醫(yī)學(xué)影像學(xué)：骨和軟組織腫瘤7

Bone and Soft Tissue Tumor Bone and Soft Tissue Tumor and Tumor-like Diseaseand Tumor-like DiseaseRadiological examination is essential before any attempt at diagnosis of a bone tumor is made.The diagnosis of a bone tumor requires the cooperation of the clinician,radiologist and pathologist.Radiology provides the earliest useful diagnostic evidence of the nature of a bony lesion.Radiological assessment of bone tumors location,rate of growth,number，matrix mineralization,periosteal reaction,regularity of the margin,soft tissue mass age of presentation，incidence rate，symptom and physical sign，the result of laboratory examinationDifferentiation of Benign Bone Tumors from the MalignantBenignBenignMalignantMalignantDevelopmentDevelopmentSlowly.No adjoining tissue Slowly.No adjoining tissue extension or only displacement extension or only displacement by pressuring.by pressuring.rapidly.Adjoining tissue or rapidly.Adjoining tissue or organs extensions common.organs extensions common.MetastasisMetastasisNoNoYesYesLocal bone Local bone changeschangesExpanding lesion with well-Expanding lesion with well-defined and sharp endosteal defined and sharp endosteal margin.Cortex thinned and margin.Cortex thinned and expanded with continuity.expanded with continuity.Permeating destructive pattern Permeating destructive pattern with ill-defined margin and with ill-defined margin and wide zone of transition.wide zone of transition.Adjacent cortex frequently Adjacent cortex frequently destroyed.Probable tumor bone destroyed.Probable tumor bone formation.formation.Reactive Reactive periosteal periosteal boneboneAbsence or presence after Absence or presence after pathological fracture without pathological fracture without destruction.destruction.Variousness frequently with Variousness frequently with destruction.destruction.Adjoining Adjoining soft tissue soft tissue changeschangesAbsence or mass with well-Absence or mass with well-defined margindefined marginPermeating soft tissue mass Permeating soft tissue mass with ill-defined margin.with ill-defined margin.Benign Bone Tumor生骨組織良性：骨樣骨瘤良性骨母細(xì)胞瘤骨樣骨瘤下肢脛骨和股骨骨干最多見(jiàn)。85%發(fā)生于骨皮質(zhì)。其他可見(jiàn)骨膜下，髓內(nèi)和關(guān)節(jié)內(nèi)多見(jiàn)于30歲以下的青少年，男性多于女性起病緩慢，常發(fā)病后數(shù)月至數(shù)年，因局部疼痛而就診。夜間和休息時(shí)加重。服用水楊酸類藥物后夜間和休息時(shí)加重。服用水楊酸類藥物后疼痛可緩解。為本病的特點(diǎn)之一疼痛可緩解。為本病的特點(diǎn)之一病 理由成骨細(xì)胞及其產(chǎn)生的骨樣組織所構(gòu)成。由成骨細(xì)胞及其產(chǎn)生的骨樣組織所構(gòu)成。由瘤巢和周圍硬化兩部分組成。瘤巢一般較小，呈圓形或卵圓形，由血管豐富的結(jié)締組織、放射狀骨樣小梁和不同程度的鈣化或骨化所構(gòu)成X線表現(xiàn)皮質(zhì)內(nèi)圓形或卵圓形的透亮區(qū)有時(shí)透亮區(qū)內(nèi)可見(jiàn)鈣化或骨化（“窩中生蛋”）周圍高密度的增生硬化環(huán)包繞有時(shí)會(huì)將真正的瘤巢覆蓋。需加深曝光或CT掃描發(fā)現(xiàn) 骨樣骨瘤和成骨細(xì)胞瘤鑒別骨樣骨瘤和成骨細(xì)胞瘤鑒別在病理上骨樣組織為主，骨母除骨樣組織外，富有骨母細(xì)胞病灶的大小:骨樣骨瘤直徑一般小于2cm而成骨細(xì)胞瘤直徑大于2cm前者無(wú)膨脹，硬化明顯，后者膨脹明顯，硬化輕至中度骨樣骨瘤有典型的夜間痛鑒別鑒別局限性骨膿腫：局部有紅腫熱痛，反復(fù)發(fā)作，多位于干骺端，破壞區(qū)內(nèi)無(wú)鈣化。增強(qiáng)掃描瘤巢有強(qiáng)化應(yīng)力性骨折：有長(zhǎng)期勞損病史，有好發(fā)部位，可顯示內(nèi)部的骨折線骨母細(xì)胞瘤又稱成骨細(xì)胞瘤，發(fā)病率低，少于1%為良性侵襲性病變，組織學(xué)結(jié)構(gòu)和骨樣骨瘤類似，富含有骨母細(xì)胞。腫瘤較大，超過(guò)2cm。無(wú)明顯的增生硬化和核心瘤巢好發(fā)年齡10-20歲，男女比例2：1。多發(fā)生于多發(fā)生于脊椎的橫突、棘突（30-44%），也可以蔓延到椎體；其次其次是是長(zhǎng)管狀骨，多見(jiàn)于干骺端或骨端，不侵犯骨骺。多見(jiàn)于股骨和脛骨（29%），手足骨常累及距骨距骨（18%），其他見(jiàn)于顱骨、肩胛骨、肋骨、髕骨、頜骨和骨盆。10-15%術(shù)后可復(fù)發(fā)，多次復(fù)發(fā)可惡變影像學(xué)改變脊柱：多見(jiàn)于頸椎的橫突和棘突，膨脹性骨破壞，邊緣清楚，周圍反應(yīng)性增生。破壞區(qū)內(nèi)不同程度斑片狀骨化影。椎體的病變多由附件蔓延所致管狀骨：沿骨干長(zhǎng)軸走向的橢圓形骨質(zhì)破壞區(qū)，內(nèi)有斑點(diǎn)狀、條索狀的鈣化或者骨化影，病灶邊緣清楚，有硬化邊，骨膜反應(yīng)少，多數(shù)偏心生長(zhǎng)，亦可中心生長(zhǎng)。診斷較難鑒別診斷骨樣骨瘤軟骨母細(xì)胞瘤ABC：均為膨脹性改變。骨母輪廓清晰，邊緣硬化，中央骨化單無(wú)分隔。短骨骨母膨脹明顯，更累似ABC，但短骨骨母好發(fā)，ABC少見(jiàn)生軟骨組織良性：u骨軟骨瘤u軟骨瘤內(nèi)生軟骨瘤骨膜軟骨瘤多發(fā)內(nèi)生軟骨瘤病u軟骨母細(xì)胞瘤osteochondroma最常見(jiàn)的良性骨腫瘤。分單發(fā)和多發(fā)，后者有遺傳傾向，且較前者更易發(fā)生惡變僅見(jiàn)于軟骨內(nèi)化骨的骨骼。以股骨下端和脛骨上端的干骺端最常見(jiàn)好發(fā)于兒童，常見(jiàn)于10-30歲，男女發(fā)病率相同早期一般無(wú)癥狀，局部可摸及一硬結(jié)病 理因基底形態(tài)不同分為帶蒂和廣基兩種瘤體由三部分組成：v外有包膜外有包膜包繞并與骨干骨膜相延續(xù)v腫瘤頂端有透明軟骨覆蓋腫瘤頂端有透明軟骨覆蓋，稱為軟骨帽，厚約1-6mm，軟骨帽的厚度與年齡相關(guān)，年齡越小，軟骨層愈厚v基底骨皮質(zhì)基底骨皮質(zhì)和骨干皮質(zhì)相延續(xù) 腫瘤中心為松質(zhì)骨和骨髓，與骨干的松質(zhì)骨和髓腔相通。在骨生長(zhǎng)停止后，腫瘤也中止生長(zhǎng) X線表現(xiàn)分單發(fā)和多發(fā)，后者導(dǎo)致的畸形突出。腫瘤起于干骺端，背離關(guān)節(jié)或垂直骨干生長(zhǎng)，隨骨骼生長(zhǎng)而移向骨干。腫瘤以廣基或蒂與母骨相連。母骨骨皮質(zhì)自骨干或干骺向腫瘤骨性基底遠(yuǎn)端延伸并逐漸變薄、止于軟骨帽。腫瘤中心部松質(zhì)骨也與母骨正常松質(zhì)骨或髓腔相互移行。腫瘤頂部為軟骨帽，可見(jiàn)點(diǎn)狀、環(huán)狀和不規(guī)則的鈣化。亦可完全骨化形成骨板。軟骨鈣化是判斷軟骨鈣化是判斷腫瘤生長(zhǎng)活躍的標(biāo)志。腫瘤生長(zhǎng)活躍的標(biāo)志。多發(fā)骨軟骨瘤約1%的骨軟骨瘤可惡變?yōu)檐浌侨饬?，極少為骨肉瘤惡變后表現(xiàn)為：惡變后表現(xiàn)為：v生長(zhǎng)緩慢或停止生長(zhǎng)的腫瘤突然生長(zhǎng)加速v軟骨帽增厚或突然出現(xiàn)大量不規(guī)則的鈣化v軟骨帽鈣化的密度變淡，邊緣不清，鈣化環(huán)殘缺不全或邊緣模糊v瘤體周圍出現(xiàn)軟組織腫塊 骨軟骨瘤惡變Osteochondroma軟骨瘤僅見(jiàn)于軟骨內(nèi)化骨的骨骼，病理認(rèn)為是骺板留下的軟骨細(xì)胞異常增殖所致。半數(shù)手足短管狀骨，半數(shù)手足短管狀骨，特別是手；其次股骨，肱骨，再次脛骨，肋骨，特別是手；其次股骨，肱骨，再次脛骨，肋骨，尺橈骨等。短管狀骨尺橈骨等。短管狀骨病變開(kāi)始與干骺端，向骨干蔓延，長(zhǎng)管狀骨病變常位于干骺端根據(jù)病變部位分為內(nèi)生性軟骨瘤（髓腔內(nèi)）和外生軟骨瘤（皮質(zhì)骨，骨膜下）好發(fā)年齡為10-50歲，男女發(fā)病相仿?lián)≡顢?shù)目分為單發(fā)性軟骨瘤和多發(fā)。多發(fā)性內(nèi)生軟骨瘤兒童發(fā)病，常表現(xiàn)為肢體粗短，發(fā)育不對(duì)稱。腫瘤與單發(fā)比較，膨大更明顯，鈣化，骨化少病變發(fā)生于單側(cè)時(shí)稱為Olliers disease合并肢體軟組織多發(fā)血管瘤成為MaffucciMaffuccis disease多發(fā)預(yù)后差，半數(shù)可發(fā)生惡變多發(fā)預(yù)后差，半數(shù)可發(fā)生惡變單發(fā)內(nèi)生軟骨瘤X線表現(xiàn)干骺端或骨干呈膨脹性骨破壞，鄰近皮質(zhì)變薄，邊緣凹凸不平或呈多弧狀內(nèi)可見(jiàn)點(diǎn)狀、環(huán)狀、弧線狀鈣化或骨化，軟骨鈣化軟骨鈣化是軟骨瘤的定性診斷是軟骨瘤的定性診斷周圍可有硬化，無(wú)骨膜反應(yīng)預(yù)后：短管狀骨很少惡變，長(zhǎng)骨有惡變傾向鑒別診斷短管狀骨結(jié)核：又稱骨氣臌，骨皮質(zhì)不完整，有骨膜反應(yīng)，周圍軟組織梭形腫脹，破壞區(qū)無(wú)鈣化骨囊腫：年齡輕，中央透亮，無(wú)鈣化軟骨母細(xì)胞瘤 又稱成軟骨細(xì)胞瘤。少見(jiàn)，占原發(fā)骨腫瘤的1%,多見(jiàn)于10-20歲，男女發(fā)病例基本相同。好發(fā)部位是長(zhǎng)骨骨骺區(qū)，以股骨、脛骨和肱骨多見(jiàn) 病理：其內(nèi)可見(jiàn)黃色沙礫樣鈣化，鏡下見(jiàn)軟骨母細(xì)胞和多核巨細(xì)胞，瘤內(nèi)可有出血、壞死和囊變影像特點(diǎn)多位于骺板閉合前的骨骺部骨骺部，可侵犯干骺端病灶較小病灶較小，圓形或橢圓形透亮區(qū)，可單房或多房性破壞，邊界清楚，輕中度膨脹，周圍可見(jiàn)硬化邊，內(nèi)見(jiàn)內(nèi)見(jiàn)斑點(diǎn)或半環(huán)狀鈣化可確診斑點(diǎn)或半環(huán)狀鈣化可確診病灶如穿破骨皮質(zhì)進(jìn)入軟組織，可出現(xiàn)軟組織影，要高度懷疑惡性的軟骨母細(xì)胞瘤鑒別診斷骨巨細(xì)胞瘤：發(fā)病部位類似，但巨細(xì)胞瘤年齡較大，病灶較大，內(nèi)部缺乏鈣化骨骺、干骺端結(jié)核：腫瘤破壞呈整塊，而結(jié)核多灶性破壞Giant Cell Tumor of BoneSite：About half the lesions are found either side of the knee joint.Age：almost 80%of patients are aged between 20 and 40 years.Giant Cell Tumor of BoneX-ray filmX-ray filmThe tumor is usually subcortical and related to the fused growth plate of a metaphysis.It thins the cortex,and periosteal reaction is rare in the absence of a pathological fracture.Soft tissue extention may occur in as many as 50%of cases,sometimes crossing the joint via an extracapsular route.Giant Cell Tumor of BoneThinning and destruction of the cortex is well shown by CT,CT,whilstwhilst MRI MRI will demonstrate the extent of medullary and extracortical spread and show any recurrence most clearly.The tumor is iso-or hypointense on T1WI and shows increased signal intensity on T2WI.Fluid-fluid levels may occasionally be seen.Giant Cell Tumor of Bone纖維結(jié)構(gòu)不良正常骨組織被異常增生的纖維組織所代替的一種疾病，病因和發(fā)病機(jī)理不明可發(fā)生于單骨、單側(cè)或多骨多發(fā)。單側(cè)多骨且同時(shí)并發(fā)皮膚色素沉著、性早熟等內(nèi)分泌紊亂，稱為Albright綜合征男性發(fā)病稍多于女性。11-30歲最多病變進(jìn)展緩慢。成年后停止發(fā)展，成熟期后的骨改變，主要是續(xù)發(fā)性彎曲畸形和骨的反應(yīng)性修復(fù)改變。若有生長(zhǎng)加快、疼痛加劇，則考慮惡變的可能病理：增生活躍的纖維結(jié)締組織和骨樣組織X線表現(xiàn)發(fā)病部位發(fā)病部位：軀干（包括顱面）骨發(fā)病率最高最高，下肢骨其次其次，上肢骨最少。長(zhǎng)管狀骨中，近段最好發(fā)長(zhǎng)管狀骨中，近段最好發(fā)，向遠(yuǎn)段遞減。病變開(kāi)始于干骺或近側(cè)骨干，而后逐漸向遠(yuǎn)側(cè)擴(kuò)散顱面骨以面骨面骨最常受累，其次是顱底骨和顱穹隆骨。鼻竇以蝶竇和上頜竇最常受累X線表現(xiàn)-四肢管狀骨主要是各種形態(tài)的密度減低區(qū)和骨的彎曲畸形主要是各種形態(tài)的密度減低區(qū)和骨的彎曲畸形囊狀膨脹改變：囊狀膨脹改變：可為單囊、多囊。長(zhǎng)圓形或淺分葉膨脹性透亮區(qū)，位于髓腔，邊緣清楚稍有硬化。內(nèi)緣，即髓腔緣，常呈分瓣樣，囊內(nèi)外同時(shí)可見(jiàn)少許縱形索條或斑點(diǎn)致密影磨玻璃樣改變：磨玻璃樣改變：常在囊狀膨脹性改變的基礎(chǔ)上出現(xiàn)，正常骨皮質(zhì)及髓腔界限消失，病理上為新形成的類骨組織絲瓜瓤樣改變絲瓜瓤樣改變：亦在囊狀膨脹的基礎(chǔ)上出現(xiàn)。骨皮質(zhì)松化分層的結(jié)果。表現(xiàn)為骨體膨脹增粗，皮質(zhì)變薄，少數(shù)骨小梁粗大、扭曲，呈現(xiàn)縱向分布的粗大骨紋，似絲瓜瓤蟲(chóng)蝕樣改變：蟲(chóng)蝕樣改變：病理基礎(chǔ)是增生活躍的纖維組織沿伏氏管擴(kuò)散而引起管腔的擴(kuò)大；或纖維組織結(jié)節(jié)樣增生，引起骨小梁的吸收、中斷或缺損硬化改變：硬化改變：可能是廣泛性纖維化骨形成所致X線表現(xiàn)-顱面骨 相同的病理改變導(dǎo)致顱面部隆起畸形，表現(xiàn)為“骨性獅面”等。并 發(fā) 癥和鑒別并發(fā)癥并發(fā)癥:骨骼畸形和病理骨折：常見(jiàn)于骨盆和下肢 惡變：可為骨肉瘤、骨纖維肉瘤、軟骨肉瘤和巨細(xì)胞肉瘤等。其中以骨肉瘤最多骨肉瘤最多鑒別：鑒別：骨囊腫：骨纖骨密度常不均勻，可有粗大骨紋或鈣化骨化影，常合并畸形。而骨囊腫透亮度高，無(wú)毛玻璃樣改變，骨變形輕肱骨中下段多發(fā)性骨纖肱骨中下段多發(fā)性骨纖骨囊腫（Simple Bone Cyst)SiteSite：metaphysis，Over 80%of cases are found in the proximal third of the humerus and femur.Age:Age:70%of patients are between the age of 4 and 10 years.A simple bone cyst shows central lucency with a partial thin sclerotic rim.Thinning of the cortex sometimes leads to infraction or complete fracture of the shaft.CTCT：similar to X-ray filmhomogeneous low signal on T1WI and markedly increased homogeneous on T2WI肱骨近端骨囊腫肱骨近端骨囊腫Fallen fragment signMalignant TumorOsteosarcomaThe most common type of primary malignant bone tumor.Age:About 80%of patients are aged between 11 and 20 years.The disease of young adults.Males are twice as common as females.SiteSite：Metaphisis of long bone.About 75%are found in the distal femure or the proximal tibia.Radiological featuresProduces all varieties of bone changes:Produces all varieties of bone changes:Bone destruction:Irruglar and unclear.No clear margin.Peristeal reaction:Different types,sunburst-like,Codman triangle and so on.Soft tissue mass:Adjacent to the affected bone.Tumor bone:Located in destructed lesion or in soft tissue mass.Bone hyperplasia.CT and MRICT:Find tumor bone more easily.The tiny cortex destruction.MRI:Soft tissue mass.Cortex destroyed.Tumor bone,difficult.脛骨近端骨肉瘤Sclerosis Osteosarcoma(硬化性骨肉瘤)平片顯示脛骨干骺端均勻硬化，MRI：T1WI增強(qiáng)，部分骨有強(qiáng)化。Myeloma(骨髓瘤)This is the commonest primary malignent neoplsm of bone.Age:75%of these patients are over the age of 50 years.X-ray：osteoporosis，multiple welldefined,round or oval “punched-out”lesions throughout the skeleton.MRI：multiple nodular or diffuse low signal on T1WI，呈“椒鹽狀”改變，high signal on T2WIX-ray featuresaccording to the processNormal：10-15%.Osteoporosis：myeloma cells stimulate the osteoclast cells.Bone destruction：soft tissue mass and osteolytic destruction in rapid developing tumor;expanded bone destruction in slow developing tumor.Bone sclerosis：rare.Metastatic Tumor of BoneMetastatic Tumor of BoneX-rayX-ray：成骨型、溶骨型、混合型CTCT：better than X-ray filmbetter than X-ray filmMRIMRI：better than CT,can make better than CT,can make early diagnosisearly diagnosisMetastasis in spineOccult metastasis60/M Prostatic cancer MT肺癌肺癌Metastatic tumor in the proximal tibiaSoft Tissue Tumor MRIMRI is bestlipoma Most common tumor,located in the shallow or deep area.Interesting case is the tumor will be larger when the patient is under the starve.Intra lipoma is the common type.Usually been seen in adults,mainly 30-60 years old.Male is a little bit more than female.Located in thigh,shoulder and upper limb.Fibrosis can been found in the lipoma due to capsule.Key points for MRI diagnosisTypical case:a mass with clear margin,the signal of the tumor equals to the subepithilial fat in all the sequences,the signal is homogenous,no enhancement after the contrast medial injection.Atypical case:due to contain the fibrosis in the tumor besides the fat tissue,low signal can be found in the tumor.bony absorption or osteohyperosis of adjacent bony structure due to the tumor compression.右大腿中部前內(nèi)側(cè)脂肪瘤左小腿前外側(cè)脂肪瘤上臂脂肪瘤(lipoma)HemingiomaRelatively common disease.多發(fā)生于年輕人，80-90%見(jiàn)于30歲左右。男女發(fā)病率相同血管瘤常包含大量非血管性組織，最常見(jiàn)的是脂肪組織，其他成分包括平滑肌、纖維組織、血栓和骨按照血管腔大小和血管內(nèi)皮的類型分為海綿型、毛細(xì)血管型和混合型。海綿狀血管瘤常合并有非血管成分血管瘤血管瘤平片無(wú)特異性，部分可見(jiàn)靜脈石MRI診斷要點(diǎn)T1WI信號(hào)等低于肌肉，內(nèi)可見(jiàn)等同于皮下脂肪的高信號(hào)T2WI信號(hào)升高等同于皮下脂肪信號(hào)內(nèi)部信號(hào)常常不均質(zhì)，常見(jiàn)短T1長(zhǎng)T2的脂肪成分、病灶境界相對(duì)其他良性病灶不甚清晰左小腿上部后方軟組織血管瘤腓腸肌內(nèi)血管瘤腓腸肌內(nèi)血管瘤右大腿中后部軟組織血管瘤右大腿中后部軟組織血管瘤左膝內(nèi)上部軟組織血管瘤左膝內(nèi)上部軟組織血管瘤足底血管瘤足底血管瘤Wish you happy forever!