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20b - Answer: A 19-year-old female with new diagnosis of leukemia

David Yousem MBA, MD
David M Yousem, MBA, MD
Professor of Radiology, Vice Chairman and Associate Dean
Includes DICOM files

Learn more about this case by reading the case report below. Additional instruction is provided in the Case Summary section of the course.

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Case Report

CHEST CT REPORT

HISTORY: 19-year-old female with new diagnosis of leukemia. Evaluate for infection.

TECHNIQUE: Helical CT chest without contrast was performed. Multiplanar reformats provided.

COMPARISON: None

FINDINGS:

CHEST:  
Scout view of the abdomen shows enlarged cardiac silhouette.
Lungs, airways, and pleura: Minimal dependent atelectasis. Paraspinal soft tissue thickening (for example 2-61 and 2-27), which may be extending into the spinal canal. No focal consolidation or effusion. No suspicious pulmonary nodules. Minimal debris in the trachea.


Heart and great vessels: Moderate cardiomegaly. No pericardial effusion.
Lymph nodes: No gross lymphadenopathy on this unenhanced scan.
Thyroid: No abnormalities in the partially visualized thyroid.
Esophagus: No abnormalities.

INCOMPLETELY VISUALIZED UPPER ABDOMEN:
No abnormalities.

MUSCULOSKELETAL:
Chest/upper abdominal wall: No abnormalities.
Bones: No abnormalities.

IMPRESSIONS:

  1. No evidence of infection in the chest.
  2. Paraspinal soft tissue thickening which may be extending into the spinal canal. This may be due to extramedullary hematopoiesis or leukemic infiltration. However, consider thoracic spine MRI with contrast for further evaluation and to evaluate for tumor infiltration.

MRI OF LUMBAR SPINE W/WO CONTRAST

Indication: 19-year-old female with acute myeloid leukemia. Paresthesias and urinary hesitancy, concern for leptomeningeal spread.  
 
Technique: Sagittal T1 weighted, sagittal T2 weighted, sagittal STIR, axial T1 weighted, and axial T2 weighted scans were performed through the lumbar spine. Post contrast scans after administration of 7.9 mL intravenous gadolinium contrast agent were also performed
 
Findings:  
The conus medullaris has normal signal intensity and terminates at an appropriate level.  
 
The alignment of the vertebral bodies is unremarkable. However the bone marrow signal intensity is abnormal throughout the lumbar, sacral, iliac bone.  
 
No evidence for spondylolisthesis.  
 
There is slight loss of height of the L4-5 disc space. Broad-based mild disc herniation of the L4-L5 disc space without significant spinal canal narrowing. There is subtle loss of signal intensity at this level, compatible with disc desiccation.  
Intervertebral disc spaces otherwise unremarkable and with preserved height.  
 
There is no significant spinal canal stenosis or neural foraminal narrowing noted at any level within the lumbar spine.  
 
Soft tissue is seen in the epidural fat associated with the posterior elements at the L2, L3, and L5 levels in the epidural space. In addition the anterior epidural soft tissues at the L4 and L5 levels and in the sacral region also show soft tissue masses. The soft tissue masses extend to the S3 level and possibly posteriorly at the S4 level at the edge of the imaging plane. For further evaluation a sacrococcygeal MRI scan would be required. There is also minimal paraspinal soft tissue seen along the lower lumbar vertebrae from L3 downward. Soft tissue is also present in the left neural foramen at the L1-2 level extending into a left paraspinal location.  
 
The sacrum and iliac bones show abnormal signal intensity.  
 
IMPRESSIONS:  

Extraosseous soft tissue extension of leukemia at multiple posterior epidural and anterior epidural locations throughout the lumbar spine from L1 through the lowest most visualized S4 segment. Foraminal involvement is greatest at the left L1-2 level and  paraspinal involvement is greatest on the left side at L1-2 as well but extends throughout the lumbar levels.  

BONE MARROW INTERPRETATION NOTE

Date of Procedure: 12/22/2017

DIAGNOSIS: AML

The aspirated specimen is adequate for interpretation.  The specimen is sparsely cellular. Megakaryocytes are absent.  Megakaryocytes appear not evaluable.  

The M:E ratio appears increased.

Myeloid maturation is abnormal: increased blasts.

Erythroid maturation is normal.

Comments about myeloid or erythroid maturation: None

Plasma cell number:  Normal.

Plasma cell morphology:  Normal.

Lymphocyte cell number:  Normal.

Lymphocyte cell morphology:  Normal.

Comments about plasma cell or lymphoid development:  None

Other elements identified: None

IMPRESSION:

Evidence of - leukemia appears myeloid. Please correlate with flow and biopsy.

LESSON 5, TOPIC 15

Case Challenge: Spine MRI Cases - I-MED Study

Content reviewed: May 12, 2022