脊柱肿瘤讲座

null脊柱肿瘤的影像学诊断脊柱肿瘤的影像学诊断 上海中医药大学龙华医院放射科 王 嵩 脊柱肿瘤的影像学诊断脊柱肿瘤的影像学诊断脊柱大体解剖 脊柱检查技术 脊柱影像解剖 脊柱良性肿瘤和肿瘤样病变 脊柱恶性肿瘤脊 柱脊 柱大体解剖null颈段：7个颈椎 胸段：12个胸椎 腰段：5个腰椎 骶段：5个骶椎 尾段：4个尾骨 椎间盘、椎间关节、椎旁韧带等 胸段null椎骨:椎体、椎弓和7个骨性突起组成 椎弓:椎板、椎弓根，相邻椎弓根间构成椎间孔 椎管:各椎骨的椎孔共同连成 颈椎 环椎:前后弓及两侧块 枢椎:齿状突、椎体及棘突 第3至第7椎体：逐渐增大，椎孔三角形，椎间关节面近呈水平位，钩椎关节（Luscka 关节） 胸椎：逐渐增大，椎孔心形，关节突关节面呈冠状位 腰椎：椎体逐渐增大，椎孔呈三角形，关节突关节面呈矢状位 骶骨：骶骨倒立扁三角形，5个骶椎融合而成 尾骨: 4个尾椎融合而成 骨性椎管的特点 骨间连接 骨间连接椎体间连接 前纵韧带、后纵韧带、椎间盘 椎板及附件间连接 黄韧带、棘间韧带、棘上韧带、项韧带横突间韧带、关节突关节环枢关节、环椎横韧带nullposterior Anterior null R lateralL lateralnullC1-2nullC3-7nullTnullLnullSConullnull检 查 技 术 检 查 技 术 Examination Methods检查技术检查技术常规X线 :最主要和首选的检查方法 CT:解决临床和X线诊断疑难的第二步检查方法 MRI :示X线甚至CT不能显示和显示不佳的某些组织结构 核素扫描 :一种全身骨骼检查，但缺乏特异性 影 像 解 剖 影 像 解 剖 Radiologic Anatomy常 规 X 线 常 规 X 线 CnullTnullLA-PLateralnullL- oblique CT解剖CT解剖T重建CT解剖LCT解剖MRI解剖MRI解剖C 脊柱良性肿瘤和肿瘤样病变 脊柱良性肿瘤和肿瘤样病变 Benign Spinal Tumor and Tumorlike Lesion脊柱良性肿瘤和肿瘤样病变脊柱良性肿瘤和肿瘤样病变骨血管瘤 骨软骨瘤 骨巨细胞瘤 骨样骨瘤 骨母细胞瘤 动脉瘤样骨囊肿 骨嗜酸性肉芽肿 内生骨疣 其它：软骨黏液样纤维瘤、纤维骨瘤、血管外皮细胞瘤和血管内皮细胞瘤等骨血管瘤骨血管瘤Hemangioma骨血管瘤 临床病理 骨血管瘤 临床病理 最常见的脊柱原发良性肿瘤 低血压慢血流血管组成，掺杂于骨小梁和脂肪间，易出血 病理上分毛细血管型和海绵状血管型 多胸椎椎体,多单椎体病变 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 骨血管瘤 影像表现骨血管瘤 影像表现X线 一为受累骨体积扩张，骨小梁广泛的吸收、增生和增厚，椎体呈栅栏状特征性表现 一为受累骨质有肥皂泡沫样的破坏和扩张 骨血管瘤 影像表现骨血管瘤 影像表现 CT 椎体部分或全部松质骨密度减低 病变区骨小梁减少，变粗致密 冠状面或矢状面重建显示栅栏状表现 增强扫描，病变常不强化或轻度强化 MRI T1WI和T2WI上均呈高信号 增强扫描，中度至明显强化 nullPlain film CTT骨血管瘤nullT骨血管瘤nullFig. A thickened trabeculae (corduroy sign) of a vertebral body hemangioma can be seen on this lateral view, which is coned down to the L2 vertebral body Fig. B T1WI and Fig. C T2WI show the typical increased signal intensity of a vertebral body ABC骨血管瘤骨软骨瘤骨软骨瘤Osteochondroma 临床病理 临床病理由骨质组成的基底和瘤体、透明软骨组成的帽盖和纤维组成的包膜三种不同组织构成,又称外生骨疣 发生于脊椎少见，发生于脊柱单发1.3～1.4%，多发者9% 约50%于颈椎，其次胸椎及腰椎;常见于附件 儿童期生长缓慢，青春期迅速 近1％病人的骨软骨瘤发生恶变 多儿童和青年男性，一般无症状 治疗应彻底手术切除骨软骨瘤骨软骨瘤 影像表现骨软骨瘤 影像表现X线 仅21%的起于棘突的较大病变被明确诊断 小病变和突入椎管内的肿瘤很难诊断 15%显示正常 骨软骨瘤 影像表现骨软骨瘤 影像表现CT 附件骨性肿块，皮质与椎板皮质相连 可伴脊髓受压 MRI 病灶中心T1WI呈高信号，T2WI呈中等信号 边缘皮质均呈低信号 软骨帽常既薄又小，T1WI呈低至中等信号，T2WI呈高信号 成人如软骨帽明显增厚（大于1-2cm）则应怀疑恶变null38, yr, M of CHereditary multiple exostosis with several spinal osteochondromasFigA: Lateral radiograph of the cervical spine shows a C-4 spinous process osteochondroma with pathognomonic marrow and cortical continuity solid arrow). Osteochondroma at C-1 is seen as an ossified region (open rrow)Axial FigB and sagittal FigC reconstructed CT scans reveal cortex and marrow of the osteochondroma (arrows), impingement on the spinal canal, extrinsic erosion of C-2 (arrowheads in b), and continuity with the C-1 spinous process (* in c). ABC骨软骨瘤nullSagittal T1-weighted FigDand T2* gradient-echo FigEMR images reveal the signal intensity characteristic of yellow marrow within the osteochondroma and the impression of the tumor on the spinal canal (arrows), although the marrow and cortical continuity is not well seen. 骨软骨瘤DEnullFigF: Photograph of the gross specimen shows the marrow and cortex of the osteochondroma and a small cartilage cap at its periphery (arrowheads). null35yr，F Osteochondroma of sacrum malignant transformationFigA Vague sclerosis (solid arrows) over the left sacrum and widening of the sacroiliac joint (open arrow).FigAnullFigCAxial CT scan shows the thick cartilage cap (arrows) and sacroiliac joint invasion, which represents malignant transformation.FigB Coronal reconstructed CT scan shows the cortex and marrow canal of the osteochondroma (arrows) and continuity with the sacrum (arrowheads).Fig BFigCnullmultiple hereditary exostoses. Note that the large sacral lesion has normal cortex as well as marrow arising from the underlying bone. This appearance defines an exostosis. We look for a thick cartilage cap to suggest degeneration of an exostosis to a chondrosarcoma. In this case, there is no space for a thick cap because the edge of the exostosis extends to the subcutaneous tissue. If there is any question, MR imaging can demonstrate the cartilage thickness. In this case, we recognized multiple exostoses because of the presence of sessile lesions at the anterior superior iliac spines.10, yr, M Multiple hereditary exostoses骨巨细胞瘤骨巨细胞瘤Giant Cell Tumor, GCT骨巨细胞瘤 临床病理骨巨细胞瘤 临床病理由软而脆且易出血的肉芽样组织所构成，无纤维包膜，可出血和坏死 组织学分三级：Ⅰ级为良性，Ⅱ级为过渡类型，Ⅲ级为恶性 患者多女性，发病年龄多20-40岁 约1/3发生于脊柱，最常累及骶骨，其次为胸椎、颈椎和腰椎；多见于附件 绝大多数为良性，约25%为恶性 临床症状主要为局部疼痛、无力和感觉异常 治疗多全切治疗，若仅刮除术会出现40-60%％复发骨巨细胞瘤 影像表现骨巨细胞瘤 影像表现X线 典型呈膨胀性偏心性多房性骨质破坏，骨壳较薄，轮廓一般完整，内见纤细骨嵴构成分房状 几点提示恶性 a，较明显的侵袭性表现 b，骨膜增生显著 c，软组织肿块较大，患者年龄较大，疼痛持续加重，肿瘤突然生长迅速骨巨细胞瘤 影像表现骨巨细胞瘤 影像表现CT 椎体局限性膨胀性溶骨性破坏,皮质连续 若为侵袭性可侵犯数个椎体椎弓椎间盘，皮质破坏，软组织肿块形成 发生于骶骨时，一般位于骶髂关节附近，皮质可中断 增强扫描低密度区散在强化 MRI T1WI上呈低、中等信号；T2WI上呈不均匀中等信号。可见局部出血信号 增强后明显强化 核素扫描 显示肿瘤呈弥漫性的浓聚 nullFig A and Fig B a large expansile lesion of the T-4 vertebral body (arrows), with extension into the posterior elements of T-3 and T-4 and the posterior soft tissues (arrowheads). The lesion enhances markedly with the contrast agent. FigC the lesion has only intermediate signal intensity, 28,yr,F GCT of T-3 and T-4Sag.T1WIAxi.T1WI +cSag.T2WIACBT4骨巨细胞瘤nullIntraoperative photograph obtained after incision of the skin shows a bulging, solid paraspinal mass (*) FigD骨巨细胞瘤nullsacral GCT.A-PLateraLFig AFig bnullFig CFig DFig EFig F骨巨细胞瘤nullGCT of S4-521 yr ,FA-PLateraLAB骨巨细胞瘤nullFigC:CTshowing large mass of S FigD: demonstrating an inhomogeneous mass that contains several areas of low signal intensity (arrows; contrast this signal to the very high signal intensity FigE: revealing that the lesion is of low signal intensity; the large presacral mass displacing the rectum is confirmed. FigF:revealing only mild enhancement, again with several areas of relatively low signal intensity. These low-signal regions represent a common feature in GCTsAxial CTSag. T1WIAxi. FSE T2WISag. FS T1WI +C骨巨细胞瘤nullUpper Left: Anteroposterior radiograph emonstrating the expanded lytic lesion ccupying the sacrum. Upper Right and Center Left: Axial CT scans obtained several months later, demonstrating the rather featureless lytic lesion occupying the entire sacrum, with attempted thin cortical rim unable to contain the expansive lesion. Center Right: Sagittal T1-weighted MR image (TR/TE 450/10 msec) demonstrating intensity presacral soft-tissue extension Lower Left and Right: Sagittal T2WI and axial FSE T2WI revealing the inhomogeneous mixed high and low signal intensity mass, typical of GCT. 26, yr, F GCT of the sacrum.骨巨细胞瘤nullGCT of C-7 posterior elements 16 y male骨巨细胞瘤nullTI 骨巨细胞瘤骨样骨瘤骨样骨瘤Osteoid Osteoma骨样骨瘤 临床病理骨样骨瘤 临床病理由成骨性纤维组织及骨样组织、编织骨构成，肿瘤本身为瘤巢直径约1.5cm，很少超过2厘米,周围由增生致密的反应性骨质包绕 10%发生于脊柱，多腰椎，最常起于椎弓，其次椎板，小关节面和椎弓根 单发性，肿瘤发展极慢 多为青少年和成年人，多男性，多小于30岁 患骨疼痛，夜间加重，服用水杨酸类药物可缓解为其特点。患者因肌肉痉挛而引起侧弯 治疗以用手术切除最为适宜,预后良好骨样骨瘤 影像表现骨样骨瘤 影像表现X线 肿瘤所在部位骨质破坏 周围不同程度的反应性骨硬化 偶见内钙化/骨化 分皮质型、松质型、骨膜下型 骨样骨瘤 影像表现骨样骨瘤 影像表现CT 类圆形的低密度骨破坏区，中央见不的钙化骨化影 周围不同程度的反应性骨硬化环 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。 核素扫描 肿瘤显示明显核素浓聚nullFigA: 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 ABCD骨样骨瘤瘤巢nullFigE: Photograph of the gross specimen reveals the nidus (*)extending to the facet cartilage (arrows)骨样骨瘤瘤巢nullAxial CT scan (left) revealing that a tumor arising from the left C-5 pedicle is compressing the left C-5 root. Bone scan (center) displays high uptake of contrast material. Axial CT scan (right) demonstrating that left hemilaminectomy was sufficient to remove the tumor.16, yr, M Osteoid osteoma of lamina at C-5 骨样骨瘤骨母细胞瘤骨母细胞瘤Osteoblastoma骨母细胞瘤 临床病理骨母细胞瘤 临床病理多量骨母细胞增生形成骨样组织和编织骨为特点。典型病变直径为1.5cm～2cm不等 肿瘤境界清楚，血管丰富，肿瘤体积较大时出现囊变，合并动脉瘤样骨囊肿时则多数含血囊腔。少数肿瘤可发生恶变 约30～40%发生于脊柱,颈椎、胸椎和腰椎发病率相近,肿瘤常累及附件 男性多于女性，男:女＝2:1，发病年龄90% 20～30岁 患骨局部疼痛不适，脊髓和神经压迫症状。水杨酸类药物无缓解和无明显夜间疼痛与骨样骨瘤鉴别。 治疗应手术切除，病变复发率为10-15%骨母细胞瘤 影像表现骨母细胞瘤 影像表现X线 三种表现 a：中心低密度破坏区，周围骨硬化，病灶直径大于1.5cm b：有多发小钙化的膨胀性破坏，周围伴硬化缘 c：为侵袭性表现，骨膨胀破坏，及周围软组织浸润 和混杂性钙化骨母细胞瘤 影像表现骨母细胞瘤 影像表现CT 对肿瘤内钙/骨化影显示高于平片,尤其对复杂部位肿瘤显示较好 类圆形膨胀性骨质破坏，周围有不同程度增生硬化 破坏区骨壳可中断, 周围软组织可局限性肿胀 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 病灶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 nullFig.Ashows a markedly expansile lesion involving the spinous process and laminae (arrows), with vague sclerosis suggestive of mineralization. Fig.BCT scan reveals the marked expansion of the lesion, which has a defined sclerotic rim (arrows), and its encroachment on the spinal canal. Matrix mineralization (arrowheads), 16, yr, M. osteoblastoma of C-3 Fig.A L radiographFig.B CT骨母细胞瘤nullAxi. T1WI FigC and Sag. T2WI FigD show the mass (arrows) and its degree of encroachment on the spinal canal (arrowheads in c). Because of its extensive mineralization, the mass has relatively low signal intensity on the T2-weighted image. Axi. T1WISag. T2WIFigCFigD:骨母细胞瘤nullFigE骨母细胞瘤nullFigA: CT scan shows a destructive, expansile lesion of the left lateral side of C-1 (arrows) with small foci of mineralized matrix peripherally (arrowheads) and invasion of the surrounding soft tissues and foramen transversarium. FigB: Coronal T2-weighted MR image shows high signal intensity within the mass (arrows). FigC: Digital subtraction angiogram reveals tumor stain (straight arrows) and obstruction of the left vertebral artery (curved arrow). 9, yr, M. Aggressive osteoblastoma of C1ABC骨母细胞瘤 (侵袭性)CTMRIDSAnullLeft: Anteroposterior radiograph revealing a subtly expanded lesion that is near the midline at S4-5 (arrows). Right: Axial CT scan demonstrating bone matrix within the lesion, not aggressive in appearance.16, yr, M osteoblastoma of S4-5 骨母细胞瘤nullLeft: bone scan revealing an eccentrically located area of increased uptake in the sacrum. Right: The CT scan demonstrates a minimally expanded lesion containing dense bone matrix in the right side of the lower sacrum. 16, yr, M. osteoblastoma of S4-5 骨母细胞瘤nullLateral 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 C1–6. 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 骨母细胞瘤动脉瘤样骨囊肿动脉瘤样骨囊肿Aneurysmal Bone Cyst, ABC动脉瘤样骨囊肿 临床病理动脉瘤样骨囊肿 临床病理原因不明的肿瘤样病变，分原发和继发两种 病变由大小不等的海绵状血池组成，外壁为薄壁囊状骨壳 继发者发生原有病变基础上，包括骨巨细胞瘤、骨母细胞瘤、软骨母细胞瘤和骨肉瘤等 好发于青少年，多10～20岁，女性略多 脊柱占12-30％，胸椎最常受累，其次腰椎和颈椎，骶骨罕见；病变位于椎弓及其突起 临床症状主要为病变侵犯椎管引起相应部位疼痛和神经压迫症状 可行刮除植骨术，还可栓塞治疗和放疗；总的复发率为20-30%。 动脉瘤样骨囊肿 影像表现动脉瘤样骨囊肿 影像表现X线 典型表现为脊柱附件骨显著膨胀的囊状透亮区，外侧为薄的骨壳，呈“气球状” 囊内有或粗或细的骨小梁状分隔或骨嵴动脉瘤样骨囊肿 影像表现动脉瘤样骨囊肿 影像表现CT 多呈囊状膨胀性骨破坏，骨壳菲薄 软组织密度肿块内见斑片样、条索状及不定形钙化，边缘可有硬化 有时可见液液平面，下部密度高于上部，随体位而改变。 MRI 检出液－液平面更敏感 液－液平面是本病的重要特点，T2WI上层一般为高信号，可能为浆液或高铁血红蛋白，下层为低信号，可能有含铁血黄素成分。 核素扫描 常表现为外周部位的核素摄取增加，呈“油炸圈饼”征nullFig.A and after Fig.B administration of gadopentetate dimeglumine reveal a markedly expansile lesion involving the laminae of T-3 (large arrowheads) and encroaching on the spinal canal (small arrowheads). Enhancement occurs largely in the periphery and septations of the lesion. Fig.C Sagittal T2-weighted MR image shows that the entire lesion contains fluid-fluid levels (arrows) resulting from hemorrhagic spaces and shows the extent of spinal canal narrowing. 8yr, M ABC of T3ABC动脉瘤样骨囊肿T1WI C+T1WIT2WI液-液平面(血窦)nullPhotograph of the sagittally sectioned gross specimen demonstrates the multiple blood-filled spaces (arrows) in the lesion. Fig.D血窦动脉瘤样骨囊肿nullFig.A The anteroposterior radiograph can be easily misread as normal because of the overlying bowel gas obscuring the sacrum Fig.B A lateral radiograph demonstrates only obscuration of the S-3 posterior elements (arrows) Fig.CThe lesion is more readily seen on the CT scan obtained with the patient in a prone position. This scan demonstrates a lytic lesion occupying the left S-3 ala, with a thin cortical rim surrounding the majority of the lesion. Note that the more lucent regions in the center of the lesion actually represent fluid levels. Fig.DFluid levels (short arrow) are more readily observed on a sagittal T1-weighted MR image; remember that the patient is supine in the imager and that the fluid levels on the sagittal exam would then be expected to appear vertical, as in this case. The high signal intensity portion of the fluid is blood. Most, but not all, ABCs contain fluid levels. Conversely, most lesions with substantial fluid levels are ABCs, but such levels may occur in other lesions as well. Note also in this case that there is a substantial component of the lesion located anteriorly to the fluid levels that is solid (long arrows). 14, yr, M ABC of SADCB液-液平面(血窦)动脉瘤样骨囊肿null neurysmal Bone CystFig.A Computed tomographic scan showing a lytic lesion in the posterior elements of the vertebrae at the T10-T12 level, with expansion to the vertebral body from the left. This process with a thin periosteal border enters the spinal canal, pressing the cord forward and to the right Fig.B Magnetic resonance imaging after injection with gadolinium shows a nonhomogeneous multilobular lesion at T10-T12 level, extradurally pressing the spinal cord forward and to the right, destroying the pedicle and the lamina of the vertebra. Fig.AFig.B动脉瘤样骨囊肿T1WI C+骨嗜酸性肉芽肿骨嗜酸性肉芽肿Eosinophilic Granuloma骨嗜酸性肉芽肿 临床病理骨嗜酸性肉芽肿 临床病理本病属网状内皮系统类脂质沉积病，称朗罕氏细胞组织细胞病（Langerhans cell histiocytosis） 包括三种病变：勒－雪病、韩－薛－柯病和嗜酸性肉芽肿。其孤立形式为嗜酸性肉芽肿，为良性局限性组织细胞增生，为最轻型。 椎体为主要原发部位，多单发，可多发。肉芽组织位于骨髓腔伴出血坏死和囊变；晚期常有结缔组织增生，纤维化骨化 好发于儿童及青年，男多于女 患部轻微疼痛，压痛， 伴有功能障碍治疗：保守治疗、固定、刮除、瘤内注射激素，放疗和切除等骨嗜酸性肉芽肿 影像表现 骨嗜酸性肉芽肿 影像表现 生长迅速的溶骨性病变，常导致椎体变扁和硬化，称扁平椎。 平片即可容易诊断，CT及MRI对确定病变范围很有帮助 病变延伸到周围软组织时，CT及MRI不典型，需组织学证实nullvertebra plana can be seen (arrow) in the thoracic spine, which is consistent with Langerhan's cell histiocytosis.8, yr, M of T扁平椎骨嗜酸性肉芽肿内生骨疣内生骨疣Enostosis 内生骨疣 临床病理内生骨疣 临床病理内生骨疣通常指骨岛，也称钙化性骨髓缺损、内生骨瘤 组织学上骨疣为板层骨，哈佛氏系统包埋在髓管内。病变较出生时进展，并被认为也会产生损害的病变。好发于中轴骨倾向，特别是骨盆、脊柱和肋骨。脊柱骨岛发生率仅1%。尸检14% 脊柱内生骨疣好发于胸椎(T1～T7)和腰椎（L2和L3），胸椎病变常位于中线右侧，而腰椎常位于中线左侧。病变常位于皮质下，其周围常常伴有放射状骨针。病变大小约2mmX2mm 到6mmX10mm，大于2cm为巨大内生骨疣 常无症状，偶然发现内生骨疣 影像表现内生骨疣 影像表现X线平片和CT 常具有特征性表现，为圆形或椭圆形成骨性病变，边界清楚,边缘呈“棘状放射”征或“毛刷状边缘”。周围骨小梁正常 MRI 在各序列均为低信号，棘状边缘显示清楚。周围骨髓信号正常 核素扫描 绝大多数内生骨疣显示为正常，无异常放射性核素浓聚。少数出现浓聚的病变通常为巨大内生骨疣，占33％ 病变自然病史不同，绝大多数病变变化不大，部分可缓慢生长或体积减小（31.9％）。6个月内病变直径增加25%或1年内50%时应考虑该病nullFig.A Lateral radiograph shows a sclerotic focus in the anterior portion of L-3 (arrowhead). Fig.B CT scan reveals a densely sclerotic lesion with an irregular spiculated border just beneath the anterior cortex to the left of midline (arrowheads)66-yr-old M Enostosis of L-3Fig.AFig.B内生骨疣毛刷状边缘nullFig.A Lateral radiograph reveals a sclerotic focus (large arrows) with areas of spiculated thornlike margins (small arrows). Fig.B Photomicrograph (original magnification, X150; hematoxylin-eosin stain) shows cortical bone (arrows) with irregular margins (arrowheads). 35-yr-old FGiant enostosis of L-2Fig.BFig.B 脊柱恶性肿瘤 脊柱恶性肿瘤 Malignant Tumor脊柱恶性肿瘤脊柱恶性肿瘤脊索瘤 转移性骨肿瘤 骨髓瘤 软骨肉瘤 骨肉瘤 未分化网状细胞肉瘤和PNET 淋巴瘤 白血病绿色瘤 其它：间质软骨肉瘤、纤维肉瘤均罕见 脊索瘤脊索瘤 Chordoma脊索瘤 临床病理脊索瘤 临床病理少见，起源于脊索残余，占骨病变不到4% 50%于骶骨（主要S4-S5），其次35%斜坡，15%椎体（主要C2）.也为骶骨最常见的原发骨肿瘤 肿瘤呈分叶状，有纤维假包膜，内含灰白或浅黄色胶状物；可出血、假囊腔以及肉芽样组织 肿瘤生长缓慢，局部侵袭性，不转移,偶远处转移, 主要为肺、淋巴结、蛛网膜下腔和脊髓 多男性，男：女=2-3 :1；30-60岁，高峰年龄50岁 症状多由肿瘤扩大侵犯或压迫邻近重要组织或器官所引起治疗以手术切除为主脊索瘤 影像表现脊索瘤 影像表现X线 肿瘤为溶骨性破坏，伴大的软组织肿块 骶椎患骨常膨胀，瘤内50-70%见钙化 钙化多无定形，位于病变周围 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 脊索瘤 影像表现脊索瘤 影像表现CT 主要呈溶骨性破坏 肿瘤分叶状，囊实性混杂密度，可见不规则钙化 软组织肿块 增强，轻至中度强化 不易与转移瘤鉴别脊索瘤 影像表现脊索瘤 影像表现MR T1WI：中等信号（占75% ） ；低信号（占25% ） T2WI：呈高信号，信号高于CSF 增强：明显强化 MRI在显示病变侵及的范围方面优于CT CT在确定肿瘤的性质特点方面优于MRInullFig.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nullFig.C T1WI Sagittal 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nullFig.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nullFig.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 man1-yr history of intermittent low back pain.Fig.AFig.B脊索瘤nullSagittal 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.CFig.DnullFig.E gross 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nullUpper 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 M chordoma involving S3-5脊索瘤null Fig. A and B: Preoperative axial CT scan and MR image revealing a sacral chordoma. Fig. C: Photograph of a hemisection of gross pathological specimen demonstrating complete en block resection of the sacrum. Fig. D and E: Postoperative anteroposterior and lateral radiographs.Fig.脊索瘤nullchordomaFig.AFig.B脊索瘤 转移性骨肿瘤 转移性骨肿瘤 Secondary Tumor or Metastatic Tumor 临床病理 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51～60岁最多 临床表现为疼痛、持续性、夜间加重。可出现肿块、病理骨折和压迫症状 治疗可选用对原发瘤有效的化学治疗(包括激素)和中药治疗，放疗可试用于单发转移 转移性骨肿瘤转移性骨肿瘤 影像表现转移性骨肿瘤 影像表现X线 分为溶骨型、成骨型和混合型 溶骨型：椎体广泛或局限性骨质破坏，椎体常变扁，椎间隙多保持完整。椎弓根常受侵蚀破坏 成骨型：少见。大多前列腺癌引起，少数为乳癌、鼻咽癌、肺癌和膀胱癌。呈斑片状、结节状高密度，位于松质骨内，边界清楚或不清。骨皮质多完整，骨轮廓多无改变 混合型转移兼有溶骨型和成骨型转移的骨质改变转移性骨肿瘤 影像表现转移性骨肿瘤 影像表现CT 较X线敏感 能显示局部软组织肿块的范围、大小及邻近脏器的关系 溶骨型为松质骨和或皮质骨的低密度缺损区，常伴软组织肿块 成骨型为松质骨内斑点状、片状、棉团状或结节状边缘模糊的高密度灶，一般无软组织肿块 混合型兼有两者改变 MRI 能检出X线CT甚至核素显像不易发现的病灶 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nullMagnetic resonance imaging study of the spine shows a destructive lesion in the second lumbar vertebra with extension into the spinal canal.Abdominal computed tomographic scan shows hepatic metastases and an irregular mass in the region of the pancreas. Fig.AFig.BFig.BFig.Anullsclerotic metastasesnullFigure. 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 FMetastatic breast cancernullFracturenullFracture stenosisnullmassnullExtensive osseous metastases from lung carcinoma. Anterior (left) and posterior (right) wholebody bone scintigrams show multiple, randomly distributed foci of abnormal radiotracer uptake. The focivary in size and intensity.nullFig.A : Sagittal T2-weighted MR image demonstrating involvement of the posterior elements of L-3 (arrow). Fig.B :