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(xì)胞瘤,巨細(xì)胞瘤 惡性腫瘤：脊索瘤, 骨髓瘤，淋巴瘤，轉(zhuǎn)移瘤 腫瘤樣病變: 嗜酸性肉芽腫,動(dòng)脈瘤樣骨囊腫 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(gòu)成：低血壓慢血流薄壁血管、脂肪基質(zhì)、存留骨小梁 毛細(xì)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(dāng)?shù)拿舾行?臨床病理 ct表現(xiàn): 椎體呈椎體呈病灶呈低密度溶骨區(qū)，病灶呈低密度溶

2、骨區(qū)，境界清晰，增厚的骨小梁呈多數(shù)圓點(diǎn)狀高密度，境界清晰，增厚的骨小梁呈多數(shù)圓點(diǎn)狀高密度，。增強(qiáng)掃描很少出現(xiàn)強(qiáng)化或。增強(qiáng)掃描很少出現(xiàn)強(qiáng)化或輕度強(qiáng)化。輕度強(qiáng)化。mri表現(xiàn): 病灶t1wi，t2wi呈斑點(diǎn)或條狀高信號(hào)或等信號(hào)，增粗的骨小梁t1wi, t2wi均呈低信號(hào)。t12臨床病理 由成骨細(xì)胞及骨樣組織構(gòu)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(diǎn)。 治療以用手術(shù)切除最為適宜,預(yù)后良好影像表現(xiàn) x線 腫瘤所在部位骨質(zhì)破壞，偶見內(nèi)鈣化

3、/骨化 周圍不同程度的反應(yīng)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(yīng)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 area of calcification (small arrowhead) and minimal surrounding sclerosis.

4、 figc: radiograph of the resected specimen shows that the nidus was entirely removed (arrows).figd: posterior bone scan shows intense uptake of the radionuclide by the nidus (arrow) 17, yr, m osteoid osteoma of lamina at t-11 mri 腫瘤未鈣化部分t1wi呈低至中等信號(hào)，t2wi呈高信號(hào) 鈣化及周圍硬化帶均呈低信號(hào) 增強(qiáng)后，病變強(qiáng)化明顯。臨床病理 “巨大骨樣骨瘤” ，膨脹

5、性生長，直徑為2cm10cm 血管豐富，較大者可有囊變，少數(shù)夾雜動(dòng)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 2030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(yīng)手術(shù)切除，復(fù)發(fā)率為1015 % 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(nèi)磨玻璃樣密度升高或骨化，周圍伴硬化緣 c：為侵襲性表現(xiàn)，膨脹溶骨性破壞，周圍軟組織浸潤 和混雜性鈣化影像表現(xiàn) mri 非鈣/骨化部分t1wi呈低至中等信號(hào),t2wi呈高信號(hào), 鈣/骨化部分呈低信號(hào) 周圍骨髓和軟組織反應(yīng)性充血水腫，為長t1長t2信號(hào)

6、 可顯示骨殼中斷，椎管內(nèi)延伸和脊髓受壓 合并動(dòng)脈瘤樣骨囊腫時(shí)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(xiàn)fig.a l radiographfig.b ctfig.d sag. t2wifig.c axi. t1wilateral x-ray 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 fro

7、m c16.axial ct scan (d) demonstrating a typical 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 approach (f) occipitocervical fixa

8、tion 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 臨床病理 由單核基質(zhì)細(xì)胞和多核巨細(xì)胞構(gòu)成，潛在惡性 組織學(xué)分三級(jí)：級(jí)為良性，級(jí)為過渡型，級(jí)為惡性 多發(fā)生于2040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(shù)約4

9、060%復(fù)發(fā)影像表現(xiàn) x線 早期為偏心性溶骨破壞，骨皮質(zhì)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破壞，伴骨膜反應(yīng)和軟組織腫塊，部分邊緣可見硬化 內(nèi)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(shí)，一般位于骶髂關(guān)節(jié)附近 增強(qiáng)掃描實(shí)性成分中重度強(qiáng)化 mri 膨脹性多囊性骨質(zhì)破壞 t1wi上呈低、中等信號(hào)；t2wi上呈不均勻低、中、高混雜信號(hào)；可見局部出血信號(hào)；周邊有一低信號(hào)環(huán)，相當(dāng)于輕度硬化邊影像表現(xiàn)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（35%），骶尾椎（55%）和脊柱（10%）。 生長緩慢，局部侵襲

10、性，少轉(zhuǎn)移，偶遠(yuǎn)處轉(zhuǎn)移, 主要為肺、淋巴結(jié)、蛛網(wǎng)膜下腔和脊髓影像表現(xiàn) x線 腫瘤為溶骨性膨脹性破壞，可伴有軟組織腫塊 瘤內(nèi)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(xiàn)硬化呈“象牙椎”表現(xiàn)影像表現(xiàn) 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(zhì)破壞 伴有境界清楚的軟組織腫塊 病變區(qū)不規(guī)則鈣化多見 增強(qiáng)，輕至中度強(qiáng)化影像表現(xiàn) mri t1wi：低、等信號(hào) t2wi：高強(qiáng)信號(hào)，不規(guī)則低信號(hào)鈣化、殘留骨及血管流空影 增強(qiáng)：明顯強(qiáng)化或輕度強(qiáng)化 mri在顯示病變侵及的范圍方面優(yōu)于ct ct在確定腫瘤的性質(zhì)特點(diǎn)方面優(yōu)于mr

11、ifig.alateral radiograph shows destruction of the distal sacrum and coccyx with calcification (arrow). fig.bct scan also demonstrates the bone destruction and a soft-tissue mass (arrowheads) containing calcifications (arrow). . chordoma of lower sacrum 48-year-old manfig.afig.b脊索瘤fig.c t1wi sagittal

12、 and axial t2wi fig.dmr images reveal the expansile sacrococcygeal lesion (arrowheads), which has high signal intensity on d. fig.cfig.d脊索瘤脊索瘤fig.e as seen in this sagittal section of the gross specimen, the mr imaging appearance correlates with the expansile lesion (arrowheads) and calcification (a

13、rrow). 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 rectum and posteriorly to invade the buttocks; calcification is seen within the mass. lower left and right: sagittal fast spin echo t2-weighted and

14、axial t2-weighted mr images demonstrating the lesion infiltrating the presacral region, extending to surround the rectum and the perivesical fat but not invading the bladder. 24-yr mchordoma involving s3-5脊索瘤chordomafig.afig.b脊索瘤脊索瘤殘存椎間盤形成的“分節(jié)”現(xiàn)象fig.alateral radiograph shows a dense vertebral body (

15、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 13-year-old man1-yr history of intermittent low back pain.fig.afig.b脊索瘤sagittal t1wifig.cand t

16、2wifig.d mr images better delineate the marrow involvement at l-3 and l-4 with extension through the disk (arrows). the mass has marked high signal intensity on d. fig.cfig.dfig.egross specimen depicts the extent of the neoplasm, with diffuse involvement of l-3 (arrowheads), the adjacent disk (*), a

17、nd the superior aspect of l-4 (arrows).fig.e脊索瘤臨床病理 起源于紅骨髓的惡性腫瘤 高分化型(小細(xì)胞型)：漿細(xì)胞型骨髓瘤 低分化型(大細(xì)胞型)：網(wǎng)狀細(xì)胞型骨髓瘤 椎體為其好發(fā)部位，絕大多數(shù)為多發(fā)；單發(fā)少見，且約1/3可轉(zhuǎn)變?yōu)槎喟l(fā)。晚期可廣泛轉(zhuǎn)移。 40歲以上常見，男:女2:1 表現(xiàn)為骨骼疼痛，軟組織腫塊，病理性骨折 實(shí)驗(yàn)室檢查血沉加快、尿b-j蛋白、貧血等。影像表現(xiàn) x線 廣泛性骨質(zhì)疏松 多發(fā)性骨質(zhì)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(zhì)硬化：少見，又稱硬化型骨髓瘤。 平片約10%正常表現(xiàn)影

18、像表現(xiàn) ct 較x線平片更好的顯示骨質(zhì)改變和軟組織異常 mri 對骨髓變化非常敏感 長t1長t2信號(hào)改變 stir序列病變高信號(hào)較t2wi更明顯fig. multiple plasmacytomas with cord compression.a sagittal t1wi (left) andbstir (right) mri of thoracic spine show scattered focal lesions involving vertebral bodies and posterior elements of thoracic spine. bothc transverse a

19、nd sagittal (a, left) mri show cord compression by a focal expansile mass (arrow) at the t10 spinous process.abcmyeloma of t5-t7 t1wi stir t2wi stir臨床病理 脊柱轉(zhuǎn)移常見 轉(zhuǎn)移途徑主要是血行轉(zhuǎn)移，少數(shù)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(zhuǎn)移 患者5160歲最多轉(zhuǎn)移性骨腫瘤影像表現(xiàn) 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(guān)系 mri 多數(shù)腫

20、瘤t1wi呈低信號(hào)，t2wi呈程度不高的高信號(hào) 脂肪抑制序列顯示更清楚sclerotic metastasesfigure. sagittal t1-weighted mr image of the lumbosacral spine shows multiple hypointense foci within the sacrum and lumbar vertebrae. these lesions remained hypointense with all of the mr imaging sequences and did not exhibit enhancement. plain

21、 radiography revealed sclerotic metastases.77-yr fmetastatic breast cancerfig.a : sagittal t2-weighted mr image demonstrating involvement of 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 numerous additional sites of metastatic disease (ribs, skull, and scapula) in addition to l-3 (arrow). the patient underwent simple posterior decompression.54-yr