PATOLOGIE TUMORALI ENDOCANALARI U.O. Neuroradiologia Istituto Neurologico IRCCS Fondazione C....
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Transcript of PATOLOGIE TUMORALI ENDOCANALARI U.O. Neuroradiologia Istituto Neurologico IRCCS Fondazione C....
PATOLOGIE TUMORALI
ENDOCANALARI
U.O. NeuroradiologiaIstituto Neurologico IRCCS Fondazione C. Mondino, Pavia
Dott.ssa Anna Pichiecchio
SPINAL TUMORSSPINAL 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 neurinomaLeptomeningeal dissemination
MetastasisExtension of primary bone
tumors
MRI gold standard!TR TE FOV Matrix
Sag T2-w 3500 120 275 304X225
Sag T1-w 400 10 275 304X225
Sag T2 STIR
2500 (TI=170)
70 275 256X190
Ax T2-w 4500 120 230 288X200
Ax T1-w 541 15 225 304X212
Sag T1-w fat
suppression post
contrast
400 10 275 304X212
Ax T1-w post
contrast541 15 225 304X212
EPIDURAL FAT
SUBDURAL SPACE
EPIDURAL FAT
SEPTUM POSTICUM
DURA MATER
ARACHNOIDDURAL NERVE ROOT SLEEVE
DENTICULATE LIGAMENT
SPINAL CORD AND
PIA
JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM
1. INTRAMEDULLARY TUMORS1. INTRAMEDULLARY TUMORS
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
1.a. SPINAL CORD 1.a. SPINAL CORD ASTROCYTOMAASTROCYTOMA
From astrocytesMost WHO I-II
Most common in CHILDREN
80-90% low gradePilociticFibrillary
Association with abnormalities of chromosome 17p (TP53
gene)
•20% intraspinal neoplasms•60% primary spinal cord tumors
subarachnoid dissemination may occur!
BEST DIAGNOSTIC
CLUE
Enhancing infiltrating cord mass in childNo capsule or cleavage
LOCATION Thoracic >Cervical > Lumbar
SIZE Usually 1-3 cm, less than 4 segments
MORPHOLOGY
fusiform expansion of cord, eccentric , posterior
General featuresGeneral features
Risk in patients with Neurofibromatosis (NF1 and NF2)
Demographic features:
A) Age: two peaks: 10 - 30 ys
B) Gender: M > F (1,3:1); no gender difference in
children!
b) 40% cysts and syringohydromyelia c) Solid portion (hypo-isointense)
CORD EXPANSIO
N
MR FindingsMR Findings
Usually < 4 segments
T1-w:a) Cord expansion
Occasionally multisegmental (holocord more common with
pilocytic astrocytomas)
From Rossi et al 2007
MR FindingsMR FindingsT2-w:a) Hyperintense
b) Not as hyperintense if cysts/syrinx
a) Rarely hemorrhagic
T2* GRE:
HYPERINTENSE LESION
CYSTS
From Rossi et al 2007
RARELY HEMORRAGE
CYSTS
MODERATE C.E. ALWAYS!!
From Rossi et al 2007
T1-w post-contrast:
a) enhancement
From Baker et al 1999
DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSISSARCOIDOSIS
INTRAMEDULLARY EPENDYMOMA INTRAMEDULLARY
HEMANGIOBLASTOMA
SYRINGOMYELIA
ARNOLD-CHIARI I MALFORMATION
1.b. SPINAL CORD 1.b. SPINAL CORD EPENDYMOMAEPENDYMOMA
Myxopapillary ependymomas
(from ependymal cells of filum terminale)
Cellular ependymomas (lining spinal cord central canal)
Neoplasm of ependyma lining spinal cord central canal
•Most common in ADULT (60%) in lower spine[ependymoma: 4% of all primary CNS tumors]
•2nd most common in CHILDREN
Associated with:•ESA•Superficial siderosis•NF2 deletion or traslocation chr 22
CELLULAR EPENDYMOMACELLULAR EPENDYMOMA
BEST DIAGNOSTIC
CLUE
Circumscribed, enhancing cord mass with hemorrhage
LOCATION Conus> Cervico-Thoracic
SIZEMultisegmental (typically 3-4 segments)
MORPHOLOGY
Well-circumscribed, symmetric cord expansion, occasional exophytic component
General featuresGeneral features
Demographic features:
A) Age: 40 yrs
B) Gender: M:F=3:1
C) Ethnicity: non racial predilection
Radiological featuresRadiological features
MR FindingsMR Findings
T1-w:
a) Iso- or slightly hypointense to spinal cord
b) Hemorrhage
ISO- HYPOINTENSE LESION
Radiological featuresRadiological features
MR FindingsMR FindingsT2-w:
c) Syrinxd) Focal hypointensitye) Surrounding cord
oedema
Hemosiderin“Cap sign”
a)Hyperintenseb) Polar (rostral or caudal) or intratumoral cysts
(50-90%)
HEMOSIDERIN“CAP SIGN”
MR FindingsMR FindingsSTIR:
a) HyperintenseT1-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 featuresRadiological features
C.E.
HEMOSIDERIN“CAP SIGN”
ASTROCYTOMA
Astrocytoma Ependymoma
cervical conus
Eccentric posterior
central
- hemorragic
hyercellularity
Infiltrative (poor borders)
Pseudocapsule (plane)
EPENDYMOMA
from ependymal cells of filum terminale
MYXOPAPILLARY MYXOPAPILLARY EPENDYMOMAEPENDYMOMA
27-30% of all ependymomas
90% of all filum terminale tumors
Radiological featuresRadiological features
MR FindingsMR Findings
T1-w:a) Usually Isointense with cord
b) Hyperintensity (accumulation of mucin!)
T2-w:a) Hyperintenseb) Hypointensity at
tumor margins (hemosiderin)STIR:a) Hyperintense
T1-w post-contrast:a) Intense c.e.From Rossi et al 2007
From Rossi et al 2007
INTENSE C.E.
ARTERO-VENOUS FISTOLADIFFERENTIAL DIFFERENTIAL
DIAGNOSISDIAGNOSIS
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
1.c. SPINAL CORD 1.c. SPINAL CORD HEMANGIOBLASTOMAHEMANGIOBLASTOMA
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
BEST DIAGNOSTIC
CLUE
Intramedullary mass with serpentine “flow voids”
LOCATION
Thoracic > CervicalSubpial (posterior, rarely anterior) often associated with intraspinal cysts
SIZEFew mm to several cm
MORPHOLOGY
Round, well-defined margins
General featuresGeneral features
Demographic features:A) Age: mean age at presentation
30 ysB) Gender: M = F
Radiological featuresRadiological features
MR FindingsMR FindingsT1-w:
a) Isointenseb) Cyst!!
(> 50%)
Small: Large:a) hypo-
isointense
b) “flow voids” (lesion > 2,5 cm)
ISO-
HYPOINTENSE LESION
+ SYRINX
Radiological featuresRadiological features
MR FindingsMR FindingsT2-w:a) Uniformly hyperintense
(small lesions) mixed hyperintense (hemorrhage common)
a) +/- peritumoral oedemab) Syrinx fluid
HYPERINTENSE LESION +
CYST
Radiological featuresRadiological features
a) Subpial nodule
Well-demarcated, intense, homogeneous C.E. (often on surface of dorsal cord)
Cyst/Syrinx: no c.e.
MR FindingsMR FindingsT1-w post contrast:
SUBPIAL NODULE ON THE DORSAL
SURFACE
ARTERIOVENOUS MALFORMATION (AVM)
CAVERNOUS MALFORMATION
•Cord often normal/small, gliotic• focal nodule absent, dorsal veins prominent•M 50-60 y insidious onset of lower extremities weakness
•Pattern of prior hemorrhage, hemosiderin rim•Minimal c.e.
From Chabert E et al. J Neuroradiol 1999; 26:262-268
Ependymoma
Astrocytoma
metastasis
mass centrally located
not hypervascular; peritumoral oedema common
Crowley, Neurosurgery 2008
Renal cell carcinoma
1)they tend to enlarge the cord either focally or diffusely
2) on T2-w they produce high signal intensity
3) They enhance
Demylinating diseases Infections Inflammation
Multiple SclerosisADEM
Cord swelling from extramedullary infectious process (as meningitis producing vascular compromise)AIDS
SarcoidLES
Syringohydromyelia Vascular lesions Causes of subacute necrotizing myelopahty
HemorrageAcute infarctionVenous hypertensionCavernous angiomaArterovenous malformation
ADEMDevic, MS HZV,Rubeola, Mononucleosis, mumpsToxo, TBCLupusSpinal dural AVMVenous hypertension
Symptoms include pain, weakness and muscle atrophy
EPIDURAL FAT
SUBDURAL SPACE
EPIDURAL FAT
SEPTUM POSTICUM
DURA MATER
ARACHNOIDDURAL NERVE ROOT SLEEVE
DENTICULATE LIGAMENT
SPINAL CORD AND
PIA
JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM
2. INTRADURAL EXTRAMEDULLARY 2. INTRADURAL EXTRAMEDULLARY TUMORSTUMORS
Schwannoma, Neurinoma Neurofibroma
Arise from single nerve, from one side Typically dorsal root Schwann cellsDo NOT envelope the adiacent nerve rootLobulatedSingle
Schwann cells and fibroblasts between dispersed nerve fibers, mps matrixSpreads apart axonsDO envelope the adiacent nerve rootFusiformMultiple
2.a. SCHWANNOMA2.a. SCHWANNOMA
Neoplasm of nerve sheath in PNS
Most common intradural extramedullary mass30% primary spinal tumors
•Mostly sporadic (inactivation of NF2 gene)• Association with NF2, bilateral multiple
WHO grade I
BEST DIAGNOSTIC
CLUE
Well-circumscribed, “dumbbell” shaped, enhancing spinal mass
LOCATION
Thoracic > Cervical = Lumbar
70-75% intradural extramedullary15% completely extradural15% “dumbbell” (both intra- and extradural)
SIZE Few mmGiant schwannoma: > 2 vertebral segments
MORPHOLOGY
Round, lobulated
General featuresGeneral features
Demographic features:
A) Age: 40 ys
B) Gender: M = F
C) Ethnicity: no racial predilection
Radiological featuresRadiological features
T1-w:Isointense
T2-w:a) hyperintenseb) 45%cyst 10% hemorragec) “Target sign”
HYPERINTENSE LESION WITH TARGET SIGN
ISOINTENSE LESION
Radiological featuresRadiological features
T1-w post-contrast:a) Intense c.e.
(uniform or peripheral)
C.E.
2.b. NEUROFIBROMA2.b. NEUROFIBROMA
Localized, diffuse or plexiform neoplasm
of nerve sheath
WHO grade IWHO grade III/IV
•5% of all benign soft tissue tumors
•Association with neurofibromatosis 1 (NF1) 13-65% have spinal neurofibromas
ISOINTENSE LESION
HYPERINTENSE LESION
+ HYPOINTENSE
SEPTATIONS
C.E.
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISCHRONIC INFLAMMATORY DEMYELINATING
POLYNEUROPATHY (CIDP)
2.c. MENINGIOMA2.c. MENINGIOMAOrigin from arachnoid
Attached to the dura mater for infiltration
SECOND MOST COMMON
INTRADURAL EXTRAMEDULLAR
Y TUMOR> 25% WHO I
Solitary
Genetic predisposition in women! •Almost all have chromosome 22 abnormalities•Association with neurofibromatosis 2 (NF2)
Meningothelial Fibroblastic
Psammomatousangiomatous
BEST DIAGNOSTIC
CLUE
Enhancing intradural extramedullary mass with “dural tail”
LOCATION
Thoracic (80%)>> Cervical (16%) > Lumbar (4%)Typical intradural extramedullaryPosterolateral (anterior cervical)
SIZE Variable
MORPHOLOGY
Typically round with dural attachment, Ca ++ < 5%
General featuresGeneral features
Demographic features:A) Age: 50-60 yrs
B) Gender: F:M=4:1 (>70-80% female!)
Radiological featuresRadiological features
T2-w:a) Isointenseb) Iso- hyperintensec) Hypointense
(calcification)
MR FindingsMR Findings
ISOINTENSE LESION WITH
CALCIFICATION
T1-w:
Radiological featuresRadiological features
T1-w post-contrast:a) Prominent c.e.b) May see
enhancing “dural tail”
C.E.
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
DROP METASTASIS
EPIDURAL FAT
SUBDURAL SPACE
EPIDURAL FAT
SEPTUM POSTICUM
DURA MATER
ARACHNOIDDURAL NERVE ROOT SLEEVE
DENTICULATE LIGAMENT
SPINAL CORD AND
PIA
JUNCTION OF DURAL SLEEVE AND SPINAL NERVE PERINEURIUM
3. EXTRADURAL TUMORS3. EXTRADURAL TUMORS
LYMPHOMA
From Thurner et al.
METASTASIS
Female (breast and lung)Male (prostate and lung)
Thoracic (70%)> lumbar (20%) > cervical (10%)
DROP METASTASIS
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISANGIOMIOLIPOMA
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISGRANULOMATOSIS
INTRADURAL ARACHNOID CYST
EPIDURAL EMATOMA
Grazie per l’attenzione