metastatic and metabolic disease, the paediatric population demonstrates a different range of diagnoses. This article reviews the typical imaging findings of the more common underlying acquired pathological causes of vertebral collapse in children, including Langerhans cell histiocytosis, chronic recurrent multifocal osteomyelitis, osteogenesis imperfecta. Other causes include pyogenic osteomyelitis and tuberculosis and neoplastic lesions, either primary, metastatic or of haematological origin.

Epithelioid sarcoma of the spine: case report and literature review

Epithelioid sarcomas are rare mesenchymal neoplasms mainly arising in the limbs of young adults. We report the case of a 24-year-old male presenting low back pain radiating to both lower limbs, constipation and urinary retention. The MRI scan showed an intraspinal lesion extending from L4 to S2. Surgery resulted in gross total removal of the extradural lesion and partial removal of the intradural component. The immunohistological study of the lesion was consistent with an epithelioid sarcoma. The patient was submitted to radiotherapy and chemotherapy, but a local recurrence of the lesion and dissemination along the neuraxis were observed 3 months after surgery. Despite treatment, the patient died 4 months after the surgical procedure due to multiorgan failure. Despite there being isolated reports of epithelioid sarcomas appearing in the spine, this is, to our knowledge, the first case with intradural extension.

Ivory vertebra on 18F-sodium fluoride scan: an old sign in a new modality

We report a case of ivory vertebra on 18F-sodium fluoride. A prostate cancer patient had a 18F-sodium fluoride PET scan to evaluate overall spread of disease. In addition to other findings of metastatic disease, the patient had an ivory vertebra.

Spinal osteosarcoma

Although osteosarcoma represents the second most common primary bone tumor, spinal involvement is rare, accounting for 3%–5% of all osteosarcomas. The most frequent symptom of osteosarcoma is pain, which appears in almost all patients, whereas more than 70% exhibit neurologic deficit. At a molecular level, it is a tumor of great genetic complexity and several genetic disorders have been associated with its appearance. Early diagnosis and careful surgical staging are the most important factors in accomplishing sufficient management. Even though overall prognosis remains poor, en-block tumor removal combined with adjuvant radiotherapy and chemotherapy is currently the treatment of choice. This paper outlines histopathological classification, epidemiology, diagnostic procedures, and current concepts of management of spinal osteosarcoma.

Telangiectatic osteosarcoma: a review of literature

Telangiectatic osteosarcoma is a rare variant of osteosarcoma and hence its occurrence, presentation, and prognosis are poorly understood. With advancements in technology and available treatment options, the scenario of its diagnosis, management, and outcome has changed. Chemotherapy with surgery was challenged previously, but has now been proved to be beneficial. We reviewed the available literature and compared results to define the characteristics of the disease, its presentation, radiographic and pathologic features, optimal treatment, and prognosis.

Survival and recurrence rate after treatment for primary spinal sarcomas

Objective

We have limited understanding on the presentation and survival of primary spinal sarcomas. The survival, recurrence rate, and related prognostic factors were investigated after treatment for primary sarcomas of the spine.

Methods

Retrospective analysis of medical records and radiological data was done for 29 patients in whom treatment was performed due to primary sarcoma of the spine from 2000 to 2010. As for treatment method, non-radical operation, radiation therapy, and chemotherapy were simultaneously or sequentially combined. Overall survival (OS), progression free survival (PFS), ambulatory function, and pain status were analyzed. In addition, factors affecting survival and recurrence were analyzed : age (≤42 or ≥43), gender, tumor histologic type, lesion location (mobile spine or rigid spine), weakness at diagnosis, pain at diagnosis, ambulation at diagnosis, initial treatment, radiation therapy, kind of irradiation, surgery, chemotherapy and distant metastasis.

Results

Median OS was 60 months, the recurrence rate was 79.3% and median PFS was 26 months. Patients with distant metastasis showed significantly shorter survival than those without metastasis. No factors were found to be significant relating to recurrence. Prognostic factor associated with walking ability was the presence of weakness at diagnosis.

Conclusion

Primary spinal sarcomas are difficult to cure and show high recurrence rate. However, the development of new treatment methods is improving survival.

Treatment and outcomes of epithelioid sarcoma of the spine

Epithelioid sarcoma (ES) is a rare soft-tissue neoplasm which is most commonly found in the extremities of young adult males. ES has a poor prognosis due to its aggressiveness as it frequently recurs locally and can undergo lymphatic metastasis to soft tissue, fascia, bone, lymph nodes, lung, and brain. The most common form is the classic-type (granuloma-like), though a more aggressive subtype known as the proximal- or axial-type has also been described. As ES of the spine is exceedingly rare, with only seven patients being reported in the literature, the outcomes of these patients is unclear. We have reviewed the literature of all existing spinal ES cases to recommend treatment strategies and report the first case of proximal-type ES in the cervical spine. Patients with spinal ES had an average age of 20.7 years, with 71.4% of cases being in males. Metastasis was common and was found in 83.3% of patients, with lung metastasis being found in 60% of these patients. Due to the high rates of local recurrence and distant metastasis, the goal of surgery remains gross total resection of all tumor and involved bony elements if feasible without significant neurological deficits. Ligation of involved nerve roots may be necessary to achieve adequate resection of the tumor mass as nerve sheaths can serve as a pathway for extension. In the cervical spine, resection of these lesions is difficult due to involvement of the vertebral arteries in addition to nerve roots, increasing the surgical risk.

Imaging of spine neoplasm

Although most often back pain is of benign origin, it can occasionally be a harbinger of a more serious spinal condition, including spine neoplasm. Knowledge of the typical clinical history of spinal tumors and an understanding of the innervation of the spine and surrounding supporting structures may allow us to better understand when to pursue advanced imaging in the evaluation of spinal pain syndromes. Many radiologists have divided the differential diagnosis of neoplasms of the spine into compartments. These compartments include the extradural compartment, intradural/extramedullary compartment, and the intramedullary compartment.

Primary spinal chondrosarcoma: radiological manifestations with histopathological correlation in eight patients and literature review

PURPOSE

The aim of this study was to delineate radiological-pathological correlation in primary vertebral chondrosarcoma.

METHODS

Eight histopathologically confirmed cases were analyzed for pathological and radiological characteristics.

RESULTS

Magnetic resonance images of three conventional and one clear cell cases showed lobulated or irregular masses with line or septa enhancement. Two conventional lesions showed signal intensity of high water content on T2-weighted images, in which aneurismal bone cysts were confirmed. The myxoid lesion showed a relatively diffuse signal and enhancement. Marked masses were found in the two mesenchymal patients, either dumbbell-like or round-like.

CONCLUSION

Primary spinal chondrosarcomas have certain radiological findings that may correlate to the pathological subtypes.

High long-term local control with sacrectomy for primary high-grade bone sarcoma in children

BACKGROUND

Sacrectomy may offer curative potential for primary sarcomas of the sacrum. However, it is unclear whether and to what extent sacrectomies achieve local control.

QUESTIONS/PURPOSE

We therefore determined the curative potential, walking ability, continence control, and quality of life for children after sacrectomy for primary bone sarcoma.

METHODS

We retrospectively reviewed eight children with high-grade primary bone sarcomas treated with sacrectomy. The average age of the patients was 14 years (range, 4-18 years). There were six Ewing sarcomas and two osteosarcomas. Five patients underwent partial and three underwent total sacrectomies with all resection margins free of tumor. We recorded local and distant recurrences, functional (Musculoskeletal Tumor Society [MSTS] score) and oncologic outcome (survival), walking ability, bladder and bowel control, independence, and reintegration in society. The average followup was 80 months (range, 54-204 months).

RESULTS

Six patients were alive without evidence of disease at last followup. Three patients had metastases develop and two died of disease 3 and 25 months postoperative. MSTS scores among survivors averaged 17.5 points (range, 5-25 points). Seven of the eight patients were able to ambulate, two independently. All initially were incontinent, but at last followup, two were continent and two were incontinent only under stress. Complications occurred in seven of eight, five of whom required additional surgery.

CONCLUSION

Despite the high incidence of neurologic deficits and complications, sacrectomy achieved local control in patients with high-grade bone sarcomas. Our observations suggest long-term survival and adequate quality of life are possible in the pediatric population.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Occipitocervical reconstruction through direct lateral and posterior approach for the treatment of primary osteosarcoma in the atlas: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a new surgical technique of the primary cervical osteosarcoma in the atlas.

SUMMARY OF BACKGROUND DATA

Primary osteosarcoma of the atlas is extremely rare. This is the first report that describes a surgical treatment of the primary osteosarcoma in the atlas. Resection of an osteosarcoma in the atlas is very difficult because of the complex and important anatomic structures that surround it, and secure reconstruction of the atlas is difficult as well.

METHODS

A 48-year-old man was referred to our institute with a 10-month history of a palpable painful mass on the right posterior neck. His neck mass was diagnosed as chondroblastic osteosarcoma by open bone biopsy. The plain radiograph of the lateral cervical spine revealed the osteoblastic lesion of the vertebra and an extraosseous mass formation from the C1 to C3 vertebrae. Computed tomography of the cervical spine revealed approximately a 7 × 3 × 7 cm-sized extraosseous calcified mass that originated from the right lateral mass of the atlas. The magnetic resonance imaging of the cervical spine did not show any spinal cord compression.

RESULTS

The patient underwent excision of this tumor using the direct lateral approach and reconstruction of the lateral mass of the atlas. On gross examination of the mass, there was a reactive thin membrane ("pseudomembrane") between soft tissue and tumor. At 3 months after surgery, the computed tomographic scan showed the solid fusion state of the occipitocervical joint. He rarely complained of any problems except for mild limitation of neck motion.

CONCLUSION

We report a rare case of complete excision of an osteosarcoma of the C1 lateral mass in our patient via a direct lateral and posterior approach to secure additional fixation of occipitocervical joint. We describe our technique for reconstructing the lateral mass of the atlas. This reconstruction technique will also be applicable to other resection surgeries involving the occipitocervical junction.

Primary telangiectatic osteosarcoma of the cervical spine

Telangiectatic osteosarcoma (TOS) is one of the 8 subtypes of osteosarcoma that infrequently affects the spine. The radiopathological features of TOS overlap with those of more benign entities, most commonly the aneurysmal bone cyst), and therefore is a significant diagnostic challenge. It is a rare but well-described entity in the thoracolumbar and sacral spine, and to the authors' knowledge has not been previously reported in the cervical spine. The authors report the case of a 15-year-old boy who presented with a 6-month history of neck pain and torticollis. He underwent preoperative glue embolization followed by a staged subtotal C-5 spondylectomy and posterior fusion for a C-5 vertebral body lytic expansile lesion. Histopathological examination showed the lesion to be TOS. The surgery was followed by adjuvant radiation and chemotherapy with a favorable outcome at the 1-year follow-up. This report reiterates that TOS is an important differential diagnosis for aneurysmal bone cyst and giant-cell tumor of the spine, as its biological behavior and clinical outcome differ from those of these more benign lesions, which it mimics.

Unusual cause of neuropathy: extensive dural spread of primary cervical osteosarcoma

We report a very rare case of a high grade osteosarcoma of the cervical spine in a 62-year-old woman. She presented with a relatively short history of a swelling in the posterior neck and cervical lymphadenopathy. This was associated with hoarseness of the voice, significant weight loss, and right upper arm radicular symptoms initially, progressing to paraplegia. Based on MR and CT imaging of the neck and an excision biopsy of an enlarged right supraclavicular lymph node, the histology revealed a high grade primary osteosarcoma of the cervical spine.