PMC6477464_01
Initial diagnostic CT scan of the cervical spine: Multiple planes of non-enhanced CT scan of the cervical spine in soft tissue (a) and bone window algorithms (b-d) demonstrate a T1 vertebral plana with thinning of the cortices associated with the paravertebral soft tissue mass lesion occupying bilateral pedicles and laminae splaying both anterior and posterior longitudinal ligaments (a-d).
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F1
Preoperative imaging revealed marked osteolysis and collapse of the T1 vertebra along with an extensive soft tissue component (Fig. 1).
Multi-sequential multiplanar magnetic resonance imaging of the cervicothoracic vertebrae, that show a flattening of the T1 vertebral body (vertebra plana), with an anteroposterior cortical bulge, resulting from the paravertebral soft tissue mass lesion (a-e). This lesion exerts an anterior mass effect upon tracheal and esophageal, as well as, posterior elements causing a significant compromise of the spinal canal (a-c, f). The lesion measures roughly 5 x 4 x 4.8 cm (transverse, AP, and CC diameters). The lesion displays intermediate to low signal intensity and intermediate signal intensity in the T1 and T2-weighted image, respectively, relative to gray matter. The lesion demonstrates homogenous enhancement with the epidural enhancing component (b, e, f). A focal cystic area is seen within the lesion tracing along the right exiting neural foramina at the same level (f). However, disc spaces are spared (a-e).
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F2
T1-weighted images and intermediate signal intensity on T2-weighted images with heterogeneous enhancement after gadolinium administration. The lesion affected the anterior and posterior longitudinal ligaments without significant compromise of the thecal sac (Fig. 2).
Follow-up post-operative images. (a) Plain CT scan of cervical spine on sagittal plane. (b) Cervicothoracic spine X-ray considered from the lateral view. Both images demonstrate status post complete T1 vertebra distraction with debulking of proven giant cell tumor by histopathology with applied anterior and posterior fixation hardwares.
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F3
T1 level with spondylectomy, as well as resection of a paravertebral soft tissue component of the tumor and decompression of the spinal cord, followed by anterior placement of a surgical plate and screws at C7-T2 levels. The 2nd stage (posterior approach) involved bilateral laminectomy and excision of the remaining tumor soft tissue extension, followed by spinal hardwire (cage) fixation at C6-T4 levels (Fig. 3).
Histopathological confirmation: Microscopic examination (Hematoxylin & Eosin staining) revealed (a) sheets of polygonal to oval mononuclear cells showing cytologically benign nuclei, in a background of abundant evenly distributed multinucleated osteoclast-like giant cells having numerous nuclei similar to the mononuclear cells' nuclei. (b) Intravascular plugs by giant cells (arrow). (c) Focus of necrosis (arrow). (d) Several mitotic figures (arrows). (e) Focal areas of fibrosis are also seen (arrows).
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F4
The diagnosis of GCT was confirmed with histopathologic and immunohistochemical examination for specific GCT markers (Fig. 4, 5).
Immunohistochemical studies: (a) Immunohistochemical studies revealed that mononuclear tumor cells are diffusely positive for SMA (smooth muscle actin) (b-d) but negative for CD34, CD68 and P63. (b) CD34 highlights delicate vascular network in the background. (c) CD68 highlights multinucleated giant cells. (e) Mononuclear tumor cells showed moderate proliferative activity (10-15% of tumor cells are positive for Ki67).
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F5
The diagnosis of GCT was confirmed with histopathologic and immunohistochemical examination for specific GCT markers (Fig. 4, 5).