Sacral bone Tumor Imaging

Transcription

1 Sacral bone Tumor Imaging Poster No.: C-1651 Congress: ECR 2016 Type: Educational Exhibit Authors: S. Zaouali, M. Ben Ammar, A. DAGHFOUS, M. Matri, L. REZGUI; tunis/tn Keywords: Bones, Oncology, Neuroradiology spine, CT, Conventional radiography, MR, Education, Neoplasia, Cancer, Metastases DOI: /ecr2016/C-1651 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 25

2 Learning objectives Sacral tumors represent only 5% of osseous tumors. Malignant lesions are the most frequent, leaded by metastasis and Chordoma. Different components that constitute the sacral bone may induce local tumors. Usually the diagnosis is late and discovered by signs of pelvic or nervous compression. The role of imaging exploring sacral bone tumors is very important. In fact, conventional X ray, CT and MRI allow the etiological diagnosis, the extension checkup; it helps the management of surgical treatment, guide biopsies and also allow the post-therapeutic supervision. Using cases seen in our department of radiology, we will illustrate the specific aspects of tumors, divided in benign and malignant tumors. Background All the structures of the sacrum can cause tumor: bone, cartilage, nerves, remnants of the notochord, meninges Imaging aim: -Positive and ethiologic diagnosis approach; -Operability assessment; -Guiding biopsies; -Follow-up post treatment. CASE NUM 1: Fig. 1 on page 9 Fig. 2 on page 10 Patient followed for breast cancer operated and treated by radio and chemotherapy for 3years. She complained of sciatic and buttock pain. Sacral metastasis of breast cancer Secondary malignant bone tumors: metastasis and sacral location of haemopathy: Page 2 of 25

3 These are the most common malignant tumors of the sacrum; they essentially see in the breast, kidney, lung, prostate, thyroide, head and neck cancers, gastrointestinals cancers and melanoma. IMAGING: Osteolytic lesions+++ without peripheral sclerosis; Sometimes ostéocondensed lesions (prostate, breast); Expansive blurred or small ones (myeloma); Extension in the soft parts usually minimal. CASE NUM 2: Fig. 3 on page 10 Fig. 4 on page 10 Fig. 5 on page 11 Patient aged 66 years old, with painfull swelling of the right buttock. Histological Diagnosis: CHORDOMA Chordoma: Represents 2 to 4% of malignant bone tumors but 40% of sacral tumors and 50% of malignant tumors of the sacrum. Developed from remnants of the notochord; M>F; peak frequency from 40 to 60 years old; 2 preferred locations: sacral(55%), spheno-occipital(40%) Low back and sacral pains, neurological deficits; Slow evolution ; long time insidious ===> delayed discovery; Local malignancy, few distant metastasis; Surgical treatment; Local recurrence in 80% of cases, constant if incomplete excision; Metastasis are rare and late (lung, bone, liver, skin); Overall survivor of 50% at 5years. IMAGING: Radiographs: Median osteolysis, polycyclic outlines, sometimes with peripheral osteosclerosis. Page 3 of 25

4 CT scan: Median location often very low S3 to S5; Frank bone osteolysis with honeycomb; Intratumoral calcifications in 50 to 60% of cases; Important pre-sacral development; Enhanced by the contrast; MRI: Iso and/or hypointense on T1; Intensly hyperintense on T2 with hypointense septas; Unobstrusive enhancement; Endo-ductal extension until subcutaneously. CASE NUM 3: Fig. 6 on page 12 Fig. 7 on page 13 Patient aged 26years old, buttock pain and bilateral sciatic pain Histological diagnosis: Giant cell tumor Giant cell tumors: Represents 68% of benign primary tumors of the sacrum; Second primary sacral tumor after the Chordoma; Malignancy in the 20% of cases; Female predominance; Peak incidence between 15 and 30 years; Surgical treatment; Discussed prior embolization. IMAGING: Radiographs: Page 4 of 25

5 Osteolytic lesion, poorly defined, without sclerosis with cortical honeycomb and sometimes cortical disruption. CT scan: Laterized lytic lesion, sometimes multiloculated Density like the muscle leaving hypodense areas relevant to the necrosis; calcifications; heterogeneous contrast enhancement; Soft tissue mass. MRI: Hypo T1/Hyper T2; Areas in hypo T2 in relation ton hemosiderine; Liquid-liquid levels. CASE NUM 4: Fig. 8 on page 14 Fig. 9 on page 14 Fig. 10 on page 15 Fig. 11 on page years old with no medical history, consulting for a left lombosciatic pain, lasting for eight months with neurogenic claudication and decrease the walking distance, all in the context of deterioration of general condition and normal biology. Histological diagnosis: Malignant SCHWANNOMA SCHWANNOMA: Tumor of the peripheral nerve sheat. Schwannomas developed at the sacral floor represent 1 to 5% of spinal Schwannomas and rarely reveal a lumbosciatic pain; Usually solitary bt may be multiple. Peak frequency between 20 and 50 years. Treatment: Excision with preservation of nerve; Recurrence is rare; Malignant transformation is rare. IMAGING: Well limited mass continues with a nerve but eccentric to him, surrounded by a halo of fat; Hypodens on CT scan Page 5 of 25

6 Iso or slightly hyperintense in T1 and hyperintense in T2 on MRI Enhancement variable, non specific but gladly central. CASE NUM 5: Fig. 12 on page 17 Fig. 13 on page 17 Fig. 14 on page years old patient with right lumbosciatic pain. Histological diagnosis: EWING's sarcoma EWING's Sarcoma The sacrum is the most frequent location of the spinal Ewing Sarcoma. Peak frequency of 10 to 30 years; Motheaten lytic tumor with cortical destruction, periosteal reaction and important extension to soft tissues. CASE NUM 6: Fig. 15 on page 18 Fig. 16 on page 20 Fig. 17 on page years old, presenting a swelling facing the right iliac wing. Histological diagnosis: dedifferentiated Liposarcoma The rare malignant primary bone tumors Liposarcoma: Rare sacral location; Frquency peak between 20 and 40years; Often high grade Chondrosarcoma: Uncommon sacral location (5%); Slight male-dominated; Frequency peak between 30 and 70 years; It develops de novo or on an enchondroma, Paget's disease or after irradiation; Page 6 of 25

7 Agressive lytic lesion and calcified tumor matrix Fibrosarcoma: Occurs on abnormal bone in 25% of cases, irradiation, Paget... Possible degeneration of a benign tumor. Osteosarcoma: Sacral localisation is uncommon; Fraquent occurance on an anormal bone. Plasmocytome solitaire. CAS NUM 7: Fig. 18 on page 21 Fig. 19 on page years old, sacral painfrom 2 years radiating to both hips, worsening progressively without fever or deterioration of general state; Review: Swelling right buttock with apyrexy Histological diagnostic: Osteoblastoma Osteoblastoma: 3% of benign bone tumors and less than 1% of all bone tumors; The sacral locations are exceptional (10%); 23years old of average age with a male predominance; Radicular pain, swelling IMAGING: Radiographs: Expansive osteolytic lesion, well limited, blowing the cortical, limited by a shell matching subperiosteal osteogenesis. The matrix is maid of combined tissue: ossification areas and or calcifications CT scan: Accurates and characterizes the tumor matrix, the outlines of the lesion, sudies periosteal reaction and the extension of the soft parts. Page 7 of 25

8 MRI: Expansive lobulate lesion, homogeneous, isointense or hypointense in T1, hyper or isosignal in T1, limited by a shell which is hypointense in T1 and T2 Clarifies the relationship between the tumor and radicular structures Differential diagnosis: Aneurysmal cyst, osteoid osteoma, abcess Brodie; Treatment: Surgical/Radiotherapy discussed CASE NUM 8: Fig. 20 on page years old, female, lumbar and pelvic pain Disturbed calcium and phosphate Cervical Sonography: Parathyroid nodule Histological diagnosis: Brown tumor Brow tumors: They are found in the primary or secondary hyperparatyhroidism; IMAGING: X-ray and CT scan: Lytic lesion well limited, sometimes expansive, rather eccentric; MRI: Hypointense in T1, hyperintense in T2, enhanced after gadolinium and sometimes liquidliquid levels. OTHER BENIGN BONE TUMORS Aneurysmal Cyst; Consists of blood-filled cavities; Young adult with a peak incidence at 20 years old Slight female predominance Page 8 of 25

9 CT: Purely lytic lesion without tissular compenent, surrounded by a thin border calcified, common and typical liquid-liquid levels. MRI: Well multiloculate limited lesion; the level images are clearly visible; Gadolinium injection reveals massive hypervascularization of the lesion Tarlov Cyst; Fig. 21 on page 22 S2/S3 topography; Pathogenesis: Acquired abnormality related to ischemia, trauma, inflammation, hemorrhage. Prevalence: 5% in adults Benign Schwannoma; Asymptomatic more often, sometimes perineal pains, sphincter disorders Diagnosis: CT, MRI. Surgical treatment if symptomatic cyst more the 15mm. Osteoid osteoma; Caverous Hemangioma Images for this section: Page 9 of 25

10 Fig. 1: Sacral tissular mass of heterogeneous signal in T2(a), hypointense T1(b) ans heterogeneous after gadolinium leaving necrotic pads(c) Fig. 2: Sacral tissular process heterogeneous signal in T2 and after contrast Fig. 3: Osteoloytic lesion of the sacrum with blurred outlines Page 10 of 25

11 Fig. 4: Sacral mass with dual component tissular and fluid, containing fine microcalcifications Page 11 of 25

12 Fig. 5: Sacrococcygeal polylobal tissular mass heterogeneously hypointense in T1 and T2, hyperintense in STIR, intensely inhanced with Gadolinium. Note the prominent epidural extension on the sagittal sequence Page 12 of 25

13 Fig. 6: Radiograph of the sacrum: Osteolytic lesion of the sacrum with blurred outlines Fig. 7: Lytic process of the sacrum with important endopelvic extension Page 13 of 25

14 Fig. 8: Intraductal mass, heterogeneous, extending the dural sheath and eroding the bone nearby Page 14 of 25

15 Fig. 9: Intraductal expansive process with lumbosacral vertebral scalloping Page 15 of 25

16 Fig. 10: Intraductal expansive process in hyper T2 Page 16 of 25

17 Fig. 11: T1 FAT SAT GADO sequence: Peripheral contrast enhancement of intraductal mass Fig. 12: Osteolytic lesion of the sacral right wing Page 17 of 25

18 Fig. 13: Osteolytic lesion of the right sacral wing with large heterogeneous endopelvic ipsilateral mass Fig. 14: Lytic sacral lesion on the right wing, spread to ipsilateral iliac wing with voluminous endopelvic mass in hypo T1, hyper T2, enhanced with Gado Page 18 of 25

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20 Fig. 15: Osteolytic sacroiliac lesion Fig. 16: Sacroiliac tissular osteolytic expansive process extended to sacral holes and to the right sacroiliac joint with significant endopelvic extension and to soft parts of the right buttock Fig. 17: Large expansive tissular process of the iliac Page 20 of 25

21 Fig. 18: Lytic lesion of the right sacral wing with thin microcalcifications Page 21 of 25

22 Fig. 19: Osteolytic expansive sacral lesion with polylobated outlines, blowing the cortical, although well limited by a hull coorosponding to a subperiosteal osteogenesis. The matrix is made of a tissue combining ossification areas and calcifications Fig. 20: Multiple lytic tissular lesions of the pelvic and the sacrum with expansion into the soft tissues in places simulating metastasis Page 22 of 25

23 Fig. 21: Intraductal cystic mass facing S3 related to TARLOV cyst Page 23 of 25

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25 Findings and procedure details Radigraphs. CT with 3D reconstructions. MRI T1, T2, STIR, T1 FAT SAT GADO. Conclusion CT and MRI are complemontary imaging modalities, the first one have an excellent special resolution of bone lesion, the second one permits soft tissue imaging with high resolution. Secondary malignant tumors are the most frequent, but it is very important that radiologists become familar with imaging features of less frequent tumors too. Personal information References Department of radiology, Trauma Center and Large Burned, Ben Arous Page 25 of 25