Spinal Tumors and Tumor-like Masses: Relevance of Initial Imaging, Karnofsky Performance Status, Age, Location, and Cord Edema

Objective: The aim of this study is to know the relevance of initial imaging, Karnofsky performance status,age,location and cord edema for future score development for radiologists. Methods: The present study was carried out on total of 32 patients who visited SRN Hospital and Kriti scanning centre between August 2009 to February 2019. General and systemic examination was done. Finally KPS score was given to each patient in accordance with their clinical status. Magnetic resonance imaging was contemplated using scanner – Magnetom SP Vision; Siemens –Supercon 1.0 Tesla system. Results: The morphologic characterization and specific assessment of various tumors and tumor like masses of spine in view of MR imaging features and their relationship with clinical features have been analyzed with Chi square test which reveal: Age versus location – χ2 = 4.32; df = 4; P > 0.36 (NS), age versus cord edema – χ2 = 4.27; df = 3; P > 0.23 (NS), and location versus cord edema – χ2 = 2.67; df = 2; P > 0.26 (NS). Chi Square test shows there is no any statistically significant association between age and location; age and spinal cord edema, and location and spinal cord edema. Correlation between clinical aggressiveness (change in follow-up KPS) and MR imaging features could not be assessed in our study because majority of patients could not be evaluated after one month because of loss of follow-up. Conclusion: Poor KPS itself lead to movement during MRI and movement related artifacts affecting initial imaging,which was managed by cotton padded neck strap. KPS depends only on general condition one of the factor for outcome so for future score development age,location and cord edema together may be useful.


INTRODUCTION
Magnetic resonance imaging (MRI), myelography, post-myelo-computed tomography, and bone scan are the mainstay of evaluation of tumors of the spine. In the extradural space, MRI is the most sensitive technique for the detection of neoplasms in the vertebrae. e MRI may be tailored specifically toward the question of spinal cord compression and signal changes and cord edema. Clinical aggressiveness of tumors increases at extreme of ages. Clinical aggressiveness also depends on tumor doubling time.
e Karnofsky performance status (KPS) scale has been used as an assessment tool for performance status in oncology since 1948. [1] It is commonly regarded as the gold standard measurement of performance status in cancer. [2,3] e KPS scale assesses three dimensions of health status -activity, work, and self-care and can be administered by any health-care professional for a quick assessment of general functioning and survival. [4] When KPS is low, it is a sensitive predictor of poor prognosis, but when high it is a poor cross-sectional indicator of prognosis. [2] KPS decrease by 20 points over a month time has been suggested as low clinical aggressiveness, 40 points decrease as moderate clinical aggressiveness, and 60 points decrease as high clinical aggressiveness. [1] e aim of this study is to know the relevance of initial imaging, KPS, age, location, and cord edema for future score development for radiologists. Written consent was taken from the patients subjected to this study. A detailed history including back pain, weakness or paralysis, sensory loss, and change of bowel function was taken. General and systemic examination was done followed by neurological examination to localize the level of cord lesion. Finally, KPS score was given to each patient in accordance with their clinical status. Patient was sent for treatment and follow-up KPS was assessed after 1 month.

MATERIALS AND METHODS
MRI was contemplated using scanner -Magnetom SP Vision; Siemens -Supercon 1 Tesla system, with only dedicated (body: L and XL for thoracic + lumbar spine and cervical spine) coils. T1W and T2W sequences in sagittal and axial plane were taken for thoracic and lumbar spine and sagittal T1W and T2W and axial T1 and gradient-recalled echo images for cervical spine as standard protocol.
In addition, short inversion time inversion recovery sequences to suppress fat in paraspinal soft tissue, FLASH, and T1W FAT-SAT sequences were also included wherever necessary.
Post contrast study was also carried out with intravenous Gadopenate Dimeglumine when needed.

RESULTS
A total of 32 patients were included in the study, 66% of affected were male and the most common age group involved was 21-40 years (34.47%) age group [ Figure 1]. e only diagnosed entity in this age group was neoplastic disease which included -metastasis, cavernous hemangioma, astrocytoma, chordoma, lipoma, lymphoma, three cases of meningioma, and two cases of ependymoma. No tumor-like mass was seen.
Overall, the most common neoplasm was meningioma (15.6%) followed by lymphoma (12.5%). e most common location involved was intradural extramedullary (37.93%) comprising meningioma, nerve sheath tumor, lipoma, epidermoid, and metastasis [ Table 1]. 34.48% of cases were seen in extradural compartment and 27.59% of cases in intramedullary compartment. Maximum incidence of secondary neoplasms was seen in extradural compartment (60% of total secondary).
e maximum incidence of spinal neoplasm was noted at dorsal spine (41.38%) followed by eight cases at dorsolumbar and lumbar spine (27.58%) in the present study.
Evidence on MRI of involvement of two consequent vertebrae and the intervening disk is virtually diagnostic of infective spondylitis. In tuberculous spondylitis, the cortical definition of the affected vertebrae was found to be invariably lost, in contradistinction to pyogenic spondylitis.
In the present study, solitary cervical cord granuloma was seen. Intracranial tuberculomas have been described as lowintensity lesions with or without central hyperintensity (due to varying amount of caseous necrosis) on T2WI and as hypo to isointense lesions on T1WI. In the present study, same features were seen. In the present study, majority of patients of both groups, having cord edema present and absent, have good KPS

DISCUSSION
e present study focuses on the MRI evaluation in tumors and tumor-like masses of the spine and correlation between MRI features of disease and clinical aggressiveness. MRI has been contemplated as the initial procedure in the evaluation of 32 cases of clinically suspected spinal tumor.
According to Nittner, approximately one-fifth of all central nervous system tumors occur in the spine with frequencies at various level of spinal canal (cervical, thoracic, and lumbar) roughly proportional to the number (and length) of segments at that level. [5,6] e same observation was quoted by Masaryk [6] In the present study, the most common location is dorsal spine (44.83%) followed by lumbar (17.24%) and then cervical (13.79%) and dorsolumbar (10.34%) spine. Chordoma in our study also had predominant large soft tissue mass anterior to sacrum as noted in other studies. [8] According to their anatomical location, spinal tumors are conveniently classified as extradural, intradural extramedullary, and intramedullary tumors with intradural extramedullary tumors being the most common (50%) followed by extradural tumors (30%) and least common were intramedullary tumors (20%). [9] e present study has same distribution as above   e primary tumor of spine may exhibit characteristic imaging features that can help in early diagnosis and improved prognosis. [10] Nittner in his 1976 review of 4885 adult spinal cord tumors presented in literature, found nerve sheath tumor [ Figure 5] (23%), meningiomas (22%), glial tumors (13.2%), ependymomas (2.5%), sarcoma (8.2%), and metastasis (6%) to be the most common. [7] e remaining 25% of cases were dispersed among a wide variety of miscellaneous mass lesions. In the present study, metastasis and meningioma account for the most common neoplasia (17.24% each), followed by nerve sheath tumor, astrocytoma, and ependymoma (10.34% each). e rest of the entities are lymphoma, lipoma, hemangioma, and chordoma.
Meningiomas are second only to nerve sheath tumors in frequency. However, in the present study, meningioma (17.24%) was more common than nerve sheath tumor (10.34%).
In the present study, from infective group of tumor-like masses, two cases were seen, one case seen of tubercular osteomyelitis and one of intramedullary granuloma.