N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g • P i c t o r i a l E s s ay Smith et al. Pediatric Intramedullary Spinal Neoplasms

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Neuroradiology/Head and Neck Imaging Pictorial Essay

CME SAM

Alice Boyd Smith1,2 Karl A. Soderlund 3 Elisabeth J. Rushing2 James G. Smirniotopolous1,2 Smith AB, Soderlund KA, Rushing EJ, Smirniotopolous JG

Radiologic–Pathologic Correlation of Pediatric and Adolescent Spinal Neoplasms

Radiologic-Pathologic Correlation of Pediatric and Adolescent Spinal Neoplasms: Part 1, Intramedullary Spinal Neoplasms OBJECTIVE. The purpose of this article is to review the neuroimaging findings of pediatric and adolescent intramedullary spinal tumors in children. The differential diagnosis for lesions in this location is limited and can be further narrowed with knowledge of specific imaging characteristics. CONCLUSION. This article reviews the radiologic findings and differential diagnosis for intramedullary neoplasms. After completing this article, the reader should have an improved understanding of the types of neoplastic processes that can involve this region of the pediatric spine.

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Keywords: intramedullary, MRI, neuroradiology, pediatric spinal neoplasm DOI:10.2214/AJR.10.7311 Received November 16, 2010; accepted after revision May 9, 2011. All authors have no financial relationships to disclose. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Air Force, Army, Navy, or Defense. 1 Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, MD. 2 Department of Radiologic Pathology, Armed Forces Institute of Pathology, 6825 16th St. NW, Washington, DC 20306-6000. Address correspondence to A. B. Smith ([email protected]). 3 Department of Radiology and Radiological Sciences, National Naval Medical Center, Bethesda, MD.

CME/SAM This article is available for CME/SAM credit. AJR 2012; 198:34–43 0361–803X/12/1981–34 © American Roentgen Ray Society

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ediatric intramedullary neoplasms encompass the same tumors that affect adults, as well as more primitive neoplasms that only occur in childhood. These lesions arise within the spinal cord and include astrocytomas, ependymomas, and gangliogliomas. This pictorial essay reviews the imaging characteristics of intramedullary spinal neoplasms in the pediatric population. Intramedullary Neoplasms Neoplasms of the spinal cord account for less than 10% of all pediatric central nervous neoplasms [1, 2]. Two glial tumors (astrocytoma and ependymoma) make up the majority of the intramedullary neoplasms, together accounting for approximately 90% of such neoplasms [3]. These neoplasms affect all age groups, but more frequently occur in children around the end of the first decade, and lack sex predilection. These tumors typically grow slowly and frequently present with vague symptoms and nonspecific findings, often resulting in a prolonged period between symptom onset and diagnosis. Back pain is the most common symptom and occurs in up to 67% of patients [4]. The pain is usually diffuse in nature and worsens when the patient is in the horizontal position, leading to the complaint of nighttime pain. Any child presenting with back pain should undergo assessment for a potential spinal neoplasm [3, 4]. Progressive scoliosis may be seen, and, if the neoplasm aris-

es near the cervicomedullary junction, lower cranial nerve palsies may result. In younger children, symptoms include motor regression and frequent falls. Hydrocephalus has been reported in up to 15% of patients, but the cause is not completely understood [5]. Intramedullary neoplasms result in expansion of the spinal cord and narrowing of the surrounding CSF space (Fig. 1). If there is abnormal signal or attenuation, but no cord expansion is present, a nonneoplastic process, such as demyelination, infarction, myelomalacia, or infection, should be considered [1]. Both tumoral and nontumoral cysts are frequently associated with intramedullary lesions. It is important to distinguish between the two cyst types, because tumoral cysts may result from necrosis, fluid secretion, or degeneration of the neoplasm. Tumoral cysts need to be resected along with the solid portion of the tumor because there is a high likelihood of neoplastic cells within the cyst wall. Nontumoral cysts are located at the cranial or caudal pole of the neoplasm and may resolve once the neoplasm is resected. Tumoral cysts show peripheral enhancement (Fig. 2), whereas peritumoral cysts do not [1]. Many of these neoplasms grow slowly, and as a consequence, the spinal canal may remodel around the lesion, resulting in canal widening and scalloping of the posterior aspect of the vertebral body. MRI is the imaging modality of choice because of its excellent soft-tissue contrast and lack of ionizing radiation. Treatment of many of these neoplasms

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remains controversial, but evidence indicates that microsurgical resection is the best option, with adjunctive treatment being reserved for recurrences or high-grade lesions [6]. Astrocytomas Astrocytomas arise from astrocytic glial cells and account for up to 60% of pediatric intramedullary tumors [1, 2]. Patients typically present with pain and motor dysfunction but may also show gait disturbance, scoliosis, and torticollis. There is an association with neurofibromatosis type 1. The most common histologic subtypes are pilocytic astrocytomas (World Health Organization [WHO] grade I) and fibrillary astrocytomas (WHO grade II). Glioblastoma (WHO grade IV) rarely occurs in the spine, accounting for only 0.2–1.5% of cord astrocytomas [3]. On histologic evaluation, fibrillary astrocytomas show widespread parenchymal infiltration with variable degrees of nuclear atypia and increased cellularity. Similar to cerebral astrocytomas, the presence of mitoses warrants the “anaplastic” designation (WHO grade III). Pilocytic astrocytomas tend to displace rather than infiltrate the cord (Fig. 3). Histologically, they are often biphasic with dense and looser areas. Pilocytic astrocytomas generally lack mitotic figures and other high-grade features and may harbor Rosenthal fibers (intracytoplasmic proteinaceous inclusions) and thickened vascular walls. Astrocytomas usually have a vertical extent less than four vertebral body segments in length. Holocord involvement may occur, especially with pilocytic astrocytomas [1]. In most cases, the neoplasm usually involves a portion of the cord, and nonneoplastic rostral and caudal cysts involve the remainder. True holocord involvement by the entirety of the tumor mass is rare but may occur [7]. CT may show canal widening and scalloping of the vertebral bodies. MRI reveals low T1 signal and increased T2 signal. Contrastenhanced imaging typically shows irregular enhancement (Fig. 4), although lack of enhancement has been reported in up to 30% of intramedullary astrocytomas [8]. The enhancement tends to be less intense and less sharply demarcated than that seen in ependymomas. Because of the infiltrative nature of grade II–IV astrocytomas, intraspinal fiber tracts may be disrupted, and this can be evaluated with diffusion-tensor imaging. Unlike intracranial astrocytomas, enhancement may be present regardless of grade. Higher-grade astrocytomas typically have

poorly defined margins, whereas pilocytic astrocytomas are almost always well circumscribed. Astrocytomas are sometimes associated with intratumoral and polar cysts. Because they arise from the cord parenchyma, astrocytomas typically are eccentric in location. Unlike ependymomas, hemorrhage is an uncommon feature. CSF dissemination may occur, especially with the higher grade neoplasms, but it has also been reported with pilocytic astrocytomas [9]. Therefore, imaging of the entire neuroaxis is indicated. Surgical excision is the treatment of choice, and prognosis is related to the grade of the astrocytoma. Resection is almost always histologically incomplete, but nearly total resection is associated with a long progression-free survival (up to 95% 5-year survival for grades I and II). Five-year survival among patients with grades III and IV remains low. In patients with neurologic dysfunction preoperatively, the risk for neurologic deterioration is increased [6]. Ependymomas Ependymomas arise from the ependymal cells lining the central canal and, therefore, are frequently located centrally within the cord. This central location explains the more frequently observed sensory symptoms that result from the close proximity to the spinothalamic tracts. These tumors are the second most common intramedullary neoplasm in the pediatric population and represent 30% of pediatric intramedullary spinal neoplasms [3]. They occur sporadically but may also be associated with neurofibromatosis type 2, in which case, multiple intramedullary ependymomas may be present. Most ependymomas are histologically benign and well demarcated and compress the adjacent cord rather than infiltrating it (Fig. 5A). There are four histologic subtypes of CNS ependymomas: cellular, papillary, clear cell, and tanocytic. The cellular form is the most common intramedullary variant. On histologic evaluation, perivascular pseudorosettes are the cardinal histologic feature (Fig. 5B), and there is moderate cellularity with low mitotic activity. Unenhanced CT shows canal widening, scoliosis, and vertebral body scalloping. On MRI, ependymomas appear typically as central well-circumscribed iso- or hypointense lesions on T1-weighted imaging and as isoor hyperintense on T2-weighted imaging (Fig. 6). Because of their compressive rather than infiltrative nature, a cleavage plane may

occasionally be seen on imaging. Diffusiontensor imaging may show how the tumors displace the fiber tracts rather than interrupt them. Contrast enhancement is variable and may be homogeneous or heterogeneous, but some degree of enhancement is typically seen. A rim of low signal along the border of the neoplasm, referred to as the “cap sign,” may be seen on T2-weighted images (Fig. 7). This occurs in approximately 20% of cases and represents hemosiderin deposition secondary to intratumoral hemorrhage [10]. When present, the cap sign is highly suggestive of ependymoma. Ependymomas also commonly have polar cysts, but intratumoral cysts are less common than with astrocytomas [1, 3]. CSF dissemination rarely occurs, but when seen, is more commonly associated with higher-grade tumors. The prognosis for patients with spinal ependymoma depends on the tumor grade, degree of resection, and presence or absence of CSF dissemination. Gross total resection may be achieved in approximately 50% of cases, and in those patients, the 5-year survival rate is close to 85%. For patients with less than gross total resection, the 5-year survival rate is approximately 57% [11]. Gangliogliomas Gangliogliomas were once thought to be very rare, but they are now known to account for up to 15% of intramedullary neoplasms in the pediatric age group [12]. They are composed of a combination of neoplastic ganglion cells and glial elements. Gangliogliomas typically grow slowly and are low grade (I–II) but have a high likelihood of local recurrence after resection. On histology, these neoplasms show large cells that potentially represent neurons with atypical features, such as abnormal orientation and binucleation (Fig. 8). In addition, eosinophilic granular bodies, stromal desmoplasia, calcification, and lymphoplasmacytic infiltrates are often seen. On imaging, scoliosis and remodeling are common but nonspecific findings [12]. Calcification may be seen on CT, but it is much less common than in gangliogliomas that occur intracranially [1]. Gangliogliomas have highly variable MRI findings and may be indistinguishable from astrocytomas, but Patel et al. [13] described several clinical and imaging findings that are characteristic of gangliogliomas: young patient age, long tumor length, tumoral cysts, absence of edema, mixed signal intensity on T1-weighted imaging (resulting from dual cellular elements of

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the tumor), patchy tumor enhancement, and cord surface enhancement (Fig. 9). Gangliogliomas are typically eccentrically located. Surgical resection is the treatment of choice. After resection, there is a 5-year survival rate of 89% [14]. Hemangioblastomas Hemangioblastomas are benign (WHO grade I) capillary-rich neoplasms. The majority of these lesions are intramedullary (75%), but they can also be within the intradural space or even extradural [1] (Fig. 10). Hemangioblastomas make up less than 10% of spinal tumors and only rarely occur in children. They occur sporadically or are associated with von Hippel–Lindau (VHL) syndrome in approximately one third to one half of cases. Multiple tumors should raise the suspicion for VHL syndrome. In pediatric patients with hemangioblastomas, screening for mutations in the VHL gene (chromosome 3) is recommended [1, 15]. These neoplasms are slow growing and may present with sensory changes, pain, and motor dysfunction. Spinal hemangioblastomas are usually intramedullary; however, they may be intradural extramedullary when they arise from spinal nerve roots. They typically arise along the cervical and thoracic cord. In pediatric patients with hemangioblastomas, screening for mutations in the VHL gene (chromosome 3) is recommended [15]. Gross examination reveals a red-to-orange well-circumscribed nodular lesion. On histology, large vacuolated stromal cells are embedded within a rich capillary network. These lesions do not undergo malignant degeneration. Angiography of the spine shows a prominent vascular blush with a feeding artery and draining vein. On unenhanced CT, hemangioblastomas appear as a hypoattenuating cystic mass. On MRI, hemangioblastomas are well-circumscribed nodular masses with variable T1 intensity (most commonly isointense), prominent enhancement with gadolinium, and hyperintensity on T2-weighted imaging. Flow voids, adjacent cysts, and hemorrhage are also common findings (Fig. 11). The signal within the cyst may vary depending on the protein content within the cyst fluid. A syrinx may be present, and there may also be long segment cord edema without syrinx. The imaging differential diagnosis would include arteriovenous malformations, hypervascular cord neoplasms, and cavernous malformations. Hemangioblastomas are usually treated by surgical resection. Endovascular emboliza-

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tion may be performed before resection to decrease blood loss. Radiosurgery and gamma knife have been used for treatment of tumors that are not surgically resectable [16, 17]. Primitive Neuroectodermal Tumors Primitive neuroectodermal tumors (PNETs) are aggressive embryonal tumors with the capacity for differentiation along neuronal astrocytic, ependymal, melanotic, or muscular lines [18]. Spinal PNETs are rare, and most cases are secondary to metastatic spread through the CSF from a primary intracranial tumor [1]. PNETs are aggressive neoplasms, and local recurrence and leptomeningeal spread commonly occur. PNETs involving the spine in children occur at an older age than those that occur intracranially and are most commonly found in young adults [19]. PNETs can be intramedullary, extramedullary intradural, or extradural in location. Histologically, they are composed of closely apposed small round blue cells that sometimes form rosettes. Because of the rarity of these neoplasms, consistent imaging findings have not been described. On MRI, PNETs show diffuse heterogeneous enhancement, and because CSF seeding commonly occurs, leptomeningeal enhancement may be seen (Fig. 12). Prognosis is poor, and most patients die within 2 years despite surgical resection and postoperative treatment with chemotherapy and radiation therapy. Atypical Teratoid/Rhabdoid Tumors Spinal atypical teratoid/rhabdoid tumors (ATRTs) are very rare highly cellular malignant neoplasms of uncertain origin. ATRTs most commonly occur in children younger than 2 years, but the oldest reported patient was 43 years old [20, 21]. They may be either intramedullary or intradural extramedullary. The term “rhabdoid” reflects the histologic similarity of the tumor to cells seen in rhabdomyosarcoma that have abundant eosinophilic cytoplasm and eccentric nuclei. Imaging findings of ATRT are nonspecific, but in cases reported thus far, they have an imaging appearance similar to those of intracranial ATRTs and PNETs [22]. They are variable in appearance on MRI because of variable degrees of necrosis, hemorrhage, and calcification. They are iso- or hypointense on T2-weighted imaging because of hemorrhage, and they heterogeneously enhance with gadolinium [20, 22]. Cord expansion and edema are common findings (Fig. 13). High signal on

diffusion-weighted imaging with low apparent diffusion coefficient values have been reported and most likely representing the highly cellular nature [23]. CNS dissemination occurs and may be seen at the time of diagnosis; therefore, imaging of the entire neuroaxis is required. Prognosis is poor, and most patients die within 1 year [24]. Metastatic Disease Intramedullary metastases very rarely occur and result from hematogenous spread or direct extension from the leptomeninges. The presence of intramedullary disease carries a poor prognosis. Conclusion Intramedullary neoplasms are uncommon in the pediatric and adolescent population and have a limited differential diagnosis. Knowledge of specific imaging characteristics of the intramedullary neoplasms helps to further narrow the differential diagnosis. References 1. Koeller KK, Rosenblum RS, Morrison AL. From the archives of the AFIP: neoplasms of the spinal cord and filum terminale—radiologic-pathologic correlation. RadioGraphics 2000; 20:1721–1749 2. Wilson PE, Oleszek JL, Clayton GH. Pediatric spinal cord tumors and masses. J Spinal Cord Med 2007; 30(suppl 1):S15–S20 3. Huisman TA. Pediatric tumors of the spine. Cancer Imaging 2009; 9(spec no A):S45–S48 4. Wilne S, Walker D. Spine and spinal cord tumours in children: a diagnostic and therapeutic challenge to healthcare systems. Arch Dis Child Educ Pract Ed 2010; 95:47–54 5. Rifkinson-Mann S, Wisoff JH, Epstein F. The association of hydrocephalus with intramedullary spinal cord tumors: a series of 25 patients. Neurosurgery 1990; 27:749–754 6. Kothbauer KF. Neurosurgical management of intramedullary spinal cord tumors in children. Pediatr Neurosurg 2007; 43:222–235 7. Schittenhelm J, Ebner FH, Tatagiba M, et al. Holocord pilocytic astrocytoma: case report and review of the literature. Clin Neurol Neurosurg 2009; 111:203–207 8. Seo HS, Kim JH, Lee DH, et al. Nonenhancing intramedullary astrocytomas and other MR imaging features: a retrospective study and systematic review. AJNR 2010; 31:498–503 9. Abel TJ, Chowdhary A, Thapa M, et al. Spinal cord pilocytic astrocytoma with leptomeningeal dissemination to the brain: case report and review of the literature. J Neurosurg 2006; 105(suppl 6):508–514

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Pediatric Intramedullary Spinal Neoplasms 10. Nadkarni TD, Rekate HL. Pediatric intramedullary spinal cord tumors: critical review of the literature. Childs Nerv Syst 1999; 15:17–28 11. Benesch M, Weber-Mzell D, Gerber NU. Ependymoma of the spinal cord in children and adolescents: a retrospective series from the HIT database. J Neurosurg Pediatr 2010; 6:137–144 12. Rossi A, Gandolfo C, Morana G, Tortori-Donati P. Tumors of the spine in children. Neuroimaging Clin N Am 2007; 17:17–35 13. Patel U, Pinto RS, Miller DC, et al. MR of spinal cord ganglioglioma. AJNR 1998; 19:879–887 14. Lang FF, Epstein FJ, Ransohoff J, et al. Central nervous system gangliogliomas. Part 2: Clinical outcome. J Neurosurg 1993; 79:867–873 15. Vougioukas VI, Glasker S, Hubbe U, et al. Surgical treatment of hemangioblastomas of the central nervous system in pediatric patients. Childs Nerv

Fig. 1—8-year-old girl with pilocytic astrocytoma. Coronal T1-weighted image shows hypointense lesion resulting in expansion of thoracic cord with narrowing of adjacent CSF space. Scoliosis is also present.

Syst 2006; 22:1149–1153 16. Asthagiri AR, Mehta GU, Zach L, et al. Prospective evaluation of radiosurgery for hemangioblastomas in von Hippel-Lindau disease. Neuro-oncol 2010; 12:80–86 17. Tago M, Terahara A, Shin M, et al. Gamma knife surgery for hemangioblastomas. J Neurosurg 2005; 102(suppl):171–174 18. Hrabalek L, Kalita O, Svebisova H, et al. Dumbbell-shaped peripheral primitive neuroectodermal tumor of the spine: case report and review of the literature. J Neurooncol 2009; 92:211–217 19. Albrecht CF, Weiss E, Schulz-Schaeffer WJ, et al. Primary intraspinal primitive neuroectodermal tumor: report of two cases and review of the literature. J Neurooncol 2003; 61:113–120 20. Bambakidis NC, Robinson S, Cohen M, Cohen AR. Atypical teratoid/rhabdoid tumors of the cen-

tral nervous system: clinical, radiographic, and pathologic features. Pediatr Neurosurg 2002; 37:64–70 21. Zarovnaya EL, Pallatroni HF, Hug EB, et al. Atypical teratoid/rhabdoid tumor of the spine in an adult: case report and review of the literature. J Neurooncol 2007; 84:49–55 22. Moeller KK, Coventry S, Jernigan S, Moriarty TM. Atypical teratoid/rhabdoid tumor of the spine. AJNR 2007; 28:593–595 23. Niwa T, Aida N, Tanaka M, et al. Diffusionweighted imaging of an atypical teratoid/rhabdoid tumor of the cervical spine. Magn Reson Med Sci 2009; 8:135–138 24. Rorke LB, Packer RJ, Biegel JA. Central nervous system atypical teratoid/rhabdoid tumors of infancy and childhood: definition of an entity. J Neurosurg 1996; 85:56–65

Fig. 2—13-year-old girl with pilocytic astrocytoma. Sagittal T1-weighted image reveals multiple rim-enhancing cystic areas (arrows) associated with more solid area of enhancement (asterisk). Presence of rim enhancement suggests that these are intratumoral cysts. Also, note expansion of spinal canal and mild scalloping of C4 posterior vertebral body.

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Smith et al.

Fig. 3—3-year-old boy with pilocytic astrocytoma. A, Sagittal T2-weighted image shows hyperintense expansile intramedullary lesion with associated edema (arrow) that extends superiorly into medulla. B, Sagittal contrast-enhanced T1weighted image reveals patchy enhancement of tumor. C, Intraoperative photograph shows cleavage plane (arrow) between tumor and spinal cord.

A

Fig. 4—12-year-old girl with glioblastoma. A, Sagittal T2-weighted image reveals mild cord expansion and ill-defined T2 signal prolongation involving cervical cord. B, Sagittal T1-weighted contrast-enhanced image shows patchy ill-defined enhancement.

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Fig. 5—20-year-old man with ependymoma. A, H and E stain of cross-section of spinal cord. Cleavage plane (arrow) is noted between cord and ependymoma (asterisk). B, H and E stain reveals tumor cells with round to oval nuclei. Perivascular pseudorosettes (arrows) are characteristic finding in ependymomas.

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Fig. 6—18-year-old woman with ependymoma. A, Sagittal T2-weighted image shows well circumscribed mass lesion (arrow) with heterogeneous signal. Lesion results in scalloping of posterior aspect of vertebral body and expansion of canal. There is extensive syrinx, resulting in only thin rim of thoracic cord. B, Contrast-enhanced sagittal T1-weighted image shows relatively homogeneous enhancement. Enhancement is associated with cystic areas immediately superior and inferior to mass, suggesting that these are polar cysts.

Fig. 7—28-year-old man with ependymoma with “cap sign.” Sagittal STIR image shows rim of low signal (arrow) along inferior aspect of tumor, consistent with hemosiderin.

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Fig. 8—18-year-old woman with ganglioglioma. H and E stain reveals multiple large cells (asterisk), potentially representing dysplastic neurons.

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Fig. 9—21-year-old man with ganglioglioma. A, Sagittal T1-weighted image shows heterogeneous-appearing expansile lesion involving thoracic cord. More superior aspect of tumor shows slightly increased T1 signal. B, Sagittal T2-weighted image with fat saturation reveals region of low signal intensity, most likely reflecting calcification seen on histology. C, Sagittal T1-weighted contrast-enhanced image reveals heterogeneous enhancement of tumor. More distal aspect of ganglioglioma has only faint enhancement. D, H and E stain shows numerous concentric calcifications (arrows).

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Pediatric Intramedullary Spinal Neoplasms

Fig. 10—19-year-old woman with hemangioblastoma. A, Intraoperative photograph shows bright red (i.e., vascular) intramedullary lesion. Prominent vessels are noted along surface of cord. B, H and E stain reveals rich capillary network with large vacuolated stromal cells interspersed between.

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Fig. 11—16-year-old boy with hemangioblastoma. A, Catheter angiogram reveals markedly vascular lesion along upper cervical cord. B, Sagittal T2-weighted image reveals large T2hyperintense lesion (arrow) along upper aspect of cervical spine with adjacent flow voids. Cyst is located just superior to mass. There is widening of upper cervical cord, which shows T2 signal prolongation and cystic-appearing areas. (Fig. 11 continues on next page)

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Fig. 11 (continued)—16-year-old boy with hemangioblastoma. C, Sagittal T1-weighted contrast-enhanced imaging shows avid enhancement of solid portion of lesion. D, Intraoperative photograph reveals reddish mass (asterisk) with associated cyst and prominent surrounding vessels (arrow).

Fig. 12—14-year-old boy with primitive neuroectodermal tumor. A, Sagittal T1-weighted contrast-enhanced image shows enhancing mass (arrow) involving thoracic cord. In addition, there is diffuse intradural enhancement due to CSF dissemination. B, Axial T1-weighted contrast-enhanced image reveals marked intracranial leptomeningeal enhancement and mild hydrocephalus.

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Pediatric Intramedullary Spinal Neoplasms

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Fig. 13—4-year-old boy with atypical teratoid/rhabdoid tumor. A, Sagittal T2-weighted image shows heterogeneous expansile mass involving upper cervical cord. Foci of T2 signal shortening (arrows) are present consistent with hemorrhage. B, Sagittal T2-weighted image reveals layering (arrow) in distal thecal sac secondary to hemorrhage. C, Sagittal T1-weighted image shows foci of T1 signal shortening within and adjacent to lesion consistent with hemorrhage. D, Sagittal T1-weighted contrast-enhanced image shows lesion enhancement.

F O R YO U R I N F O R M AT I O N

This article is part of a self-assessment module (SAM). Please also refer to “Radiologic-Pathologic Correlation of Pediatric and Adolescent Spinal Neoplasms: Part 2, Intradural Extramedullary Spinal Neoplasms,” which can be found on page 44. Each SAM is composed of two journal articles along with questions, solutions, and references, which can be found online. You can access the two articles at www.ajronline.org, and the questions and solutions that comprise the Self-Assessment Module via http://www.arrs.org/Publications/AJR/index.aspx. The American Roentgen Ray Society is pleased to present these SAMs as part of its commitment to lifelong learning for radiologists. Continuing medical education (CME) and SAM credits are available in each issue of the AJR and are free to ARRS members. Not a member? Call 1-866-940-2777 (from the U.S. or Canada) or 703-729-3353 to speak to an ARRS membership specialist and begin enjoying the benefits of ARRS membership today!

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