MRI findings of giant cell tumors of the spine

Malignant Brain and Spinal Tumors Originating from Bone or Cartilage

Malignant bone tumors affecting the brain and spine are a rare and exceedingly difficult-to-treat group of diseases. Most commonly consisting of chordoma and chondrosarcoma, these tumors also include giant-cell tumors and osteosarcomas. This chapter will cover the background, epidemiology, genetics, molecular biology, histopathology, radiographic features, clinical manifestations, therapeutic approaches, and clinical management of each entity.

Imaging Features of Aggressive Giant Cell Tumors of the Mobile Spine: Retrospective Analysis of 101 Patients From Single Center

STUDY DESIGN

Retrospective study.

OBJECTIVES

Giant cell tumors (GCTs) of the mobile spine can be locally aggressive. This study described and classified the typical and atypical appearance of aggressive spinal GCTs according to imaging findings to help the imaging diagnosis, especially for patients with rapid neurological deficit that may require emergent surgery without biopsy.

METHODS

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of patients diagnosed with aggressive spinal GCTs at single center were reviewed.

RESULTS

Overall, 101 patients with 100 CT images and 94 MR images were examined. All lesions were osteolytic with cortical destruction; 95 lesions showed epidural extension; 90 were centered in the vertebral body; 82 showed pathological fracture and/or collapse of the vertebral body; 78 had pseudotrabeculation on CT; 80 showed low-to-iso signal intensity or heterogeneous high-signal intensity with cystic areas on the T2-weighted images; 9 showed fluid-fluid level on T2-weighted images; and 61 patients showed marked enhancement on contrast-enhanced CT and/or MRI. Forty-one lesions (40.6%) had at least 1 atypical radiographic feature: 19 involved ≥2 segments; 11 were centered in the posterior neural arch; 10 had a paravertebral mass over 2 segments; 16 showed partial margin sclerosis with partial cortical destruction on CT scans; and 3 showed mineralization within the tumor on CT. Eighty-eight patients underwent CT-guided biopsy with a diagnostic accuracy rate of 94.3%.

CONCLUSIONS

Spinal GCTs might appear more radiologically atypical, and about 40% of the lesions may have at least 1 atypical feature. CT-guided biopsies are recommended for definitive diagnosis.

Diagnosis and Treatment of Lumbar Giant Cell Tumor of the Spine: Update on Current Management Strategies

(1) Background: Giant Cell Tumor of the spine remains a difficult tumor to treat. Recent advances in adjuvant therapy such as denosumab and innovations in surgical technique in the last 5 years have given providers new options for treatment after a successful diagnosis of the tumor. (2) Methods: Articles published between 1927 and 2021 were selected from PubMed and Scopus searches using key words “Giant Cell Tumor” AND “Lumbar Spine” AND “Treatment”. Relevant articles were reviewed and selected by the authors. (3) Results: A total of 191 articles were discovered. Complete en bloc spondylectomy remains the most definitive treatment option; however, this surgery is challenging and carries a high rate of complication. New adjuvant therapies including denosumab offer a viable alternative to surgery. (4) En bloc spondylectomy remains the gold standard treatment for Giant Cell Tumor of the spine with the lowest published recurrence rate. The use of (neo)adjuvant denosumab improves recurrence rates. More data are needed to determine if denosumab alone is a viable standalone definitive treatment.

Giant cell tumour of the tendon sheath of the spine: clinical features and imaging findings

Objectives

To review the clinical and imaging data of spinal giant cell tumour of the tendon sheath (GCTTS) to improve our understanding of the disease.

Methods

The imaging findings, clinicopathological features and clinical outcomes of 14 patients with pathologically confirmed spinal GCTTS were analysed retrospectively.

Results

All 14 patients had a single spinal lesion, including ten cervical vertebra lesions and four thoracic vertebra lesions. CT scan findings: The lesions showed osteolytic bone destruction and were centred on the facet joint, eroding the surrounding bone with a paravertebral soft tissue mass. MRI scan findings: all the lesions manifested predominantly as isointense or hypointense on T1-weighted imaging (T1WI). On T2-weighted imaging (T2WI), eight lesions were hypointense, and four were isointense. The remaining two lesions showed slight hyperintensity. The enhanced scans of eight lesions showed moderate to marked homogeneous or heterogeneous enhancement. PET/CT findings: Among the five patients who underwent PET/CT, three presented lesions with well-defined, sclerotic borders, and the uptake of ¹⁸F-FDG was markedly increased. One lesion showed an ill-defined border and an uneven increase in ¹⁸F-FDG uptake with an SUVmax value of 8.9. A recurrent lesion was only found on PET/CT 45 months after surgery and the SUVmax was 5.1.

Conclusions

Spinal GCTTS is extremely rare. Osteolytic bone destruction in the area of the facet joint with a soft tissue mass and hypointensity on T2WI images are indicative of the spinal GCTTS. GCTTS shows high uptake of ¹⁸F-FDG, and PET/CT is helpful in detecting recurrent lesions.

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.

Radiological Assessment of Giant Cell Tumour of Bone in the Sacrum: From Diagnosis to Treatment Response Evaluation

Giant cell tumour of bone (GCTB) typically occurs in young adults from 20-40 years old. Although the majority of lesions are located in the epi-metaphyses of the long bones, approximately one third of tumours is located in the axial skeleton, of which only 4% in the sacrum. Sacral tumours tend to be large at the time of presentation, and they present with aggressive features such as marked cortical destruction and an associated soft tissue component. The 2020 World Health Organisation classification of Soft Tissue and Bone Tumours describes GCTB as neoplasm which is locally aggressive and rarely metastasizing. The tumour contains three different cell types: neoplastic mononuclear stromal cells, macrophages and osteoclast-like giant cells. Two tumour subtypes were defined: conventional GCTB and malignant GCTB. Only 1-4% of GCTB is malignant. In this review article, we will discuss imaging findings at the time of diagnosis to guide the musculoskeletal radiologist in reporting these tumours. In addition, imaging for response evaluation after various treatment options will be addressed, such as surgery, radiotherapy, embolization and denosumab. Specific findings will be presented per imaging modality and illustrated by cases from our tertiary sarcoma referral center. Common postoperative and post radiotherapy findings in GCTB of the sacrum on MRI will be discussed.

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.

Sacral Tumours on MRI: A Pictorial Essay

Tumours of the sacrum can be primary or secondary. Since the sacrum is rich in haematopoietic bone marrow, bone metastases are the most frequent aetiologies. However, tumours can arise from all components of the sacrum and primary bone tumours should be considered in case of a solitary lesion and absence of oncologic history. As the clinical signs are usually non-specific, magnetic resonance imaging has become an indispensable tool in narrowing the differential diagnosis and determining the therapeutic approach. This pictorial essay illustrates specific features of the most common sacral tumours on magnetic resonance (MR) imaging.

Axial giant cell tumor - current standard of practice

Giant cell tumors of bone are relatively rare in the axial skeleton, accounting for approximately 6.7% of all cases. Due to their anatomical complexity, difficult access and proximity to vital neurovascular structures, management of these tumors poses a huge challenge on the treating surgeon. Several data series reported on axial GCTB involve short series of limited cases with varied methods used in their local control due to which, proper guidelines are unavailable for the management of such difficult cases. Though the present data support the use of denosumab for effective management of these lesions but there is varied consensus on dosage and duration of treatment. This review article summarizes the basic features and treatment modalities related to axial GCTB stressing on multidisciplinary approach to achieve optimum outcomes.

Giant cell tumor with pathological fracture of C2 with C1-C2 instability: A rare case with review of literature

Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Involvement of the axial skeleton is very rare and majority of them are seen in the sacrum. The authors report a rare case of a 19-year-old female who presented with a C2 dens GCT with a pathological fracture and atlantoaxial dislocation. The patient was operated in two stages: first stage, with posterior instrumentation and stabilization followed by the second stage, tumor resection by anterior transoral approach. The residual tumor cavity was packed with autologous corticocancellous bone grafts. At a 5-year follow-up, computed tomography scan showed a C1-C2 fusion mass. There was no radiological or clinical evidence of tumor recurrence with the patient having good functional outcome without any neurological deficit.

MR Imaging of Primary Chest Wall Neoplasms

Primary chest wall neoplasms are uncommon and comprise a heterogeneous group of lesions that may be challenging to classify and diagnose. These tumors may be primary or secondary, malignant or benign, and arise from cartilaginous/osseous structures or soft tissues. The role of magnetic resonance (MR) imaging in the evaluation of chest wall tumors continues to expand given its superior soft tissue contrast relative to computed tomography. MR imaging can facilitate differentiation of neoplasms from normal chest wall structures and other disease processes due to infection and inflammation, and can fully characterize abnormalities by demonstrating the various internal components of complex lesions. It is important that radiologists be able to identify key features of primary chest wall neoplasms on MR imaging to provide focused differential diagnoses and guide patient management.

Imaging of Benign Tumors of the Osseous Spine

The purpose of this paper is to present an overview of the imaging features of the most prevalent benign bone tumors involving the spine. Benign tumors of the osseous spine account approximately for 1% of all primary skeletal tumors. Many lesions exhibit characteristic radiologic features. In addition to age and location of the lesion, radiographs are an essential step in the initial detection and characterization but are limited to complex anatomy and superposition. CT and MR imaging are often mandatory for further characterization, assessment of local extension and guiding biopsy.

En-bloc Resection of a Giant Cell Tumor Causing Cervical Vertebral Collapse

Giant cell tumors (GCTs) are rare, benign, and locally aggressive primary bone neoplasms. Spine is seldom affected, especially above the level of sacrum. In this report, we describe a case with GCT of the cervical vertebrae which causes collapse of the corpus. A 32-year-old female presented with gradual neck pain and abrupt paresthesia of the left hand. Computed tomography scan showed C6 vertebral collapse and magnetic resonance imaging demonstrated vertebral plana of C6 by a low signal intensity lesion on T1- and T2-weighted images. Emergent surgical intervention was taken due to the possibility of spinal injury. The tumor was removed by en-bloc resection and histopathological investigation confirmed GCT. In most of the cases, en-bloc resection of GCTs of the spine is not feasible. Despite the location and close contact of the lesion with spinal cord, later approach was successful for our case; thus, appropriate differential diagnosis for vertebral column lesions as well as selecting an optimum treatment is mandatory.

Giant Cell Tumor of Cervical Spine Presenting as Acute Asphyxia: Successful Surgical Resection After Down-Staging With Denosumab

STUDY DESIGN

Case report and literature review.

OBJECTIVE

To describe treatment of a unique case of acute airway obstruction by a large C7 giant cell tumor (GCT) with preoperative denosumab followed by surgical resection, and review the literature on this rare entity.

SUMMARY OF BACKGROUND DATA

Standard treatment for GCTs includes surgical resection or curettage and packing. Large lesions in the spine may require preoperative therapy with denosumab, a human monoclonal antibody to RANKL, to facilitate surgery. It is highly unusual for GCT arising in cervical spine to present with acute asphyxia (requiring tracheostomy).

METHODS

We report a patient with large C7 GCT that caused tracheal compression with almost complete airway obstruction requiring emergency intubation.

RESULTS

The tumor responded to subcutaneously administered denosumab with marked decrease in size and relief of symptoms. Increased tumor mineralization in response to therapy facilitated subsequent successful surgical tumor resection. The patient remains symptom-free 2 years after surgery without tumor recurrence.

CONCLUSION

Denosumab can shrink the size of large GCTs, providing symptom relief before surgery and facilitate tumor resection.

LEVEL OF EVIDENCE

5.

Morphological and dynamic contrast enhanced MR imaging features for the differentiation of chordoma and giant cell tumors in the Axial Skeleton

PURPOSE

To characterize the morphological and dynamic-contrast-enhanced (DCE) MRI features of chordoma and giant cell tumor (GCT) of bone occurring in the axial skeleton.

MATERIALS AND METHODS

A total of 13 patients with chordoma and 26 patients with GCT who received conventional T1, T2, and DCE-MRI on 3 Tesla MR scanners were retrospectively identified and analyzed. Two radiologists evaluated morphological features independently, including the lesion location, expansile bone changes, vertebral compression, presence of paraspinal soft tissue mass, fibrous septa, and the signal intensity on T1WI and T2WI. The inter-observer agreement was evaluated by kappa test. The DCE kinetics was measured to obtain the initial area under curve (IAUC) and the wash-out slope; also the two-compartmental pharmacokinetic model was applied to obtain K^trans and k_ep . The diagnostic accuracy was evaluated by CHAID decision tree and ROC analysis.

RESULTS

Chordomas were more likely to show soft tissue mass than GCTs (13/13 = 100% versus 15/26 = 58%; P = 0.007), as well as fibrous septa (9/13 = 69% versus 0; P < 0.001). In decision tree analysis, presence of fibrous septa and lesion location yield 31/39 = 79% accuracy. The DCE-MRI pharmacokinetic parameters K^trans and k_ep of GCTs were significantly higher than those of chordomas, 0.13 ± 0.65 versus 0.06 ± 0.04 (1/min) for K^trans , 0.62 ± 0.22 versus 0.17 ± 0.12 (1/min) for k_ep , P < 0.001 for both. If using kep = 0.43/min as the cut-off value, it achieved 100% sensitivity and 92% specificity to differentiate chordoma from GCT, with an overall accuracy of 37/39 = 95%. The IAUC was highly correlated with K^trans (r = 0.94), and the slope was highly correlated with k_ep (r = 0.95).

CONCLUSION

Several morphological features were significantly different between chordoma and GCT, but their diagnostic performance was inferior to that of DCE-MRI.

LEVEL OF EVIDENCE

4 J. Magn. Reson. Imaging 2017;45:1068-1075.

Differentiation of spinal giant cell tumors from chordomas by using a scoring system

INTRODUCTION

Few reports have compared the clinical features and imaging characteristics of giant cell tumor and chordoma of the spine. The aim of the present study was to investigate whether the two types of tumors could be differentially diagnosed, by comparing clinical characteristics as well as magnetic resonance imaging (MRI) or computed tomography (CT) findings and then scoring the characteristic findings.

METHODS

A total of 18 patients were retrospectively assessed. To elucidate the characteristic findings, we investigated the following 10 items: age at diagnosis, sex, and site of occurrence; for MRI findings, the pattern of tumor expansion, T1-weighted images, T2-weighted images, septal structure, and cystic changes; and for CT findings, calcification or residual bone fragments and incomplete bone shells. Then, we developed a unique scoring system and investigated whether the two tumors could be differentiated by this scoring system.

RESULTS

Six items, including, age, site of occurrence, tumor expansion pattern, T2-weighted images, septal structure, and incomplete bone shells, were significantly different between giant cell tumor and chordoma patients. By using newly developed scoring system, the mean scores of 0.9 ± 0.6 (range 0-2) for giant cell tumor and 4.8 ± 1.5 (range 3-6) for chordoma patients were significantly different (P < 0.001), thereby allowing the differential diagnosis by setting the cutoff value to three.

CONCLUSIONS

We found that the six items were useful for differentially diagnosing giant cell tumor and chordoma. These results indicate that it may be possible to distinguish the two types of tumor by scoring these items.

Giant cell tumor of the rib with direct invasion into the thoracic spine

Giant cell tumors of bone are relatively rare, benign, but locally aggressive osteolytic skeletal neoplasms of young adults. They usually affect the epiphyses of long bones, especially around the knee joint, and are rarely seen in the ribs. The mainstay of therapy is surgical resection. Herein, we report a case of successful resection in a patient who presented with primary giant cell tumor of the rib, directly invading the thoracic spine. Computed tomography and magnetic resonance imaging were helpful for assessing the depth of tumor invasion. Radical resection of the tumor and reconstruction of the vertebrae with preserved allograft bone were performed. No respiratory or neurological problems occurred, and the patient remained well 2 years after surgery.

Obstructive hydrocephalus as a result of giant cell tumor of the thoracic spine: A case report

Giant cell tumors (GCTs) are rare bone tumors that account for ~5% of all primary bone tumors. When GCTs occur in the spine, patients usually present with localized pain and neurological symptoms, such as radiating pain or hyperesthesia. In the current report, an unusual case of a GCT of the thoracic spine associated with hydrocephalus is described. A 48-year-old male presented with urinary retention, loss of sensation in the lower limbs and inability to walk. The patient eventually developed hydrocephalus combined with altered consciousness, indicated by an inability to follow simple commands. Magnetic resonance (MR) imaging demonstrated the presence of a soft tissue mass at the T2 level, and biopsy examination of the tissue confirmed that it was a GCT. The patient experienced a sudden loss of consciousness due to an acute episode of obstructive hydrocephalus. A ventriculoperitoneal shunting procedure was performed to treat the hydrocephalus, and the patient regained normal consciousness, although the paraplegia persisted. An MR examination performed 30 months following surgery demonstrated that the tumor size was stable, consistent with the slow growth that is characteristic of GCTs. Diagnosis of GCTs may be challenging, and relies on radiographic and histopathologic findings. Although rare, acute hydrocephalus as a result of GCTs should not be excluded from a differential diagnosis.

Giant cell tumor of soft tissue: a case report with emphasis on MR imaging

Giant cell tumor of soft tissue is a rare neoplasm, histologically resembling giant cell tumor of bone. In this report, we describe a deep and solid giant cell tumor of soft tissue interpreted as a benign soft tissue tumor based on magnetic resonance (MR) findings with hypointense to intermediate signals on T2-weighted images and impeded diffusivity (water movement) on diffusion-weighted imaging (DWI), which could suggest a giant-cell-containing benign soft tissue tumor, despite the malignancy suggested by 18F-fluorodeoxyglucose positron emission tomography-computed tomography in a 35-year-old male. To our knowledge, this report introduces the first deep, solid giant cell tumor of soft tissue with MR features of a giant-cell-containing benign soft tissue tumor, despite the malignancy-mimicking findings on 18F-FDG PET-CT.

Imaging appearance of giant cell tumour of the spine above the sacrum

Giant cell tumour (GCT) of the spine is rarely encountered in daily clinical practice. Most of the tumours occur at the sacrum instead of at the spine above the sacrum, which has been reported to account for 1.3-9.3% of all spine GCTs. This article is a review of our radiological experience of the diagnosis of spine GCT above the sacrum based on 34 patients at a single institution. The purpose of this pictorial review is to highlight the imaging findings of GCT and to provide clues that may distinguish it from other, more common neoplasms.

Modified kraske procedure with mid-sacrectomy and coccygectomy for en bloc excision of sacral giant cell tumors

Sacral giant cell tumors are rare neoplasms, histologically benign but potentially very aggressive due to the difficulty in achieving a complete resection, their high recurrence rate, and metastization capability. Although many treatment options have been proposed, en bloc excision with tumor-free margins seems to be the most effective, being associated with long term tumor control, improved outcome, and potential cure. An exemplifying case of a 29-year-old female with progressive complaints of pain and paresthesias in the sacral and perianal regions, constipation, and weight loss for 6 months is presented. The surgical technique for en bloc excision of a large sacral giant cell tumor through a modified Kraske procedure with mid-sacrectomy and coccygectomy is described. Complete resection with wide tumor-free margins was achieved. At 5 years of follow-up the patient is neurologically intact, without evidence of local recurrence on imaging studies. A multidisciplinary surgical procedure is mandatory to completely remove sacral tumors. In the particular case of giant cell tumors, it allows minimizing local recurrence preserving neurovascular function, through a single dorsal and definitive approach.

The hypermetabolic giant: 18F-FDG avid giant cell tumor identified on PET-CT

An 87 year-old white female presented with a two-year history of intermittent discomfort in her left foot. PET-CT identified intense18F-fluorodeoxyglucose (FDG) uptake corresponding to the lesion. Histology of a fine needle aspiration and open biopsy were consistent with a benign giant cell tumor (GCT) of the bone. GCT of bone is an uncommon primary tumor typically presenting as a benign solitary lesion that arises in the end of the long bones. While GCT can occur throughout the axial and appendicular skeleton, it is exceedingly uncommon in the bone of the foot. While 18F-FDG has been established in detecting several malignant bone tumors, benign disease processes may also be identified. The degree of 18F-FDG activity in a benign GCT may be of an intensity that can be mistakenly interpreted as a malignant lesion. Therefore, GCT of the bone can be included in the differential diagnosis of an intensely 18F-FDG-avid neoplasm located within the tarsal bones.

[Benign and semimalignant spinal tumors. Characteristics in children and adults]

Diagnostic radiology and magnetic resonance imaging (MRI) are the most important imaging tools in the evaluation of benign bone tumors. Computed tomography (CT) is an additional tool for bony lesions, such as in cases of confirmation of the diagnosis of osteoid osteomas. For benign bony lesions three-stage skeletal scintigraphy is an optional additional diagnostic tool. The identification of benign or semimalignant bone tumors is not always clear; therefore percutaneous biopsy is necessary in most cases. In benign spinal tumors an intralesional curettage with reconstruction and stabilization is sufficient. In cases of semimalignant tumors, e.g. giant cell tumors localized in the spine, an en bloc resection is necessary because of the high recurrence rate.

Giant cell tumours of the mobile spine: characteristic imaging features and differential diagnosis

PURPOSE

The aim of this study was to investigate the characteristic imaging features of giant cell tumours (GCTs) of the mobile spine.

MATERIALS AND METHODS

Thirty pathologically proven GCTs of the mobile spine were reviewed. X-ray (n = 18), computed tomography (CT) (n = 24) and magnetic resonance (MR) (n = 21) images were retrospectively evaluated.

RESULTS

Five tumours were located in the cervical spine, 15 tumours were located in the thoracic spine and 10 tumours in the lumbar spine. The characteristic X-ray findings included an osteolytic and expansile lesion with a "soap bubble" or purely lytic appearance. Cortical destruction was commonly seen. Margin sclerosis was seen in two lesions. No mineralised tumour matrix or periosteal reaction appeared. The CT findings were similar but outlined the cortical alterations in a more accurate way. The characteristic MR findings included a well-defined and expansile mass with heterogeneous low-to-iso signal intensity on T2-weighted images. Cystic areas were commonly seen in 17 cases. Five cases presented fluid-fluid levels, suggesting the development of aneurysmal bone cyst. The solid portions of the tumours were enhanced with a very heterogeneous signal pattern reflecting high blood supply after contrast-enhanced scan. Tumour involvement in the epidural space occurred in 12 cases, causing spinal cord and/or nerve root compression. Involvement of intervertebral discs and/or adjacent vertebrae appeared in two cases.

CONCLUSIONS

Although rare, GCT can occur in the mobile spine as a kind of benign but locally aggressive tumour. Radiologists should be familiar with its characteristic imaging features in order to make a correct diagnosis and to help preoperative evaluations.

Neuroradiology in women of childbearing age

PURPOSE OF REVIEW

This review summarizes safety concerns associated with diagnostic neuroimaging in patients who are of childbearing age, focusing on diagnostic modalities and radiologic features of neurologic conditions encountered by pregnant women.

RECENT FINDINGS

During pregnancy, women experience a range of physiologic changes that can affect neurologic function. These include endocrine, hemodynamic, endothelial, immunologic, and coagulopathic changes that can alter susceptibility to stroke, subarachnoid hemorrhage, demyelination, venous thrombosis, and other neurologic conditions. Unique safety concerns are associated with imaging procedures performed to diagnose neurologic conditions that occur during pregnancy.

SUMMARY

This review discusses the use of diagnostic neuroimaging, including administration of IV contrast, in pregnant women and in nonpregnant women of childbearing age.

Current treatment of sacral giant cell tumour of bone: a review

Sacral giant cell tumour of bone has an insidious onset and slow growth rate, making early diagnosis difficult. The tumour has a high recurrence rate and is often fatal. Magnetic resonance imaging and computed tomography (CT), including CT-guided fine-needle biopsy, are useful for early diagnosis. Although therapy for sacral giant cell tumour often involves surgical resection and reconstruction challenges, improvements in various treatment modalities, including arterial embolization and radiotherapy, have widened the effective treatment options. The current surgical and adjuvant treatment modalities available for the management of sacral giant cell tumour are systematically reviewed and a suggested treatment algorithm is provided. En bloc excision remains the surgical procedure of choice, with functional reconstruction important in cases where the lesion is high in the sacrum. The use of adjuvant radiotherapy and chemotherapy remains controversial and should be studied further. Determination of the optimum treatment for sacral giant cell tumour will require randomized controlled trials. Early diagnosis, complete surgical resection with tumour-free margins and comprehensive treatment are important for local tumour control and improved outcome.

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.

Administration of sodium ibandronate in the treatment of complicated giant cell tumor of the spine

STUDY DESIGN

Case study.

OBJECTIVE

To present three complicated cases of giant cell tumor of the spine treated with sodium ibandronate.

SUMMARY OF BACKGROUND DATA

Spinal giant cell tumors are a rare clinical entity with a high recurrence rate after operation. Furthermore, complete resection of such lesions remains a challenging surgical problem. Up to this point, no effective adjuvant therapy has been reported for primary or recurrent spinal giant cell tumors.

METHODS

One patient with a recurrent giant cell tumor of the seventh thoracic vertebra, one patient with a fifth lumbar vertebral giant cell tumor, and one patient with recurrent giant cell tumor of the sacrum were treated with sodium ibandronate either postoperatively or upon recurrence of the tumor.

RESULTS

The first patient with recurrent thoracic giant cell tumor recovered both clinically and radiologically after treatment with sodium ibandronate without reoperation at 6-years follow-up. The second patient also recovered with no recurrence of the tumor at 4-years follow-up. In the third case, although not fully recovered, the recurrent sacral tumor was under control after treatment with sodium ibandronate at 2-years follow-up.

CONCLUSION

These case studies demonstrate the potential promise of using sodium ibandronate in the treatment of primary and recurrent giant cell tumors of the spine. Furthermore, clinical evaluation should be performed in future studies.

Imaging appearance of primary bony tumors and pseudo-tumors of the spine

We aim to review the imaging appearance of primary bony tumors of the spine and simulating lesions. Benign bone tumors commonly appear as well-circumscribed, slow-growing lesions with a calcified or sclerotic matrix. Malignancy is often aggressive permeative lesions with bone destruction, cortical invasion and associated soft-tissue mass. CT is an excellent imaging modality for characterization of the tumor matrix, exact location, extension and osseous changes, while MR imaging is superior for evaluation of the associated soft-tissue mass, bone marrow infiltration and intraspinal extension. There is a spectrum of pseudotumors that may also involve the spine. The imaging appearance of primary spinal bone tumor in conjunction with the patient's age, gender and lesion location allows a high percentage of correct diagnosis. Imaging plays an important role in diagnosis, characterization and extension of bone tumors of the spine which will help guide therapy.

[Giant-cell bone tumors of the spine: report of two cases and literature review]

Giant cell tumours (GCT) are relatively rare neoplasms, most often benign. They are characterized by their local aggression. We report two observations of GCT, the spine in a 51-year-old woman and a 14-year-old boy. They were revealed by spinal pain and cord compression for the second observation. Computed tomography and magnetic resonance imaging showed osteolysis of the body and vertebral arch of L5 for the first and a process affecting the vertebral body and medullary canal of T6-T7 with spinal cord compression for the second case. The diagnosis was confirmed by histological examination in two cases. An external radiation at a dose of 45 Gy on L4, L5 and the sacrum was made in the first case and the dose of 40 Gy on the vertebrae of T4 to T9 and an additional 6 Gy on T5-T8 in the second case. The patients are alive without progress with five years and 18 months follow-up, respectively. Radiation could be proposed as a standard treatment for patients with incomplete excision or where surgery would induces functional deficits.

Diagnostic imaging of solitary tumors of the spine: what to do and say

Metastatic disease, myeloma, and lymphoma are the most common malignant spinal tumors. Hemangioma is the most common benign tumor of the spine. Other primary osseous lesions of the spine are more unusual but may exhibit characteristic imaging features that can help the radiologist develop a differential diagnosis. Radiologic evaluation of a patient who presents with osseous vertebral lesions often includes radiography, computed tomography (CT), and magnetic resonance (MR) imaging. Because of the complex anatomy of the vertebrae, CT is more useful than conventional radiography for evaluating lesion location and analyzing bone destruction and condensation. The diagnosis of spinal tumors is based on patient age, topographic features of the tumor, and lesion pattern as seen at CT and MR imaging. A systematic approach is useful for recognizing tumors of the spine with characteristic features such as bone island, osteoid osteoma, osteochondroma, chondrosarcoma, vertebral angioma, and aneurysmal bone cyst. In the remaining cases, the differential diagnosis may include other primary spinal tumors, vertebral metastases and major nontumoral lesions simulating a vertebral tumor, Paget disease, spondylitis, echinococcal infection, and aseptic osteitis. In many cases, vertebral biopsy is warranted to guide treatment.

Giant cell tumor of the spine

Giant cell tumors are benign but locally aggressive neoplasms that typically affect the extremities. When involving the spine, the tumors occur predominantly in the sacrum. Gross total resection of the tumor with wide margins yields good results in terms of survival. However, it carries a significant potential for morbidity and disability. Subtotal resection with adjuvant radiation carries a risk for recurrence or, more concerning, sarcomatous malignant transformation. Endovascular tumor embolizations have also been attempted to control unresectable tumors, and have been performed with moderate degrees of success. Outcomes are analyzed outcomes following surgery, radiation therapy, and tumor embolization.