脊柱肿瘤和肿瘤样病变

脊柱肿瘤和肿瘤样病变spinal bone tumor and tumor-like conditions,脊柱肿瘤发生率,骨肿瘤占全身肿瘤0.4%脊椎肿瘤占骨肿瘤10%以下,概述,良性肿瘤：血管瘤,骨样骨瘤,骨母细胞瘤,巨细胞瘤恶性肿瘤：脊索瘤, 骨髓瘤，淋巴瘤，转移瘤肿瘤样病变: 嗜酸性肉芽肿,动脉瘤样骨囊肿,血管瘤,Hemangioma,最常见的脊柱原发良性肿瘤，约占全部血管瘤的14%，其中90%位于胸、腰椎构成：低血压慢血流薄壁血管、脂肪基质、存留骨小梁毛细血管型和海绵状血管型任何年龄均可发生，一般无症状，多女性对放射线有相当的敏感性,临床病理,X线表现:,椎体横行骨小梁吸收,纵行骨小梁增厚.呈栅栏状或网格状。,CT表现:,椎体呈圆点花纹状改变病灶呈低密度溶骨区，境界清晰，增厚的骨小梁呈多数圆点状高密度，周围可有软组织肿块。增强扫描很少出现强化或轻度强化。,MRI表现:,病灶T1WI，T2WI呈斑点或条状高信号或等信号，增粗的骨小梁T1WI, T2WI均呈低信号。,T12,骨样骨瘤,Osteoid Osteoma,临床病理,由成骨细胞及骨样组织构成由瘤巢和周围硬化两部分组成；瘤巢较小，直径 2厘米 10%发生于脊柱，56%于腰椎，最常起于椎弓单发性，肿瘤发展极慢 ，有自限性好发于20岁以下青少年患骨疼痛，夜间加重，服用水杨酸类药物可缓解为其特点。治疗以用手术切除最为适宜,预后良好,影像表现,X线肿瘤所在部位骨质破坏，偶见内钙化/骨化周围不同程度的反应性骨硬化CT类圆形的低密度骨破坏区，中央见不规则的钙化骨化影周围不同程度的反应性骨硬化环核素扫描肿瘤显示明显核素浓聚,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. 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,A,B,C,D,骨样骨瘤,瘤巢,MRI 肿瘤未钙化部分T1WI呈低至中等信号，T2WI呈高信号 钙化及周围硬化带均呈低信号 增强后，病变强化明显。,骨母细胞瘤,Osteoblastoma,临床病理,“巨大骨样骨瘤” ，膨胀性生长，直径为2cm10cm血管丰富，较大者可有囊变，少数夹杂动脉瘤样骨囊肿组织约40%发生于脊柱，颈、胸、腰椎发病率相近, 常累及附件2030岁，男性多于女性水杨酸类药物无缓解和无明显夜间疼痛治疗应手术切除，复发率为1015 %,X-Ray 及 CT a：中心低密度，周围骨硬化，病灶直径大于1.5cm（类似骨样骨瘤）b：膨胀性低密度区内磨玻璃样密度升高或骨化，周围伴硬化缘c：为侵袭性表现，膨胀溶骨性破坏，周围软组织浸润 和混杂性钙化,影像表现,MRI非钙/骨化部分T1WI呈低至中等信号,T2WI呈高信号, 钙/骨化部分呈低信号周围骨髓和软组织反应性充血水肿，为长T1长T2信号可显示骨壳中断，椎管内延伸和脊髓受压合并动脉瘤样骨囊肿时可见囊腔及液液平面 核素扫描肿瘤显示明显核素浓聚,影像表现,Fig.A L radiograph,Fig.B CT,Fig.D Sag. T2WI,Fig.C Axi. T1WI,Lateral 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 from 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 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,骨母细胞瘤,骨巨细胞瘤,Giant Cell Tumor, GCT,临床病理,由单核基质细胞和多核巨细胞构成，潜在恶性组织学分三级：级为良性，级为过渡型，级为恶性多发生于2040岁成年人好发于骺板愈合后的骨端，股骨下端及胫骨上端最常见约7%发生于脊柱，最常累及骶骨多全切治疗，若仅刮除术约4060%复发,影像表现,X线早期为偏心性溶骨破坏，骨皮质膨胀变薄后期可有压缩性骨折伴软组织肿块CT偏心性囊状膨胀性溶骨性破坏，伴骨膜反应和软组织肿块，部分边缘可见硬化内部可见骨性间隔及液-液平面，骨化及钙化少见，发生于骶骨时，一般位于骶髂关节附近增强扫描实性成分中重度强化,MRI膨胀性多囊性骨质破坏T1WI上呈低、中等信号；T2WI上呈不均匀低、中、高混杂信号；可见局部出血信号；周边有一低信号环，相当于轻度硬化边,影像表现,脊索瘤,Chordoma,临床病理,起源：残留或异位脊索组织，低度恶性。发病年龄：多见于50-70岁。发病部位：颅底（35%），骶尾椎（55%）和脊柱（10%）。生长缓慢，局部侵袭性，少转移，偶远处转移, 主要为肺、淋巴结、蛛网膜下腔和脊髓,影像表现,X线肿瘤为溶骨性膨胀性破坏，可伴有软组织肿块瘤内50-70%见钙化，且形态不一起病于骶尾部的肿瘤，多位于下部骶椎骶椎以上节段患骨较少膨胀改变，并可出现硬化呈“象牙椎”表现,影像表现,CT发生于颅底者呈大片状或溶冰样骨破坏发生于骶尾部者多呈膨胀性骨质破坏伴有境界清楚的软组织肿块病变区不规则钙化多见增强，轻至中度强化,影像表现,MRIT1WI：低、等信号T2WI：高强信号，不规则低信号钙化、残留骨及血管流空影增强：明显强化或轻度强化MRI在显示病变侵及的范围方面优于CTCT在确定肿瘤的性质特点方面优于MRI,Fig.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 man,Fig.A,Fig.B,脊索瘤,Fig.C T1WI Sagittal and axial T2WI 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 correlates 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 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 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,chordoma,Fig.A,Fig.B,脊索瘤,残存椎间盘形成的“分节”现象,Fig.ALateral radiograph shows a dense vertebral 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 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). 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 (arrows).,Fig.E,脊索瘤,骨髓瘤,Myeloma,临床病理,起源于红骨髓的恶性肿瘤高分化型(小细胞型)：浆细胞型骨髓瘤 低分化型(大细胞型)：网状细胞型骨髓瘤椎体为其好发部位，绝大多数为多发；单发少见，且约1/3可转变为多发。晚期可广泛转移。40岁以上常见，男:女2:1表现为骨骼疼痛，软组织肿块，病理性骨折实验室检查血沉加快、尿B-J蛋白、贫血等。,影像表现,X线广泛性骨质疏松多发性骨质破坏：穿凿状、鼠咬状、蜂窝状、皂泡状软组织肿块：位于破坏区周围，很少跨越椎间盘水平至邻近椎旁骨质硬化：少见，又称硬化型骨髓瘤。平片约10%正常表现,影像表现,CT较X线平片更好的显示骨质改变和软组织异常MRI对骨髓变化非常敏感长T1长T2信号改变STIR序列病变高信号较T2WI更明显,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 and sagittal (a, left) MRI show cord compression by a focal expansile mass (arrow) at the T10 spinous process.,a,b,c,多发浆细胞瘤,Myeloma of T5-T7,T2WI,T1WI,T1WI+C,T1WI STIR T2WI STIR,转移性骨肿瘤,Secondary Tumor or Metastatic Tumor,临床病理,脊柱转移常见转移途径主要是血行转移，少数直接蔓延原发肿瘤常包括：前列腺癌、肾癌、甲状腺癌、乳癌、肺癌和鼻咽癌等。骨肉瘤、尤文瘤和淋巴瘤也可发生骨转移患者5160岁最多,转移性骨肿瘤影像表现,X线溶骨型、成骨型和混合型CT能显示局部软组织肿块的范围、大小及邻近脏器的关系MRI多数肿瘤T1WI呈低信号，T2WI呈程度不高的高信号脂肪抑制序列显示更清楚,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 hypointense 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 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 M,metastatic renal cell carcinoma,A,B,C,肺Ca骨转移,骨外NHL骨转移,脊椎骨髓瘤与转移瘤鉴别：,椎体破坏+软组织肿块倾向骨髓瘤椎体破坏+广泛性骨质疏松倾向骨髓瘤。椎体破坏伴椎弓及附件早期破坏倾向转移瘤。,动脉瘤样骨囊