Neoplastic Disease of the Vertebral Column: Radiologic-Pathologic Correlation

Bone island. (A) Specimen from a trocar biopsy demonstrates dense compact bone characteristic of a bone island or enostosis. (B) SPECT/CT bone scan shows a sclerotic lesion with spiculated borders abutting the cortical surface and demonstrating an abrupt transition to normal trabecular bone. The subtle blue background corresponds to normal background activity from the bone scan. No abnormal uptake is present within the bone island. (C) Axial T2 sequence with a giant bone island demonstrating decreased signal intensity on all pulse sequences (T1 not shown). Note again the irregular spicules or “thorny radiations” extending from the periphery and abrupt transition to normal trabecular bone.

Sclerotic metastasis. (A, B) Axial CT demonstrates a sclerotic lesion in the anterior aspect of the vertebral body adjacent to the cortical margin. However, there are poorly defined borders and a gradual transition of density into adjacent medullary bone. SPECT/CT bone scan (B) reveals avid uptake of radiotracer consistent with a metastatic focus in this patient with prostate cancer. (C) Two separate lesions with decreased signal intensity on T1 (not shown) and T2. Numerous lesions were identified in the lumbar and thoracic spine and there was corresponding both peripheral and central enhancement (not shown). Note how 1 lesion does not contact the cortical bone. Also, the margins of the lesions are ill-defined with gradual transition to normal medullary bone. The larger lesion also demonstrates nonuniform sclerosis, atypical for a simple bone island.

Poems syndrome. (A) Biopsy demonstrates an atypical plasma cell population. Immunostaining was positive for CD138 and lambda light chain restriction was demonstrated on fluorescent in situ hybridization. (B-D) Forty-four-year-old patient with a clinical history of polyneuropathy, hepatosplenomegaly, and peripheral edema. Laboratory analysis demonstrated an IgA lambda paraproteinemia. A CT examination shows a well-defined sclerotic lesion with fluffy margins (“mulberry appearance”) at the left of the T5 thoracic vertebrae, which extends posterior to involve the pedicle. SPECT/CT bone scan shows no significant uptake relative to normal marrow activity. MRI shows the characteristic decreased T1 (not shown) and T2 signal of a blastic lesion.

Osteoid osteoma. (A, B) Subtle dextroscoliosis in the lumbar spine with a subtle lytic lesion (black arrow) projecting at the left inferior facet of L4 (A). This osteoid osteoma is located at the characteristic concave portion of the curve apex. Axial CT image (B) demonstrates a well-defined nidus with central calcification. (C, D) Histology shows a piece of the nidus. These high-power views demonstrate the characteristic features of osteoid osteoma including the anastomosing trabeculae of woven bone, which are easier to appreciate on the polarized image (black arrows, C). The bony trabeculae are rimmed by osteoblasts (blue arrow), and the spaces in between the bony trabeculae show capillary proliferation (green arrow).

Chondrosarcoma. (A-D) Axial CT (A) shows an aggressive lesion centered in the left transverse process of T5 with central arc-like calcifications, characteristic of chondroid matrix. Select axial MRIs reveal a destructive soft-tissue component extending into the central canal resulting in cord compression. The characteristic bright T2 signal (B) and peripheral and septal enhancement pattern (C) are characteristic of a chondroid lesion and the aggressive features are consistent with a chondrosarcoma. Histology (D) demonstrates infiltration and destruction of bone (arrows) by the chondrosarcoma. This tumor was grade 2 of 3, consisting of large, atypical chondrocytes in a solid to wispy chondroid matrix.

Paget disease. (A, B) On histology (A), hyperplastic bone is present with irregular thickened trabeculae lined by osteoblasts. The marrow is acellular with occasional osteoclasts (not shown). Axial CT demonstrates the typical coarsened trabeculae and expanded appearance to bone seen with Paget disease.

Hemangioma. (A, B) Axial T1 and T2 (not shown) MRIs demonstrate characteristic increased T1 and T2 signal. The high T1 signal suggests the presence of a high proportion of intervening adipocytes when correlated with histology. Axial CT shows the characteristic “honeycomb” appearance with reinforced trabeculae in a vertebral hemangioma (B).

Compressive hemangioma. (A-D) Compressive hemangioma with the characteristic “polka-dot” pattern on axial CT (A). Axial SPECT/CT bone scan (B) reveals no abnormal uptake within the vertebral body; however, activity associated with degenerative change is noted within the posterior elements. Axial T1 MRI shows diffuse high signal on T1 (C) representing fat, a highly specific sign for a hemangioma. A second case in the L1 vertebral body (D) shows a different pattern, which is more difficult to diagnose prospectively due to the extraosseous soft-tissue extension and lack of the typical “polka-dot” pattern of reinforced trabeculae.

Epithelioid hemangioendothelioma. Axial enhanced CT image in bone windows shows an aggressive lytic lesion within the T10 vertebral body extending into the left pedicle. The mass causes moderate central canal stenosis.

Aneurysmal bone cyst. Histologically, (A), large blood-filled spaces with associated osteoclast-like giant cells are present in a cellular background composed of cells morphologically consistent with fibroblasts, myofibroblasts, and histiocytes. Axial T2-weighted MRI (B) shows an aggressive, mildly expansile mass centered in the right transverse process with fluid levels and extension into the lamina and pedicle. Mass results in moderate-to-severe central canal stenosis. Thin peripheral enhancement is present without a solid enhancing component (C).

Plasmacytoma. Histologically (A) demonstrates an extramedullary lesion composed of sheets of atypical neoplastic plasma cells. (B) An aggressive, lytic mass destroying bone at the level of the sacrum. Sagittal T1-weighted MRI shows an expansile, destructive mass at the level of the sacrum replacing normal fatty marrow (C). A second case in the cervical spine (D) reveals marrow replacement and cortical thickening, the so-called “mini-brain” appearance, which is said to be suggestive of plasmacytoma.

Giant cell tumor. Histologically, (A) demonstrates numerous osteoclast-like giant cells (arrows) in a monomorphic cellular stroma consisting of neoplastic mesenchymal cells. Axial T2-weighted MRI (B) reveals an aggressive mass centered within the right side of the vertebral body and extending into both soft tissues and the posterior elements. The T2-weighted sequence demonstrates the characteristic intermediate signal (significantly lower than adjacent cerebrospinal fluid) of a giant cell tumor. Axial SPECT/CT bone scan (C) shows peripheral increased radiotracer uptake and is the SPECT/CT correlate of the “donut sign.”

Chordoma. Histologically, (A), there are cords and nests of cells resembling notochord tissue with moderate eosinophilic cytoplasm and large, dark nuclei in a myxoid stroma. Occasional large cells with vacuolated cytoplasm are encountered, the physaliferous cells (arrows). Sagittal T2-weighted image (B) reveals a destructive mass at the posterior C2 vertebral body. The large epidural component has a “mushroom” or “collar-button” appearance and is a typical feature of cervical chordoma. (C) A second cervical chordoma on SPECT/CT bone scan shows typical extension into, and with enlargement of, the right neural foramen. Note the absence of significant radiotracer activity, which is characteristic of chordoma.