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Neurosurgery > Neoplasms of the vertebrae and spinal cord > Flashcards

Neoplasms of the vertebrae and spinal cord Flashcards

1
Q

Are large or small breed dogs more likely to be affected by neoplasms of the vertebrae and spinal cord?

A

Large breed dogs.

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2
Q

Cats with lymphoma of the spinal cord are typically positive for which virus?

A

FeLV

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3
Q

Are intradural/extramedullary or intramedullary neoplasms typically associated with a more rapid onset of clinical signs?

A

Intramedullary (longest onset for intradural/extramedullary).

Dogs with secondary/metastatic neoplasms also tend to have a more acute onset.

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4
Q

What are the most common clinical signs of vertebral, spinal cord, spinal nerve, or nerve root neoplasms in dogs and cats?

A

Dogs: pain.
Cats: paresis/paralysis

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5
Q

What are some common differential diagnoses for neoplasms of the vertebrae and spinal cord?

A

IVDH, cervical spondylomyelopathy, degenerative myelopathy, degenerative lumbosacral disease.

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6
Q

In which region of the vertebral column do neoplasms most frequently occur in dogs?

A

Cervical

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7
Q

What percentage of tumours occur in extradural, intradural/extramedullary, and intramedullary locations? For each, what are some examples of common neoplasms at these locations.

A

Extradural account for 50%: most commonly vertebral neoplasms, or lymphoma (cats).

Intradural/extramedullary 25-35%: meningioma, nerve sheath neoplasms.

Intramedullary: primary or secondary neoplasms.

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8
Q

What are some diagnostic tests that should be run when vertebral or spinal cord neoplasia are suspected?

A

CBC, biochemistry, urinalysis, FeLV/FIV testing, thoracic radiographs, abdominal ultrasound, CT +/- myelogram, MRI, FNA/biopsy (if possible, normally for vertebral rather than spinal cord lesions)

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9
Q

Based on anatomic location, when can FNA/biopsies of vertebral neoplasms be obtained?

A

Able: Lesions affecting the spinous, transverse or articular processes of most vertebrae,

Unable: Lesions affecting the body of the cervical (due to proximity to the trachea, esophagus, carotid sheath and vertebral arteries), and thoracic vertebrae (proximity to dorsal lungs and ribs). Challenging to obtain samples from the L6/L7 vertebrae due to the ilial wings.

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10
Q

When are early and late effects of radiation therapy expected?

A

Early: start immediately (affect rapidly dividing cells such as epithelium and bone marrow). Normally resolve within weeks of completion.

Late: 6-months to years after therapy. affect non-proliferating tissues such as nervous tissue, vascular tissue, and bone. Can be life limiting but relatively rare (5%).

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11
Q

What would a typical definitive radiation protocol for neoplasms of the vertebra and/or spinal cord consist of?

A

Daily administration of 18-22 treatments (fractions) for a total administered dose of 45-55 Gy.

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12
Q

What are some newer radiation technologies available to increase the dose of radiation to the neoplasm?

A

Intensity modulated radiation therapy, tomotherapy, stereotactic radiotherapy (or radiosurgery), EDTMP.

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13
Q

What is a unique challenge of treating intradural CNS neoplasms with chemotherapy?

A

Many chemotherapeutic agents do not cross the blood brain barrier

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14
Q

What are some CNS neoplasms that may be primarily treated with chemotherapy?

A

Multiple myeloma, leukemia, disseminated histiocytic sarcoma, lymphoma.

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15
Q

What is the mechanism of action of biphosphanates, and give two examples.

A

Pamidronate and zoledronate (zoledronate is potent, newer generation biphosphanate).

Biphosphanates work by inhibiting osteoclast activity and bone resorption, resulting in decreased osteolysis, improved mineralization and pain relief.

Nephrotoxicity is possible with both drugs.

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16
Q

List 7 common extradural neoplasms that may be identified in dogs and cats?

A
  1. Osteosarcoma
  2. Lymphoma
  3. Histiocytic sarcoma
  4. Myxoma
  5. Calcinosis circumscripta
  6. Infiltrative lipoma
  7. Osteochondromatosis
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17
Q

What is the typical signalment of a patient with vertebral neoplasia?

A

Large breed, 5-10 years of age, males>females in some studies.

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18
Q

Are vertebral neoplasms more likely to be primary or secondary?

A

Primary

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19
Q

What is the most common primary vertebral neoplasm in dogs and cats?

A

Osteosarcoma.

Other neoplasms include hemangiosarcomas, fibrosarcomas, chondrosarcomas.

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20
Q

What are the most common metastatic neoplasms of the vertebral column?

A

Vascular (hemangiosarcoma) or epithelial (thyroid, mammary, urinary, prostatic) in origin.

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21
Q

What is the most common clinical sign associated with vertebral neoplasia?

A

Pain

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22
Q

Which neoplasm is associated with multiple punctate areas affecting multiple vertebrae?

A

Multiple myeloma.

Metastatic neoplasia may also be more likely to have a soft tissue mass and affect more than one vertebrae.

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23
Q

What are typical MRI findings with vertebral neoplasms?

A

Hypointense lesion of T1W images, hyperintense image on T2W, variability in contrast enhancement after IV contrast.

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24
Q

What is the location of the lesion in the image? (extradural, intradural, etc).

A
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25
Q

What vertebral neoplasms are highly radiation responsive?

A

Lymphoma, plasma cell neoplasia.

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26
Q

Is osteosarcoma in cats associated with a high or low metastatic rate?

A

Low (regardless of location)

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27
Q

What is the median survival time of dogs with vertebral osteosarcoma?

A

55-155 days.

Improved outcomes reported in dogs with better neurologic status and with adjunctive therapies.

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28
Q

What adjunctive therapies can be considered in the treatment of vertebral osteosarcoma?

A

Radiation therapy, chemotherapy (unsure of prolongs survival, but warranted based on high metastatic rate), biphosphanates

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29
Q

What is the metastatic rate of vertebral osteosarcoma in dogs?

A

40-45%.

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30
Q

What is the survival time of cats with vertebral osteosarcoma?

A

Undetermined, if local control is achieved likely long term survival.

May be influenced by completeness of excision, neoplasm grade, and mitotic index.

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31
Q

What regions of the spinal cord are most commonly affected by lymphoma in cats?

A

Thoracic or lumbar.

Can be extradural, intradural-extramedullary, or intramedullary.

Typically of high grade.

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32
Q

Is it common or uncommon for lymphoma to involve multiple central nervous system sites in cats?

A

Common (43% of cases involve multiple sites)

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33
Q

What percentage of cats with central nervous system lymphoma have involvement of other extraneural sites?

A

> 80%.

43% involve multiple CNS sites.

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34
Q

Is extradural, intradural or intramedullary lymphoma most common in dogs and cats?

A

Extradural (90% invade the adjacent meninges in cats).

35
Q

What is the expected median survival time of dogs and cats with CNS lymphoma?

A

<5 - 7 months (some complete responders survive greater than 1 year).

36
Q

What drugs are involved in CHOP for lymphoma treatment?

A

Doxorubicin, vincristine, prednisone, cyclophosphamide.

37
Q

What is histiocytic sarcoma?

A

Neoplastic proliferation of cells of the dendritic or macrophage lineage.

Localized or disseminated forms are described.

38
Q

What are clinical signs associated with histiocytic sarcoma?

A
  1. Central CNS signs can occur with disseminated disease.
  2. Disease of the spinal cord can be localized or disseminated, causing either focal or multifocal neurologic signs.
39
Q

Is histiocytic sarcoma normally intramedullary or extramedullary?

A

Intradural-extramedullary and/or intramedullary.

Strong enhancement of the entire dura is often observed on MRI following contrast.

40
Q

What is the median survival time for histiocytic sarcoma of the CNS?

A

3-4 months

41
Q

How does infiltrative lipoma cause neurologic signs?

A

Invades along spinal nerves to enter the vertebral foramen.

42
Q

What are the imaging features of infiltrative lipoma on CT and MRI?

A

Hypoattenuating on CT, hyperintense on T1W and T2W MRI

43
Q

What is the recurrence rate following excision of infiltrative lipoma?

A

Recurrence occurs in 36-50% of cases.

Adjunctive radiation therapy may be beneficial for local control.

44
Q

What is a myxoma?

A

Rarely encountered benign neoplasm arising from the synovium. Can involve the zygapophyseal joint.

Dobermans and labradors are over-represented.

45
Q

What is the MRI appearance of a myxoma?

A

Hyperintense on T2W and hypointense on T1W, typically enhances on T1W images

46
Q

What is the outcome following surgical excision of a myxoma?

A

Long-term control has been described following surgical removal with hemilaminectomy.

47
Q

What is calcinosis circumscripta?

A

An uncommon disease where there is ectopic mineralization of soft tissues.

48
Q

What are the three classifications of calcinosis circumscripta?

A

Metastatic: secondary to abnormal calcium homeostasis.

Dystrophic: secondary to tissue damage.

Idiopathic.

Idiopathic and dystrophic are most common.

49
Q

What is the typical signalment for dogs with calcinosis circumscripta?

A

Young, large breed dogs. German shepherds appear overrepresented.

Occurs most commonly between the dorsal arch and spinous process of C1 and C2.

50
Q

What is the treatment for calcinosis circumscripta?

A

Surgical excision (typically a dorsal approach due to more common dorsal location). Long-term control has been reported.

51
Q

What is osteochondromatosis/multiple cartilaginous exotoses?

A

Also known as osteochondroma or multiple cartilaginous exostoses this is a benign lesion involving bones that develop by endochondral ossification.

52
Q

What is the proposed pathogenesis of osteochondromatosis in dogs and cats?

A

Occurs secondary to migration of chondrocytes from the physeal region into the metaphyseal region of the bone.

Lesions have been reported to undergo malignant transformation to osteosarcomas or chondrosarcomas.

53
Q

What are the differences between osteochondromatosis in dogs and cats?

A

In dogs typically ceases with skeletal maturity, in cats it continues to progress beyond skeletal maturity and is associated with FeLV.

54
Q

How do osteochondroma and osteochondromatosis lesions differ in cats?

A

Osteochondroma typically used to describe solitary lesions in adult cats. Polyostotic version (osteochondromatosis or multiple cartilaginous exostoses) typically occurs in young adult cats.

55
Q

What is the appearance of the cartilaginous cap in osteochondromatosis on MRI?

A

Hypointense on T1W and hyperintense on T2W.

Lesions appear as well-circumscribed calcified lesions affecting the vertebrae and other bones.

56
Q

What is the prognosis for osteochondroma/osteochondromatosis?

A

Favourable so long as the lesion is accessible for surgical excision.

57
Q

What are the some common intradural/extramedullary neoplasms?

A
  1. Meningioma.
  2. Nerve sheath neoplasms.
  3. Extrarenal nephroblastoma
58
Q

What is the most common primary nervous system neoplasm of the spinal cord in dogs?

A

Meningioma.

Middle aged to older dogs, large breed dogs most commonly affected. Boxers may be predisposed.

Typically presents with a protracted course over 3-6 months.

59
Q

Which part of the spinal cord do meningiomas most frequently affect?

A

The cervical spinal cord (cranial to C3).

60
Q

From where do meningiomas arise?

A

The meningothelial cells of the arachnoid or pia mater

61
Q

What are the reported grades of meningioma, and which is most common in dogs?

A

Grade 1 (benign)
Grade 2 (atypical)
Grade 3 (anaplastic)

Grade 1 and 2 most common.

62
Q

Are meningiomas most common extradural, intradural/extramedullary, or intramedullary?

A

Intradural/extramedullary

63
Q

What are the MRI characteristics of meningioma?

A

Iso to hypointense on T1W images, hyperintense on T2W images, strong and uniform contrast enhancement.

64
Q

What is the treatment for meningiomas?

A

Gross resection or cytoreductive surgery with durectomy. Closure of the dural defect is not necessary.

May be firmly adherent to the spinal cord. In some cases rhizotomy may be required (take care when near an intumescence).

65
Q

What is the prognosis for dogs with spinal meningioma?

A

Typically good for dogs improving neurologically and surviving the post-operative period. Reported MST of 19 months.

Adjunctive radiation therapy should be considered.

66
Q

What is the reported MST in cats with spinal cord meningioma?

A

426 days.
High rate of recurrence is reported.

67
Q

Are primary or secondary nerve sheath neoplasms more common?

A

Primary (most frequently malignant).

68
Q

Do nerve sheath neoplasms frequently metastasize?

A

No, behave similar to soft tissue sarcomas (locally aggressive but low rate of metastatic disease)

69
Q

What is the typical signalment of patients with nerve sheath neoplasms?

A

Middle aged, large breed dogs.

Most commonly present with a progressive, unilateral lameness. Average duration of clinical signs of 5-6 months.

70
Q

Are the thoracic or pelvic limbs more commonly affected in patients with nerve sheath neoplasms?

A

Thoracic. Atrophy of the supraspinatous and infraspinatous muscles is common. May also observe Horner’s or absent cutaneous trunci muscle ipsilateral to lesion.

71
Q

What diagnostics can be considered for the work-up of nerve sheath neoplasms?

A
  1. MRI (although can be difficult to differentiate from neuritis). Typically hypointense on T1W and hyperintense on T2W images. Can use fat suppression techniques to help delineate from normal tissues.
  2. Myelography (may show an extradural, or intradural/extramedullary filling defect, or can be normal).
  3. Ultrasound (can help to guide aspirates).
  4. Electrophysiologic testing (can help to differentiate from orthopedic disease).
72
Q

What is the treatment for nerve sheath tumours?

A

Wide surgical excision. Typically requires amputation.

Limb sparing surgery of the thoracic limb may be contemplated for distal locations, but care must be taken to preserve the radial nerve.

Post-operative radiation therapy may be beneficial.

73
Q

What is the prognosis for nerve sheath neoplasms?

A

Long term survival may be possible following amputation if the neoplasm is located on the distal limb (MST 1416 days), in dogs with lesions involving the spinal nerve or nerve roots MST is 5 months.

74
Q

What has been shown to be prognostic for survival in dogs with nerve sheath neoplasms?

A

Histologic grade.

75
Q

What is the expected signalment in a patient with extrarenal nephroblastoma

A

Normally young (6-36 months) German Shepherds and retrievers.

76
Q

In what vertebral segments are extrarenal nephroblastoma almost exclusively found?

A

T10 - L2 (causing T3-L3 myelopathy). This repeatable location thought to be due to entrapmment of primitive nephrons at this location during embryogenesis.

77
Q

What is the treatment for extra-renal nephroblastoma?

A

Surgical removal via laminectomy and durotomy.

Areas of invasion into the spinal cord occur commonly and preclude complete removal.

78
Q

What are the reported survival times for extrarenal nephroblastoma?

A

4 months to > 3 years.

Metastatic disease is not reported.

79
Q

What are the most common intramedullary spinal cord neoplasms in dogs and cats?

A

Dogs: ependymoma, astrocytoma (other glial cells tumors also possible; oligodendroglioma, undifferentiated glial neoplasms. Primary sarcomas also reported).

Cats: glial.

80
Q

Are clinical signs more frequently chronic or acute in patients with intramedullary neoplasia?

A

Acute (<3 weeks prior to presentation).

81
Q

In which region of the spinal cord might FNA of an intramedullary lesion be appropriate?

A

Lumbar, due to the risk of severe and permanent loss of function in other locations.

82
Q

What is the prognosis for intramedullary spinal cord neoplasms?

A

Too few cases have been reported to accurately predict survival (surgical treatment involves laminectomy, durotomy/durectomy and myelotomy).

83
Q

In a study by Morabito 2023 in JVIM, what two MRI findings were associated with higher tumour grade for peripheral nerve sheath tumours?

A

Larger tumour size, increased peripheral contrast enhancement.

Neurosurgery (11 decks)

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