骨肌系统疾病

Musculoskeletal ImagingBone lesions organized by cell of origin,Anatomy of the bone,Bone Lesions Organized by Cell of Origin(p367),Terminology,Enostosis (bone island): 内生骨疣Osteoma: 骨瘤Melorheostosis: 肢骨纹状肥大Osteoid osteoma: 骨样骨瘤Osteoblastoma: 成骨细胞瘤Osteosarcoma: 骨肉瘤Synovial chondromatosis/ osteochondromatosis: 滑膜骨软骨瘤Enchondroma: 内生软骨瘤Osteochondroma: 骨软骨瘤Chondroblastoma: 软骨母细胞瘤Chondromyxoid fibroma: 软骨黏液样纤维瘤Chondrosarcoma: 软骨肉瘤,Bone Lesions Organized by Cell of Origin(p367),Terminology,Nonssifying fibroma/ fibrous cortical defect: 纤维骨皮质缺损Malignant fibrous histiocytoma: 恶性纤维组织细胞瘤Fibrous dysplasia: 骨纤维异常增殖症Hemangioma: 血管瘤Angiosarcoma of bone: 血管肉瘤Giant cell tumor (osteoclastoma): 巨细胞瘤Eosinophilic granuloma (langehans cell histiocytosis): 嗜酸性肉芽肿Ewing sarcoma: 尤文氏肉瘤Multiple myeloma/ plasmacytoma: 浆细胞瘤Lymphoma: 淋巴瘤Lipoma: 脂肪瘤Liposarcoma: 脂肪肉瘤,Bone Lesions Organized by Cell of Origin(p367),Terminology,Chordoma: 脊索瘤Simple bone cyst: 单纯性骨囊肿Aneurysmal bone cyst: 动脉瘤样骨囊肿Adamantinoma: 釉质瘤Myositis ossificans: 骨化性肌炎Brown tumor: 棕色瘤Osteomyelitis: 骨髓炎,Bone Lesions Organized by Cell of Origin(p367),Contents,Bone Lesions Organized by Cell of OriginBone forming (Osteo-) lesionCartilage-forming (Chondro-) lesionLesions of fibrous originLesions of vascular originLesions of hematopoietic originFat (Lipo-) lesionsNotochordal lesionLesions of unknown cell originOsseous metastasis Benign tumor mimics,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion,Benign and incidental: Enostosis (bone island)内生骨疣Osteoma骨瘤Melorheostosis肢骨纹状肥大 Osteoid osteoma骨样骨瘤 Osteoblastoma成骨细胞瘤Malignant: Osteosarcoma骨肉瘤,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Enostosis (bone island),Benign and incidental findingA small spiculated osteoblastic focus小针状成骨细胞聚集Differentiate from an osteoblastic metastasis, osteoid osteoma, or a low-grade osteosarcoma (if the lesson 2 cm)成骨性转移、骨样骨瘤或低级别骨肉瘤进行鉴别Normal in bone scanOsteopoikilosis is an autosomal dominant syndrome of multiple bone islands and keloid formation全身脆性骨硬化表现为多发骨岛和瘢痕疙瘩，是一种常染色体显性综合征Osteopathia striata is a benign, asymptomatic sclerotic dysplasia characterized by linear bands of sclerosis in the long bones and fan-like sclerosis in the flat pelvic bones条纹性骨病是一种良性、无症状性硬化性发育不良，其特征为在长管状骨出现条纹状硬化，骨盆扁平骨呈扇形硬化,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Osteoma,Benign and incidentalA slow-growing lesion, from the cortex of the skull or the frontal/ethmoid sinusesGardner syndrome is an autosomal dominant syndrome of multiple osteomas, intestinal polyposis, and soft-tissue desmoid tumors Gardner综合征是一种常染色体显性综合征，表现为多发骨瘤、肠息肉病和软组织韧带样纤维瘤In contrast to a bone island, osteoma arises from the cortex rather than the medullary canal相比较于骨岛起源于骨髓腔，骨瘤起源于骨皮质,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Osteoma,Osteoma: Axial head CT in bone window shows a densely sclerotic osteoma arising from the cortex of the frontal sinus,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Melorheostosis,Benign and incidental肢骨纹状肥大Non-neoplastic proliferation of thickened and irregular cortex with a typical candle-wax appearance非新生物增生改变，表现为骨皮质增厚且不规则，呈蜡泪状改变Pain, decreased range of motion, leg-bowing, leg-length discrepancyAssociated with scleroderma-like skin lesions over the affected region肢骨纹状肥大可以伴随硬皮样皮肤病灶，皮肤病灶范围超过骨患病区域Usually in a single lower limb (in the distribution of a single sclerotome). A sclerotome represents a zone supplied by a single sensory nerve 常见于单侧小腿，分布于单个生骨节。一个生骨节代表单一感觉神经供应的区域Melorheostosis features intense uptake on bone scan,Bone Lesions Organized by Cell of Origin(p367),Melorheostosis: Frontal radiograph of the right tibia and fibula shows thickened, irregular wavy cortex of the medial tibia (arrow),Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Melorheostosis,1. Bone forming (Osteo-) lesion: Osteoid osteoma,Benign. The etiology: Inflammatory, vascular, and viral causesThe classic clinical presentation: night pain, relieved by aspirin in a teenager or young adult 11-30岁Location: the diaphyses of the leg long bones (femur and tibia) (most commonly); the posterior elements of the spine (about 20%)最好发于下肢长管状骨骨干（股骨和胫骨）。大约20%发生于脊柱后部。脊柱骨样骨瘤是导致疼痛性脊柱侧弯的重要原因。Radiography and CT: a lucent nidus is surrounded by sclerosis, central calcification within the nidus半透明的瘤巢伴周围环绕骨质硬化。瘤巢中央发生钙化Bone scan: positive, with the double density sign representing intense uptake centrally in the region of the nidus and adjacent reactive uptake corresponding to sclerosisMRI: the nidus is usually low-signal on T1WI and reactive marrow edema can obscure the lesion on T2WI, difficult to diagnosis in MRI,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Osteoid osteoma,CT shows a radiolucent nidus in the left sacral ala (posterior element location) with a large central calcification (yellow arrows) with adjacent sclerosis (red arrows) The lesion is less conspicuous on MRI and has very low signal on the T1-weighted image (yellow arrow) The posterior bone scan shows increased radiotracer uptake (yellow arrow) of the nidus, with a double density sign (red arrow; corresponding to reactive sclerosis),Bone Lesions Organized by Cell of Origin(p367),Benign, approximately four times less common than osteoid osteomaHistologically the same as an osteoid osteoma but is greater than 2 cm in size组织学和骨样骨瘤类似，但是成骨细胞瘤大于2cmIn the adolescent/young adult age range Pain, not typically relieved by aspirinThe most common location: the posterior elements of the spine, the femur and tibiaThe most common radiographic appearance: Lytic lesion with mineralizationWith a large soft-tissue mass very rarely, no metastatic potential成骨细胞瘤非常少见表现为侵袭性，伴软组织巨大肿块，但缺乏转移能力Secondary aneurysmal bone cyst, especially lesion in spinal可发生继发性动脉瘤样骨囊肿，尤其是位于脊柱,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Osteosarcoma,1. Bone forming (Osteo-) lesion: Osteosarcoma,MalignantPrimary or secondary: Secondary osteosarcoma may arise from Paget disease (extremely aggressive) or after radiation继发性骨肉瘤可以由Paget病或放疗后引起Radiographic appearance: bony destruction, production of osteoid matrix, aggressive periosteal reaction, an associated soft-tissue massEarly appearance: subtle sclerosisSubtypes: more than 10 primary subtypes, the four most important subtypesConventional (most common)TelangiectaticParosteal (pronounced PAR-osteal)皮质旁型Periosteal (pronounced PERI-osteal)骨膜型Osteosarcoma may metastasize to lungs, where the metastases typically calcify,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Conventional Osteosarcoma,Conventional (intramedullary) osteosarcoma: represents 75% of osteosarcomas and occurs in adolescents/young adults usually around the knee in the metaphysis of the femur or tibia Conventional osteosarcoma: Radiograph (left image) shows a region of subtle heterogeneous sclerosis in the medial proximal tibial metaphysis (arrow). No periosteal reaction is apparent. T1-weighted MRI shows a well-defined region of marrow replacement by tumor (red arrows). T2-weighted MRI with fat suppression demonstrates diffuse marrow edema in the tibia, with a region of decreased T2 signal (arrow) likely corresponding to the sclerosis seen on radiography,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Telangiectatic Osteosarcoma,Telangiectatic osteosarcoma: an osteolytic destructive sarcoma, which may mimic a benign aneurysmal bone cyst毛细血管扩张型骨肉瘤是溶骨性破坏性肉瘤，影像表现类似于良性动脉瘤样骨囊肿The presence of solid nodular components on MRI, helps to differentiate a telangiectatic osteosarcoma from a benign aneurysmal bone cyst MRI上固体结节成分的存在有助于区分毛细血管扩张型骨肉瘤和良性动脉瘤样骨囊肿No bony matrix: unlike other osteosarcomas不同于其他类型骨肉瘤，毛细血管扩张型骨肉瘤不产生骨基质,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Parosteal Osteosarcoma,Parosteal (PAR-osteal) osteosarcoma: a juxtacortical osteosarcoma, arised from the outer periosteum皮质旁型骨肉瘤是近皮质骨肉瘤的一型，来源于骨膜外层The most commonly location: at the posterior aspect of distal femoral metaphysis; has a cauliflower-like exophytic morphology, a lucent line separating it from the cortex最常见发生在股骨远端干骺端的后部，呈菜花状外生性病灶，一条透亮线与骨皮质相分离The age of Patients: usually 3040 years, older compared to other osteosarcoma subtypesThe least malignant of all osteosarcomas: with 90% 5-year survival,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Parosteal Osteosarcoma,Parosteal (PAR-osteal) osteosarcoma is a juxtacortical osteosarcoma that arises from the outer periosteum. There is a cauliflower-like exophytic morphology and a lucent line separating it from the cortex,Bone Lesions Organized by Cell of Origin(p367),1. Bone forming (Osteo-) lesion: Periosteal Osteosarcoma,Periosteal (PERI-osteal) osteosarcoma, the other juxtacortical osteosarcoma, arising from the inner periosteum骨膜型骨肉瘤是另一型近皮质骨肉瘤，起源于骨膜内层，非常少见Radiographic appearance: cortical thickening, aggressive periosteal reaction, and a soft-tissue mass皮质增厚、骨膜反应受侵犯和软组织肿块Histological feature: chondroid differentiation显示软骨分化The most common location: the diaphysis of the femur or tibiaPatients tend to be younger than 20 years old,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion,Benign: Synovial chondromatosis/osteochondromatosis滑膜骨软骨瘤病/骨软骨瘤病Enchondroma内生软骨瘤Osteochondroma骨软骨瘤Chondroblastoma良性成软骨细胞瘤Chondromyxoid fibroma软骨粘液样纤维瘤Malignant:Chondrosarcoma软骨肉瘤,Bone Lesions Organized by Cell of Origin(p367),Bone Lesions Organized by Cell of Origin(p367),Histological feature: the formation of intra-articular lobulated cartilaginous nodules, which may or may not ossify; if ossify (osteochondromatosis )特征是形成关节内分叶状软骨结节，伴或不伴骨化，骨化称为骨软骨瘤病The location: a monoarticular disorder, knee (most common), shoulders, hip, and elbow; Not to directly cause arthropathy, although the intraarticular nodules may cause mechanical erosions and secondary osteoarthritisRadiography: multiple round intra-articular bodies of similar size and variable mineralizationThe primary differential from osteoarthritis: intra-articular bodies tend to be more varied in size and shape and fewer in number in osteoarthritisMRI: variable, depending on the degree of ossification and the presence of chondroid matrix, multiple globular and rounded foci of low signal if calcified or ossified, but the MRI finding is nonspecific and can also be seen in pigmented villonodular synovitis (PVNS)色素绒毛结节性滑膜炎, rounded calcified bodies in osteochondromatosis in a radiagraph Malignant degenerate to chondrosarcoma: very rarely,2. Cartilage-forming (Chondro-) lesion: synovial chondromatosis/ osteochondromatosis,Synovial osteochondromatosis: Frontal external rotation (left image) and internal rotation (right image) radiographs of the shoulder show multiple small round calcifications tracking along the expected location of the long head of the biceps tendon sheath (arrows),Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: synovial chondromatosis/ osteochondromatosis,2. Cartilage-forming (Chondro-) lesion: synovial chondromatosis/ osteochondromatosis,Synovial osteochondromatosis: Lateral radiographs of the knee show multiple small round calcifications,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Benign, mature hyaline cartilage rests良性发育成熟透明软骨病灶Enchondroma features in the long bones: characteristic chondroid calcifications (popcorn or ring and arc)特征为软骨钙化（爆米花或环或弧形）The differential diagnosis of enchondroma: medullary bone infarct (which produces serpentine sclerosis) and chondrosarcoma区分梗塞和内生软骨瘤，骨髓梗塞呈盘旋状硬化T2-weighted images: enchondroma has a characteristic lobulated hyperintense signalEnchondroma features in the hand: enchondroma typically does not produce visible matrix and appears as a geographic lytic lesionPathologic fracture; rarely undergo malignant transformationOllier and Maffucci syndrome: the key finding of malignant transformation being new pain in the absence of fracture; other findings including soft-tissue mass, destruction of the cortex, thickening of the cortex,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Radiograph of the distal femur shows an enchondroma with Characteristic ring and arc chondroid-type calcification (arrow),Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Radiograph of the distal tibia shows an enchondroma with Characteristic ring and arc chondroid-type calcification,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Enchondroma of the middle finger proximal phalanx (left image) complicated by pathologic fracture seen in a subsequent radiograph (right image). The enchondroma (arrow) has no perceptible chondroid matrix, which is a typical appearance of an enchondroma in the hand. Note the interval partial fusion of the physes occurring in the time interval between the two radiographs,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Multiple enchondromas: the two familial enchondromatosesOllier syndromes(multiple enchondromas only)仅见于多发内生软骨瘤Maffucci syndromes(multiple enchondromas and venous malformations producing phleboliths) 多发内生软骨瘤和静脉畸形产生静脉石Both syndromes carry an increased risk of malignant transformation to chondrosarcoma, with a higher risk in Maffucci syndrome,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Frontal radiograph of the hand in a patient with Ollier syndrome shows numerous expansile,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Enchondroma,Frontal radiograph of the foot in a patient with Maffucci syndrome shows numerous expansile enchondromas most rominently in the great toe (red arrows). Multiple phleboliths (yellow arrows) represent soft-tissue venous malformations. Note the relative paucity of chondroid calcification, which is typical of the enchondromas seen in Maffucci syndrome,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: osteochondroma,The most common benign bone lesion Histological feature: cartilagecapped bony growth projecting outward from bone, often pedunculated软骨帽样外突生长，常常带柄Key features in radiolography: the continuity of cortex of host bone with the cortex of the osteochondroma and communication of the medullary cavities骨皮质和肿瘤骨皮质相连续，髓腔相通。骨软骨瘤起源于干骺端，背离骨骺生长Location: from the metaphysis and grows away from the epiphysisMalignant transformation to chondrosarcoma, uncommon, an associated soft-tissue mass, a cartilage cap thickness 2 cm on MRI伴发软组织肿块， MRI显示软骨帽厚度2 cm提示恶性转变为软骨肉瘤Multiple osteochondromas: in familial osteochondromatosis (multiple hereditary exostoses), with increased risk for malignant transformation.家族性骨软骨瘤病（多发遗传性外生骨疣），增加恶性转变风险Familial osteochondromatosis: an autosomal dominant skeletal dysplasia, with the knees most commonly involved家族性骨软骨瘤病常染色体显性骨骼发育不良，膝关节最好发,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: osteochondroma,Osteochondroma: Frontal knee radiograph in a skeletally immature patient shows a pedunculated exostosis (arrow) of the tibial metaphysis, with characteristic continuity of the cortex and communication of the medullary cavities. The lesion arises from the metaphysis and projects away from the epiphysis,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: osteochondroma,Osteochondroma: Frontal knee radiograph in a skeletally mature patient shows a pedunculated exostosis of the femur metaphysis, with characteristic continuity of the cortex and communication of the medullary cavities. Cartilage cap may be calcified,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Chondroblastoma,Histological feature: a benign lesion located eccentrically in the epiphysis of a long bone in a skeletally immature patient; most commonly occurs about the knee or proximal humerus良性病灶，偏心性位于骨骼发育尚未成熟患者的长管状骨骨骺。最常见于膝关节和肱骨近端。Calcified chondroid matrix: almost all CT studies, only 50% of the time on radiographsMRI: Chondroblastoma is unique amongst chondroid lesions in that it typically demonstrates low or intermediate signal on T2-weighted images, Most chondroid lesions are T2 hyperintense典型表现为T2WI呈低或中等信号。绝大多数软骨病灶呈T2WI高信号。Treatment: curettage, cryosurgery, or radiofrequency ablationLocal recurrence: low risk Very rarely malignant,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Chondroblastoma,Chondroblastoma: Frontal and lateral knee radiograph show a round lucency lesion located eccentrically in the epiphysis of a humerus in a skeletally immature patient,Bone Lesions Organized by Cell of Origin(p367),Benign, very rare Typically eccentric in the tibial or femoral metaphysis about the knee典型表现为膝关节周围胫骨或股骨干骺端偏心性病灶Rarely demonstrated chondroid matrix in lesion很少发现软骨基质Usually has sclerotic margins on radiography and higher signal on T2-weighted MRI平片显示软骨粘液样纤维瘤通常发生硬化边，T2WI呈高信号,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Chondromyxoid fibroma,Malignant tumor of cartilage, multiple primary and secondary variantsSecondary forms: arising from enchondroma (more commonly in the Maffucci and Ollier familial enchondromatoses), Paget disease, and osteochondroma (more common in familial osteochondromatosis)An osteochondroma with a cartilage cap thickness of 2 cm is highly suggestive of chondrosarcomaThe conventional (intramedullary) chondrosarcoma subtype: most common, typically an expansile lesion in the medullary bone, with ring and arc chondroid matrix, thickening and endosteal scalloping of the cortex, an associated soft-tissue mass影像表现特征髓腔膨胀性病灶，伴环形、弧形软骨基质。肿瘤导致皮质增厚和骨内膜扇贝样改变，常常伴有软组织肿块The dedifferentiated subtype: aggressive, contained fibrosarcoma or osteosarcoma elements软骨肉瘤未分化亚型是侵袭性，可以包含纤维肉瘤和骨肉瘤成分Other subtypes: include the rare mesenchymal and clear cell variants,Bone Lesions Organized by Cell of Origin(p367),2. Cartilage-forming (Chondro-) lesion: Chondrosarcoma,2. Cartilage-forming (Chondro-) lesion: Chondrosarcoma,Chondrosarcoma: Frontal radiograph of the p