PMC8202362_01
Preoperative X-ray showing sclerosis of L4 vertebral body
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F1
Plain radiograph of the lumbosacral spine revealed a mild reduction in the height of the L4 vertebral body with sclerosis [Figure 1].
(a and b) Sagittal T1 and T2 weighted magnetic resonance imaging respectively showing heterogenous signal intensity and mild collapse of L4 vertebral body with extradural collection compressing the dura, (c) Sagittal STIR sequence showing hyperintense lesion involving L4 body with extension into the epidural space, (d) Axial T2 weighted magnetic resonance imaging showing near complete occlusion of the spinal canal
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F2
Cauda Equina and filum terminale [Figure 2a-d]. Contrast MRI showed homogenous enhancement of the lesion in the L4 body and the canal [Figure 3a-c].
(a-c) Contrast magnetic resonance imaging showing homogenous enhancement of the lesion in L4 body with extension into the spinal canal, pre vertebral and paravertebral region
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Cauda Equina and filum terminale [Figure 2a-d]. Contrast MRI showed homogenous enhancement of the lesion in the L4 body and the canal [Figure 3a-c].
Postoperative X-ray at 1 month follow up showing the implants in situ without further collapse of L4
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F4
He underwent L3-5 posterior spinal instrumentation with pedicle screws and rods and posterior spinal decompression at stenotic level [Figure 4].
(a-c) Sagittal T2, Sagittal T1 and axial T2 weighted magnetic resonance imaging respectively at the end of one month following initial surgery showing increase in the lesion and wide involvement of the L4 body and extension of the lesion into the spinal canal
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F5
MRI of the lumbar spine revealed increase in the soft tissue component compared to the previous report extending from L3 to L5 vertebra causing complete canal stenosis along with pre and para vertebral involvement [Figure 5a-c].
Intraoperative image showing friable tissue engulfing the dural sac during revision procedure
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Positron emission tomography (PET) computed tomography revealed increased fluorodeoxyglucose uptake in the L4 body and in the prevertebral, paravertebral regions and in the spinal canal [Figure 6].
Positron emission tomography computed tomography showing increased fluorodeoxyglucose uptake in the L4 body and in the pre, para vertebral regions and in the spinal canal
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F7
Intra operatively, we found extensive friable tissue engulfing and surrounding the dura at L4 vertebral level for which extensive debulking was carried out [Figure 7].
HPE showing epitheloid cells with deeply stained eosinophilic cytoplasm and intercellular deposition of hyalinised collagen
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Many cells showed prominent cells with the epithelioid appearance and eosinophilic nuclei with adjacent lymphoid cells [Figure 8].
Immunohistochemistry showing cells positive for Epitheloid Membrane Antigen
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Subsequently, the tissue was also subjected to IHC in which the tumor cells were positive for Vimentin and Epithelioid Membrane Antigen (EMA), thereby reconfirming the diagnosis of Epithelioid Sarcoma [Figure 9].