IIDA, HIROKAZU

KASHIWAGI, NAOYA

SHIKATA, JITSUHIKO

YAMAMURO, TAKAO

Kyoto University Research Information Repository

Title Calcification of Spinal Cord Tumors : Report of Two CasesAuthor(s)SHIKATA, JITSUHIKO; YAMAMURO, TAKAO; IIDA,HIROKAZU; KASHIWAGI, NAOYACitation日本外科宝函 (1989), 58(1): 140-146Issue Date1989-01-01URL http://hdl.handle.net/2433/203851RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jpn Chir 58(1), 140～146, Jan., 1989 症例Calcification of Spinal Cord Tumors: Report of Two Cases jITSL'.HIKOメ1IIKAT1¥, TAKλ（） ＼＇λMλML"RO, HIROKλzL・ Imーし日nd NAOYλKA~lll\VAGI Department of Orthopedic Surgery, Kyoto University Received for Publication, Oct. 21, 1988. Summary Two cases of calcification of spinal cord tumors were detected by computed tomography and magnetic resonance imaging. The first; a 27-year-old male, with a very rare astrocytoma accompanied by calcification of the thoracic spinal cord, and the second; a 62-year-old female, with a rare calcified neurilemmoma in the upper cervical extradural space. The purpose of this paper is to draw attention to the fact that some spinal cord tumors occasionally contain areas of calcification, and review the literature on this subject. Introduction Tumors of the spinal cord, especially those showing calcification are extremely r日re. Our report deals with two such cases, astrocvtoma and neurilemmoma, in which calcification was accurately diagnosed preoperatively using imaging te「hniques, such as computed tomography and magnetic resonance imaging. Case Report Case 1: 27-year-old male present肌lwith gait disturbance. Weakness in the lower ex・ tremities appeared in December, 1979, causing the patient to limp. In July, 1981, he noticed decreased sensitivity in the right thigh, and began using crutches due to weakness of the right knee. In October, myelography performed at another hospital suggested a spinal cord tumor. He was admitted to our hospital for surgery on December 2nd. On admission, muscular atrophy in the right thigh, marked footdrop and pes cavus as well as spastic gait were observed町The deep tendon reflexes were exaggerated bilaterally, and Babinski’s sign, as well as patelar and ankle clonus were observed on the right side. The cremasteric reflex was totally absent Kev words: Calci品cation，討pinalcord tumor, Astrocytoma, Neurilemmoma. 索引語：石灰化，脊髄腫蕩，星状細胞腫，神経鞘腫Present addr円 b I l"partment of Orthopedic討urgery,Faculty of Medicine, Kyoto University, 54 Kawara cha, Shogoin, Sakyo-ku, Kyoto 606, Japan. CALCIFICATION OF SPINAL CORD TUMORS: REPORT OFT＼＇＼’0 CASES 141 Fig. 1 Computerized tomographic metrizamide myelogram showing the spinal cord swelling and calci五edcore (arrow) at T5・T6.on the right side, as was the lower abdominal reflex・ A decreased sensitivity to pain and temperature was noted between T5・TlOon the right, as well as a loss of sensitivity to touch and vibration in the region below T9. Roentgenograms revealed moderate scoliosis of the thoracic spine and日 wideningof the inter-pedicular distance between T2 and T8. :Vfyelography showed a marked swelling of the spinal cord from Tl to T8, while computed tomography after myelography revealed calcification, at the T5-T6 level (Fig. 1). Laminectom¥' of the first to eighth thoracic vertebrae was performed, and on opening the dura, the cord was seen to be swollen from CZ to C7. 人fterm¥'elotomy from T4 to T7, as much as possible of the intramedullary tumor was removed. The resected tumor was dark brown to yellowish white in color, and contained two calcified cores. Histopathologicalh・, a diagnosis of astrocytoma (Grade I ) was made. Post-operatively, the weakness in the lower extremities gradually disappeared and there is no sign of any recurrence. Case 2: A 62-year-old female presented with a dull pain in the left nuchal region, which she first noticed in 1977. In 1980, she developed motor disturbance in her left hand, and then in 1983, repeated tinnitus aurium started to occur. ~he ¥aS admitted to our hospital on November 14, 1985. Ro巴ntgenogramsand myelograms revealed marked enlargement of the intervertebral foramen at Cl-CZ on the left side (Fig. 2). （＇，】mputerizedtomographic metrizamide myelography (Fig. 3), and magnetic resonance imaging (Fig. 4) showed an extradural, dumbbell-type tumor on the left side at the Cl-C2 level, causing compression of the spinal cord. Cal-142 日外宝 第58巻 第1号（昭和64年1月）刊州議Zみ〉サ日Fig. 2 Roentgenogram and myelogram showing marked enlargement of the intervertebral foramen (white arrow) at Cl-C2, and spinal cord compress10n. cified cores were also found within the part of the tumor protruding from the inter-vertebral foramen. Laminectomy of the first to second cervical vertebrae and total resection of the tumor, along with that portion of the dura to which it tightly adhered, was performed. Histopatho-logically, the specimen displayed the characteristics of Antoni type A neurilemmoma, having dense spindle-shaped cells and aggregates of palisading nuclei. The post-operative course was uneventful, and the patient’s condition returned to normal, there being no further neurological symptoms. Discussion Advances in high resolution computed tomography and magnetic resonance imaging, have made possible the de五nitivedeagnosis of spinal cord lesions. Radiographic demonstration of calcification within spinal canal tumors is rare2). The most common type of lesion showing calcification is the meningioma6•7•13•15i, but calcification is also occasionally found in teratoma10≫ angioma3りglioblastoma9',ganglioneuroma w and hemangioma 19人 Calcificationassociated with neurilemmoma2•4•7•11•18) and astrocytoma5りhowever,is an extremely rare condition. EPSTEIN5) reported two children with intramedullary astrocytoma showing calci五cation,which was observed histologically but not radiographically. Our Case 1, is a very rare calcified thoracic spinal cord astrocytoma, discovered by computerized tomographic metrizamide myelography. KALAN8) CALCIFICATION OF SPINAL CORD TUMORS: REPORT OF T、，yoCASES 143 .PL tumor Fi邑.3 Illustration and computerized tomographic metrizamide myelogram showing an extradural dumbbell-type tumor on the left side at C2, C3, causing compression of the spinal cord. Calcified cores (arrows) were also found within the extraspinal canal tumor. reported that calcified areas are usually present within gliomas having a benign histologic appearance. Furthermore, he showed that there was a longer interval between the development of clinical symptoms and surgery, in those cases with calcification, than for patients in whom it was not present. KUBOTA9> reported that for his case of glioblastoma, it was reasonable to assume that it was an originally benign astrocytoma manifesting areas of calcification. The neurilemmoma is a slow growing, smoothly encapsulated tumor that may occur along a nerve root at any level of the craniospinal axis. Intradurally, it arises most frequently at the posterior nerve roots in the dorsal region16> Most of these tumors (67箔） are intrad ural in location, with only 16箔 beingentirely extradural17>. Radiographically demonstrable calci-fication within spinal neurilemmoma is rare, and it has even been said that it does not occur11•17>. Histologically, spinal and intracranial neurilemmoma are similar, showing variable proportions of interwoven bundles of long, bipolar spindle cells (Antoni type A), and loose-textured tissue (Antoni type B). In addition to cyst formation, other known secondary changes include, 144 日外宝第58巻第1号（昭和64年1月）Fi昌4 Magnetic resonance image showing the tumor (surrounded by small 、hitearrows), and calci五edcores (black arrows) within it. xanthomatnus degeneration, vascular thrombosis, and dystrophic calcification16'. Our case was Antoni type A, and ¥'as remarl王ablein that the tumor had centers of calci五cation.GR企主II with an intradural extramedullary tumor of the cauda equina. There was also a description of an extrad ural tumor in the cervical spine by BONSTELLE2'. These were both demonstrated histologically, but not radiologically. One case of radiographically demonstrable calcification of an intraclural extrameclullary neurilemmoma was reported by SHIMMEL18' DROSS引 reportedthe first case of a calcified, thoracic, extraclural neurilemmoma, which he demonstrated by computed tomographic myelography. Our Case 2, is the first reported case of a calci五ed,cervical, extrad ural neurilemmoma as demonstrated by magnetic resonance imaging, and is CALCIFICATION OF SPINAL CORD TUMORS: REPORT OF TもV<l CASES 145 only th巴 secondreport, to our knowledge, of tumor calcification within the cervical spine. The mechanism underlying the formation of calci五edareas within tumors of the central nervous system, is as yet not understood. MARTIN12> divid巴dpatients with calcified intracranial neoplasms into four main categories, on the basis of their histological patterns: (1) calci自cationswithin the blood vessel walls, in which small globules or calcospherites initially emerge within the adventitia or media of the small vessels; (2) calcium deposits in necrotic areas adjacent to blood vessels; (3) calcium salts in an area of old hemorrhage or necrosis; and (4) (a) calcific globules within tumor cells, (b) calcific changes within the stroma of the tumor or its capsule, or (c) calci五cchanges in the tumor periphery not related to types (a) or (b). He stated that pattern (1) is the most frequently encountered. Ultrastructural studies of various tumors imply that areas of calc1五cationoriginate from the mitochondria and or the matrix vesicls. KUBOTA9> also suggested, that calci五cationsin the blood vessels of the spinal cord gliomas, may derive from matrix vesicles or matrix giant bodies, and that they may be ascribable to degenerated cells within the blood vessel walls. Our report deals with two rare cases of calci白cationin spinal cord tumors detected by computed tomography and m乱gneticresonance imaging. ¥'Ve hope that in future, computed tomography and magnetic resonance imaging will help to further d巴lineatethese faintly calcified spinal cord tumors, which cannot be seen on plain roentgenograms alone. References 1. Anderson HC: Calci五cationprocess. Pathol Annu 15: 45-75, 1980. 2. Bonstelle CT., Vines FS: Calci五cationin込町rvicalintraspinal neurilemmoma. N euroradiology 10: 231-233, 1976. 3. Deeb ZL, Rosenbaum AE, Bensy ]J, et al.: Calci自edintramedullary aneurysm in spinal angioma. Neuroradiology. 14: 1 3,1977. 4. Dross PE, Raji MR: CT myelography of calci五edthoracic neurilemmoma. AJNR 6: 967-968, 1984. 5. Epstein F, Epstein N: Surgical management of holocord intramedullary spinal cord astrocytomas in children. Report of three cases. J. N eurosurg 54: 829-832, 1981. 6. Garfinkle W, Yudo AP: Calcified intraspinal meningioma detected by computed tomography. Computerized Radiology 6: 305-307, 1982. 7. Graham DI, Bond MR: Intradural spinal ossifying schwannoma. J. Neurosurg 36: 487 489, 1972. 8. Kalan C, Burrows EM: Calci凸cationin intracranial gliomata. Brit. J. Radio! 35: 589-602, 1962. 9. Kubota T, Kogure Y, Yamamoto S, et al.: Calci凸cationin glioblastoma multiforme of the cervical spinal cord. Surg. N eurol. 26: 183-186, 1986. 10. Lemmen LG, Wilson CM: Intramedullary malignant teratoma of the spinal cord. Arch. Neurol. Psychiatry 6: 61-68, 1961. 1. Lombardi G, Passerini A: Spinal cord tumors. Radiology 76: 381 391, 1961. 12. Martin F, Limmen LG: Calc1五cationin intracranial neoplasms. Am J Pathol 28: 1107 1131, 1952. 13. Memmon MY, Schneck L: Ventral spinal tumor; the value of computed tomography in its localization. Neurosurgery 8: 108-111, 1981. 14. Nakagawa H, Huang VP, Malis LI, et al.: Computed tomography of intraspinal and paraspinal neoplasma. J. Comput Assist Tomogra 1: 377 390, 1977. 15. Pear BL, Boyd HR: Roentgenographically visible calc1五cationsin spinal meningioma. Amer J Roenrgen 120: 32-45, 1974. 16. Russell DS, Rubinstein LG: Pathology of Tumors of the nervous system. London, Edward Arnold, ed. 3, 286-294, 1971. 146 日外宝第58巻第1号（昭和64年1月）17. Shapiro R: Myelography, 3d ed. Chicago. Year Book Medical. 300-309, 1975. 18.メιhimmelDH, Newton TH: Calcification within a thoracic neurilemmoma. N euroradiology 8: 5『56, 1974. 19. Tyndel FG, Bilbao JM, Hudson AR, et al.: Hernangioma calcifications of the spinal cord. Can. ]. Neurol. Sci・12:321-322, 1085. 和文抄録石灰化を伴った脊髄腫虜 2例京都大学整形外科四方貰彦，山室隆夫，飯田寛和，柏木直也石灰化を伴う脊髄腫蕩は稀な疾患であり，中でも画 症例2: 62才，女性．昭和52年＇（左項部の膨陵 lζ気像診断Kて石灰化を術前l己確認し得た例は極めて稀で づいたが，特lζ症状もなく放置していた．昭和58年頃ある．今回我々は術前画像診断にて石灰化を確認し得 より，難聴をきたす様になり， 昭和60年11月， CT,た脊髄腫蕩の2例を経験したので報告する． Myelography, CTM, MRIの結果，頚髄の腫蕩と診断症例1: 27才，男性．昭和54年12月より，右下肢の し，昭和61年1月10日腫蕩摘出術を施行した．病理組脱力を覚え，歩行障害をきたす様になった．昭和56年 織診断は neurilemmomaであった．10月より，歩行障害が増悪した.Myelography, CTM 石灰化を伴う脊髄腫蕩の報告は，現在まで astrocy・fCて髄内腫蕩を疑い，昭和57年1月12日，腫蕩摘出術 torn a: 2例， neurilemmoma: 4例が見られるのみを施行した．病理組織診断は astrocytorna,grade I であり，極めて稀なものである．であった．

石灰化を伴った脊髄腫瘍2例

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石灰化を伴った脊髄腫瘍2例

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