脊柱腫瘤和腫瘤樣病變

1、脊柱腫瘤和腫瘤樣病變spinal bone tumor and tumor-like conditions,,脊柱腫瘤發(fā)生率,骨腫瘤占全身腫瘤0.4%脊椎腫瘤占骨腫瘤10%以下,概述,良性腫瘤：血管瘤,骨樣骨瘤,骨母細胞瘤,巨細胞瘤惡性腫瘤：脊索瘤, 骨髓瘤，淋巴瘤，轉移瘤腫瘤樣病變: 嗜酸性肉芽腫,動脈瘤樣骨囊腫,血管瘤,Hemangioma,最常見的脊柱原發(fā)良性腫瘤，約占全部血管瘤的14%，其中90%位于胸、腰椎構成：低

2、血壓慢血流薄壁血管、脂肪基質、存留骨小梁毛細血管型和海綿狀血管型任何年齡均可發(fā)生，一般無癥狀，多女性對放射線有相當的敏感性,臨床病理,X線表現:,椎體橫行骨小梁吸收,縱行骨小梁增厚.呈柵欄狀或網格狀。,CT表現:,椎體呈圓點花紋狀改變—病灶呈低密度溶骨區(qū)，境界清晰，增厚的骨小梁呈多數圓點狀高密度，周圍可有軟組織腫塊。增強掃描很少出現強化或輕度強化。,MRI表現:,病灶T1WI，T2WI呈斑點或條狀高信號或等信號，增粗的骨小梁T1W

3、I, T2WI均呈低信號。,T12,骨樣骨瘤,Osteoid Osteoma,臨床病理,由成骨細胞及骨樣組織構成由瘤巢和周圍硬化兩部分組成；瘤巢較小，直徑< 2厘米 10%發(fā)生于脊柱，56%于腰椎，最常起于椎弓單發(fā)性，腫瘤發(fā)展極慢 ，有自限性好發(fā)于20歲以下青少年患骨疼痛，夜間加重，服用水楊酸類藥物可緩解為其特點。治療以用手術切除最為適宜,預后良好,影像表現,X線腫瘤所在部位骨質破壞，偶見內鈣化/骨化周圍不同

4、程度的反應性骨硬化CT類圓形的低密度骨破壞區(qū)，中央見不規(guī)則的鈣化骨化影周圍不同程度的反應性骨硬化環(huán)核素掃描腫瘤顯示明顯核素濃聚,FigA: Radiograph reveals a subtle lucent area (arrow) in a right articular mass.FigB: CT scan shows the nidus (large arrowheads) with a small central

5、area of calcification (small arrowhead) and minimal surrounding sclerosis. FigC: Radiograph of the resected specimen shows that the nidus was entirely removed (arrows).FigD: Posterior bone scan shows intense uptake of

6、 the radionuclide by the nidus (arrow),17, yr, M Osteoid osteoma of lamina at T-11,,,A,B,C,D,,骨樣骨瘤,瘤巢,,MRI 腫瘤未鈣化部分T1WI呈低至中等信號，T2WI呈高信號 鈣化及周圍硬化帶均呈低信號 增強后，病變強化明顯。,骨母細胞瘤,Osteoblastoma,,臨床病理,“巨大骨樣骨瘤” ，膨脹性生長，直徑

7、為2cm～10cm血管豐富，較大者可有囊變，少數夾雜動脈瘤樣骨囊腫組織約40%發(fā)生于脊柱，頸、胸、腰椎發(fā)病率相近, 常累及附件20～30歲，男性多于女性水楊酸類藥物無緩解和無明顯夜間疼痛治療應手術切除，復發(fā)率為10~15 %,X-Ray 及 CT a：中心低密度，周圍骨硬化，病灶直徑大于1.5cm（類似骨樣骨瘤）b：膨脹性低密度區(qū)內磨玻璃樣密度升高或骨化，周圍伴硬化緣c：為侵襲性表現，膨脹溶骨性破壞，周圍軟組織浸潤

8、和混雜性鈣化,影像表現,MRI非鈣/骨化部分T1WI呈低至中等信號,T2WI呈高信號, 鈣/骨化部分呈低信號周圍骨髓和軟組織反應性充血水腫，為長T1長T2信號可顯示骨殼中斷，椎管內延伸和脊髓受壓合并動脈瘤樣骨囊腫時可見囊腔及液液平面 核素掃描腫瘤顯示明顯核素濃聚,影像表現,Fig.A L radiograph,Fig.B CT,Fig.D Sag. T2WI,Fig.C Axi. T1WI,Lateral x-ray

9、films (a) showed a soft-tissue swelling in the retropharyngeal space. Lateral (b) and coronal (c) MR images demonstrating tumor in the C-2 body and a soft-tissue mass from C1–6.Axial CT scan (d) demonstrating a typical

10、osteoid nidus with peritumoral sclerotic rim on the right side of the C-2 body. Technetium bone scan (e) also displays pronounced uptake in this region. We performed tumor excision via an anterolateral retropharyngeal a

11、pproach (f) occipitocervical fixation by using two axis plates and titanium wires (g). Lateral x-ray films obtained immediately after (h) and 2 years postsurgery (i) showing solid fusion.,10, yr, M osteoblastoma of C2

12、,骨母細胞瘤,骨巨細胞瘤,Giant Cell Tumor, GCT,臨床病理,由單核基質細胞和多核巨細胞構成，潛在惡性組織學分三級：Ⅰ級為良性，Ⅱ級為過渡型，Ⅲ級為惡性多發(fā)生于20~40歲成年人好發(fā)于骺板愈合后的骨端，股骨下端及脛骨上端最常見約7%發(fā)生于脊柱，最常累及骶骨多全切治療，若僅刮除術約40~60%復發(fā),影像表現,X線早期為偏心性溶骨破壞，骨皮質膨脹變薄后期可有壓縮性骨折伴軟組織腫塊CT偏心性囊狀膨脹性溶骨性

13、破壞，伴骨膜反應和軟組織腫塊，部分邊緣可見硬化內部可見骨性間隔及液-液平面，骨化及鈣化少見，發(fā)生于骶骨時，一般位于骶髂關節(jié)附近增強掃描實性成分中重度強化,MRI膨脹性多囊性骨質破壞T1WI上呈低、中等信號；T2WI上呈不均勻低、中、高混雜信號；可見局部出血信號；周邊有一低信號環(huán)，相當于輕度硬化邊,影像表現,脊索瘤,Chordoma,臨床病理,起源：殘留或異位脊索組織，低度惡性。發(fā)病年齡：多見于50--70歲。發(fā)病部位：顱底

14、（35%），骶尾椎（55%）和脊柱（10%）。生長緩慢，局部侵襲性，少轉移，偶遠處轉移, 主要為肺、淋巴結、蛛網膜下腔和脊髓,影像表現,X線腫瘤為溶骨性膨脹性破壞，可伴有軟組織腫塊瘤內50-70%見鈣化，且形態(tài)不一起病于骶尾部的腫瘤，多位于下部骶椎骶椎以上節(jié)段患骨較少膨脹改變，并可出現硬化呈“象牙椎”表現,影像表現,CT發(fā)生于顱底者呈大片狀或溶冰樣骨破壞發(fā)生于骶尾部者多呈膨脹性骨質破壞伴有境界清楚的軟組織腫塊病變區(qū)不規(guī)

15、則鈣化多見增強，輕至中度強化,影像表現,MRIT1WI：低、等信號T2WI：高強信號，不規(guī)則低信號鈣化、殘留骨及血管流空影增強：明顯強化或輕度強化MRI在顯示病變侵及的范圍方面優(yōu)于CTCT在確定腫瘤的性質特點方面優(yōu)于MRI,Fig.ALateral radiograph shows destruction of the distal sacrum and coccyx with calcification (arrow).

16、Fig.BCT scan also demonstrates the bone destruction and a soft-tissue mass (arrowheads) containing calcifications (arrow). .,Chordoma of lower sacrum 48-year-old man,Fig.A,Fig.B,脊索瘤,Fig.C T1WI Sagittal and axial T2WI

17、Fig.DMR images reveal the expansile sacrococcygeal lesion (arrowheads), which has high signal intensity on D.,Fig.C,Fig.D,脊索瘤,Fig.E As seen in this sagittal section of the gross specimen, the MR imaging appearance corre

18、lates with the expansile lesion (arrowheads) and calcification (arrow). The upper sacrum (*) is spared,脊索瘤,Upper Left and Right: Axial CT scans demonstrating a large soft-tissue mass extending anteriorly to involve the

19、rectum and posteriorly to invade the buttocks; calcification is seen within the mass. Lower Left and Right: Sagittal fast spin echo T2-weighted and axial T2-weighted MR images demonstrating the lesion infiltrating the p

20、resacral region, extending to surround the rectum and the perivesical fat but not invading the bladder.,24-yr Mchordoma involving S3-5,脊索瘤,chordoma,Fig.A,Fig.B,脊索瘤,殘存椎間盤形成的“分節(jié)”現象,Fig.ALateral radiograph shows a dense ve

21、rtebral body (arrows) at L-3. Fig.BSagittal reconstructed CT scan obtained after initial open biopsy reveals not only the L-3 sclerosis but also similar findings in the superior aspect of L-4 (arrowheads).,Chordoma of L

22、 13-year-old man,1-yr history of intermittent low back pain.,Fig.A,Fig.B,脊索瘤,Sagittal T1WI Fig.Cand T2WIFig.D MR images better delineate the marrow involvement at L-3 and L-4 with extension through the disk (arrows)

23、. The mass has marked high signal intensity on d.,Fig.C,Fig.D,Fig.Egross specimen depicts the extent of the neoplasm, with diffuse involvement of L-3 (arrowheads), the adjacent disk (*), and the superior aspect of L-4

24、(arrows).,Fig.E,脊索瘤,骨髓瘤,Myeloma,臨床病理,起源于紅骨髓的惡性腫瘤高分化型(小細胞型)：漿細胞型骨髓瘤 低分化型(大細胞型)：網狀細胞型骨髓瘤椎體為其好發(fā)部位，絕大多數為多發(fā)；單發(fā)少見，且約1/3可轉變?yōu)槎喟l(fā)。晚期可廣泛轉移。40歲以上常見，男:女＝2:1表現為骨骼疼痛，軟組織腫塊，病理性骨折實驗室檢查—血沉加快、尿B-J蛋白、貧血等。,影像表現,X線

25、廣泛性骨質疏松多發(fā)性骨質破壞：穿鑿狀、鼠咬狀、蜂窩狀、皂泡狀軟組織腫塊：位于破壞區(qū)周圍，很少跨越椎間盤水平至鄰近椎旁骨質硬化：少見，又稱硬化型骨髓瘤。平片約10%正常表現,影像表現,CT較X線平片更好的顯示骨質改變和軟組織異常MRI對骨髓變化非常敏感長T1長T2信號改變STIR序列病變高信號較T2WI更明顯,Fig. Multiple plasmacytomas with cord compression.a Sag

26、ittal T1WI (left) andbSTIR (right) MRI of thoracic spine show scattered focal lesions involving vertebral bodies and posterior elements of thoracic spine. Bothc transverse and sagittal (a, left) MRI show cord compressio

27、n by a focal expansile mass (arrow) at the T10 spinous process.,,,a,b,c,多發(fā)漿細胞瘤,Myeloma of T5-T7,T2WI,T1WI,T1WI+C,T1WI STIR T2WI STI

28、R,轉移性骨腫瘤,Secondary Tumor or Metastatic Tumor,臨床病理,脊柱轉移常見轉移途徑主要是血行轉移，少數直接蔓延原發(fā)腫瘤常包括：前列腺癌、腎癌、甲狀腺癌、乳癌、肺癌和鼻咽癌等。骨肉瘤、尤文瘤和淋巴瘤也可發(fā)生骨轉移患者51～60歲最多,轉移性骨腫瘤影像表現,X線溶骨型、成骨型和混合型CT能顯示局部軟組織腫塊的范圍、大小及鄰近臟器的關系MRI多數腫瘤T1WI呈低信號，T2WI呈程度不高的高

29、信號脂肪抑制序列顯示更清楚,sclerotic metastases,Fracture,,mass,,Figure. Sagittal T1-weighted MR image of the lumbosacral spine shows multiple hypointense foci within the sacrum and lumbar vertebrae. These lesions remained hypointens

30、e with all of the MR imaging sequences and did not exhibit enhancement. Plain radiography revealed sclerotic metastases.,77-yr F,Metastatic breast cancer,Fig.A : Sagittal T2-weighted MR image demonstrating involvement o

31、f the posterior elements of L-3 (arrow). Fig.B : Axial T1-weighted MR image revealing the L-3 spinous process and lamina infiltrated by tumor, with anterior structures intact (arrow). Fig.c: Bone scan demonstrating num

32、erous additional sites of metastatic disease (ribs, skull, and scapula) in addition to L-3 (arrow). The patient underwent simple posterior decompression.,54-yr M,metastatic renal cell carcinoma,,,A,B,C,肺Ca骨轉移,骨外NHL骨轉移,脊

33、椎骨髓瘤與轉移瘤鑒別：,椎體破壞+軟組織腫塊傾向骨髓瘤椎體破壞+廣泛性骨質疏松傾向骨髓瘤。椎體破壞伴椎弓及附件早期破壞傾向轉移瘤。,動脈瘤樣骨囊腫,Aneurysmal Bone Cyst, ABC,臨床病理,原因不明的腫瘤樣病變，分原發(fā)和繼發(fā)性可繼發(fā)于骨巨細胞瘤、骨母細胞瘤、軟骨母細胞瘤和骨肉瘤等由大小不等的海綿狀血池組成，外壁為薄壁囊狀骨殼好發(fā)于10～20歲的青少年脊柱占12-30％，胸椎最常受累；病變位于椎弓及其突起

34、可行刮除植骨術，還可栓塞治療和放療；總的復發(fā)率為20-30%,影像表現,X線脊柱附件骨膨脹性囊狀透亮區(qū)，薄骨殼囊內可有骨小梁狀分隔或骨嵴CT囊狀膨脹性骨破壞軟組織腫塊、不規(guī)則鈣化，邊緣可有硬化液-液平面，下部密度高于上部,MRI檢出液-液平面更敏感液-液平面是本病的重要特點，T2WI上層一般為高信號，可能為漿液或高鐵血紅蛋白，下層為低信號，可能有含鐵血黃素成分。核素掃描常表現為外周部位的核素攝取增加，呈“油炸圈餅”征

35、,T1WI C+,T1WI,T2WI,T1WI C+,骨嗜酸性肉芽腫,Eosinophilic Granuloma,骨嗜酸性肉芽腫 臨床病理,組織細胞增生癥X包括：勒-雪病、黃脂瘤病和嗜酸性肉芽腫。其孤立形式為嗜酸性肉芽腫，為良性局限性組織細胞增生，為最輕型。單發(fā)病灶以顱骨多見；多發(fā)病變以椎體最常見好發(fā)于兒童及青年，發(fā)展緩慢，自限性,影像表現,發(fā)展迅速的膨脹性或溶骨性病變，常導致椎體變扁和硬化，稱扁平椎。平片即可容易診斷，CT及