Presentation
Lower lumbar pain with left leg weakness.
Patient Data
Osteolytic lesion with clear non-sclerotic margin on 5th lumbar vertebral and left sacral ala. The lesion causes destruction of the anterior vertebral wall with compression fracture of the vertebral body.
On inverse reconstruction of pelvis x-ray (AP view), the border of the lesion is easier to be seen.
On inverse reconstruction of pelvis xray (AP view), the border of the lesion is easier to be seen and circled by the green dashed line.
Heterogeneous soft tissue dense mass which is located at L5 and S1 region. The lesion is located off midline, which is central at left sacral ala. Cortical destruction with intra spinal canal extension and paraspinal soft tissue involved are also noted. There are no sclerosis rim or intra lesion matrix mineralization.
The mass extended laterally to the left sacroiliac joint. After contrast administration, the mass shows vivid enhancement.
MRI examination of the lumbar spine showed heterogeneous signal lesion on all sequences. It contained an area of hyperintensity on T2W, T1W and T1W fat sat images, which is consistent with intra tumor hemorrhage.
Tumor intra spinal canal and foramen extension made severe compression of the left L5 and S1 nerve roots, which causes the clinical symptom of ipsilateral leg weakness.
Case Discussion
The lesion shows aggressive behavior with irregular bone destruction, which extends to paravertebral soft tissue. Depending on the patient's age and morphology of the lesion, bone metastasis is the most popular diagnosis. Therefore, a total body CT scan examination with GI tract endoscopy had been done for further evaluation, and no malignant lesions were found.
Primary bone lesions are also differential diagnosis in this case. In the sacral region, the two most common primary bone tumors are chordoma and giant cell tumor. The lesion tends to locate off midline and in high levels of sacrum, with the left sacroiliac joint also involved. Intratumour hemorrhage is noted without matrix calcification or septation. All these images are in favor of giant cell tumor.
Core needle biopsy under CT scan guidance was performed to confirm the diagnosis with following surgical treatment for nerve root compression released. The final histopathology result was giant cell tumor.
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