脊柱转移瘤影像学诊断

Natalie J. M. Dailey Gillian Lieberman, MD Radiologic Diagnosis of Spinal Metastases Natalie J. M. Dailey, Harvard Medical Student Year III Gillian Lieberman, MD September 2002 2 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s Presenting Story • 70 year old male • Presents to the hospital for laparascopic cholecystectomy • Receives pre-operative chest x-ray 3 Natalie J. M. Dailey Gillian Lieberman, MD Pre-operative Chest X-Ray: PA view Findings: From BIDMC PACS ™Decreased volume of right lung field ™Material of density greater than cortical bone ™Abnormal lobulated pleural thickening 4 Natalie J. M. Dailey Gillian Lieberman, MD Pre-operative Chest X-Ray: lateral view From BIDMC PACS Findings: ™Major fissure ™Right middle lobe opacity ™Objects of density greater than cortical bone ™Loculations 5 Natalie J. M. Dailey Gillian Lieberman, MD What’s going on here?!! 6 Natalie J. M. Dailey Gillian Lieberman, MD The Importance of Obtaining a Full Patient History • Past history of renal cell carcinoma with resection in 1999 (hence sutures) • Past history of non-small cell lung carcinoma with resection of right middle lobe 7/02 (hence more sutures and decreased right lung volume) • Current complaints of low back pain, urinary retention, and paresthesias in right lower extremity… 7 Natalie J. M. Dailey Gillian Lieberman, MD Differential Diagnosis ™Knowing that our patient has a history of two types of cancer that frequently metastasize ™Knowing of his symptoms of back pain and parasthesias Metastatic Disease of the Spine must be at the top of our list. 8 Natalie J. M. Dailey Gillian Lieberman, MD Differential Diagnosis for Chest X-Ray Findings ™Multiple myeloma-”punched out” lytic lesions ™Paget’s-large, sclerotic bones;coarse trabeculae ™Infection ™Infarction ™Trauma ™Primary bone tumor Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 9 Natalie J. M. Dailey Gillian Lieberman, MD Common Bone Metastases– Radiographic Appearance Lytic Lesions: ™Breast ™Lungs ™Kidney ™Thyroid Sclerotic Lesions: ™Breast ™Prostate Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 10 Natalie J. M. Dailey Gillian Lieberman, MD Example of Sclerotic Lesions– Comparison Patient I Patient diagnosed with prostate cancer Courtesy of Ferris Hall, MD ™Sclerotic bone lesions 11 Natalie J. M. Dailey Gillian Lieberman, MD Common Sites of Bone Metastasis ™Spine ™Pelvis ™Ribs ™Skull ™Proximal humerus or femur Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 12 Natalie J. M. Dailey Gillian Lieberman, MD Classical Presentation of Metastatic Bone Disease ™History of new onset bone pain (present in our patient) ™Pathologic fracture (no current indication of this) Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 13 Natalie J. M. Dailey Gillian Lieberman, MD How to Work Up Possible Spinal Metastases ™If no symptoms, first do a bone scan. ™If positive scan, perform focused radiography. ™If symptoms, evaluate sites of pain by radiography. ™If radiograph is negative or equivocal, perform bone scan. Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 14 Natalie J. M. Dailey Gillian Lieberman, MD How to Work Up Possible Spinal Metastases (cont’d) ™If radiograph and bone scan disagree, remember that bone scan is more sensitive. Use CT or MRI as follow-up study. Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 15 Natalie J. M. Dailey Gillian Lieberman, MD Skeletal Scintigraphy ™Nuclide usually polyphosphates labeled with technetium-99 ™IV injection ™Visualization after 2 hours ™Increased uptake in areas of increased bone turnover: tumor, infection, fracture, arthritis, periostitis Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 16 Natalie J. M. Dailey Gillian Lieberman, MD Bone Scan of Spinal Metastases-Comparison Patient II Patient with renal cell carcinoma metastatic disease Lesions with increased uptake Enlarged soft tissue due to lymphedema Courtesy of K.P. Donohoe, MD. 17 Natalie J. M. Dailey Gillian Lieberman, MD Bone Scan of Spinal Metastases- Comparison Patient III Patient with colon cancer Areas of increased radionuclide uptake likely to be metastatic disease Courtesy of K.P. Donohoe, MD Area of increased uptake likely to be degenerative joint disease 18 Natalie J. M. Dailey Gillian Lieberman, MD Findings on Abdominal X-Ray- Comparison Patient III PA view: ™“Pedicle sign”– destruction of cortical outline of pedicle ™Malalignment ™Increased radiolucency or radiopacity From BIDMC PACS Courtesy of K.P. Donohoe, MD. 19 Natalie J. M. Dailey Gillian Lieberman, MD Findings on Chest X- Ray– Comparison Patient III(cont’d) Lateral view: ™Compression fractures/vertebral body collapse ™Changes in bone density ™Cortical destruction ™Nearby soft tissue mass From BIDMC PACS Courtesy of K.P. Donohoe, M.D. 20 Natalie J. M. Dailey Gillian Lieberman, MD After Radiography Although our patient did not exhibit classical signs of spinal metastases on plain radiographic studies, his history indicates a high suspicion for metastatic disease. What comes next? 21 Natalie J. M. Dailey Gillian Lieberman, MD CT vs. MR Advantages of CT ™Better visualization of cortical destruction ™Good visualization of replacement of fatty marrow with soft tissue density of metastasis Advantages of MR ™Visualizes the relationship between the vertebra and spinal cord (neurological symptoms) ™No need to inject contrast to view vascular structures Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 22 Natalie J. M. Dailey Gillian Lieberman, MD Axial Spinal Anatomy From Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform Vertebral Body Spinal Cord Rib Paraspinal Musculature Lungs Sternum 23 Natalie J. M. Dailey Gillian Lieberman, MD Anatomy (cont’d)– Vertebral Detail Pedicle Neural Foramen Spinous Process Spinal Cord CSF Space Exiting vertebral nerve From Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform 24 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s CT Scan From BIDMC PACS Findings with Lung Window Settings: Loculated Pleural Effusion (13 HU indicating fluid); probably resulting from resection of RML 25 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s CT Scan (cont’d) From BIDMC PACS ™Change in density within vertebral body ™Loss of cortical margin Findings with CT Bone Window: 26 Natalie J. M. Dailey Gillian Lieberman, MD Characteristics of MR Studies ™T1-weighted images are best for determining extent of marrow involvement ™T2-weighted images are best for examining cortical bone destruction and soft-tissue extension ™T2 with fat suppression: signal from fat is suppressed allowing for better contrast between normal and diseased bone marrow and better visualization of free water/edema Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1): 115-135. 27 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study From BIDMC PACS Findings on T1-weighted Image (sagittal view): ™Low-signal intensity lesions in vertebral bodies (Normal marrow should approach the brightness of subcutaneous fat.) ™CSF– low-signal intensity 28 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study (cont’d) From BIDMC PACS More Findings on T1- Weighted Imaging (Axial View): ™No apparent impingement of spinal cord ™Involvement of right pedicle ™Low-signal intensity lesion in vertebral body 29 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study (cont’d) From BIDMC PACS Findings on T1- Weighted Image (sagittal view): ™Low-signal intensity lesions in vertebral bodies ™CSF– low-intensity signal ™Bright subcutaneous fat 30 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study (cont’d) From BIDMC PACS Findings on T2- Weighted Image: ™CSF– high- signal intensity ™Lesions within vertebral body ™Obliteration of neural foramen (compare with other side) 31 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study (cont’d) From BIDMC PACS Findings on T2-weighted image with fat suppression: ™Unsuppressed marrow lesions (Signal from normal marrow should be suppressed with fat.) ™Degenerative change 32 Natalie J. M. Dailey Gillian Lieberman, MD Our Patient’s MR Study (cont’d) Findings on T2-weighted image with fat suppression: ™Unsuppressed marrow lesions (indicating the presence of edema) ™Compression fracture From BIDMC PACS 33 Natalie J. M. Dailey Gillian Lieberman, MD So what do we do now that we know that it’s metastatic disease? 34 Natalie J. M. Dailey Gillian Lieberman, MD Reasons for Performing CT-guided Bone Biopsy ™Distinguish between metastatic disease and infection ™To make a pathological diagnosis in order to determine further treatment (especially in our case with two primary malignancies) Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. 35 Natalie J. M. Dailey Gillian Lieberman, MD Approach for CT-Guided Bone Biopsy From BIDMC PACS 36 Natalie J. M. Dailey Gillian Lieberman, MD Pathology Results: Atypical squamous cells consistent with non-small cell lung cancer. Types of Non-Small Cell Lung Cancer Cotran, RS, Kumar, V, and Collins, T. Robbins Pathological Basis of Disease. Sixth edition. W.B. Saunders Company: Philadelphia, 1999. 37 Natalie J. M. Dailey Gillian Lieberman, MD Treatment Options/Prognosis Because our patient has widespread metastatic disease, his most likely treatment option is radiation therapy. This therapy is only palliative. It is likely to reduce his pain and may decrease any compression on his spinal cord, possibly ameliorating his neurological symptoms. However, his five-year survival probability is very low. Abeloff, MD, Armitage, JO, Lichter, AS, and Niederhuber, JE. Clinical Oncology. Second edition. Churchill Livingstone: New York, 2000. 38 Natalie J. M. Dailey Gillian Lieberman, MD Summary of Course of Action for Metastases 1. Bone Scan/Plain Film Radiography depending on whether or not the patient is symptomatic 2. CT and/or MRI 3. Bone Biopsy for Pathological Diagnosis, if necessary 39 Natalie J. M. Dailey Gillian Lieberman, MD Special thanks to: ™Chad Brecher, MD ™K.P. Donohoe, MD ™Daniel Saurborn, MD ™Ferris Hall, MD ™Pamela Lepkowski ™Gillian Lieberman, MD ™Larry Barbaras and Cara Lyn D’amour 40 Natalie J. M. Dailey Gillian Lieberman, MD References Abeloff, MD, Armitage, JO, Lichter, AS, and Niederhuber, JE. Clinical Oncology. Second edition. Churchill Livingstone: New York, 2000. Cotran, RS, Kumar, V, and Collins, T. Robbins Pathological Basis of Disease. Sixth edition. W.B. Saunders Company: Philadelphia, 1999. Digital Anatomist: http://www9.biostr.washington.edu/cgi-bin/DA/imageform Juhl, JH, Crummy, AB, and Kuhlman, JE. Paul and Juhl’s Essentials of Radiologic Imaging. Seventh edition. Lippincott Williams and Wilkins: New York, 1998. Stabler, A. Imaging of spinal infection. Radiol Clin North Am. 39(1): 115-135. Radiologic Diagnosis of Spinal Metastases Our Patient’s Presenting Story Pre-operative Chest X-Ray: PA view Pre-operative Chest X-Ray:�lateral view What’s going on here?!! The Importance of Obtaining a Full Patient History Differential Diagnosis Differential Diagnosis for Chest X-Ray Findings Common Bone Metastases– Radiographic Appearance Example of Sclerotic Lesions– Comparison Patient I Common Sites of Bone Metastasis Classical Presentation of Metastatic Bone Disease How to Work Up Possible Spinal Metastases How to Work Up Possible Spinal Metastases (cont’d) Skeletal Scintigraphy Bone Scan of Spinal Metastases-Comparison Patient II Bone Scan of Spinal Metastases-Comparison Patient III Findings on Abdominal X-Ray- Comparison Patient III Findings on Chest X-Ray– Comparison Patient III(cont’d) After Radiography CT vs. MR Axial Spinal Anatomy Anatomy (cont’d)– Vertebral Detail Our Patient’s CT Scan Our Patient’s CT Scan (cont’d) Characteristics of MR Studies Our Patient’s MR Study Our Patient’s MR Study (cont’d) Our Patient’s MR Study (cont’d) Our Patient’s MR Study (cont’d) Our Patient’s MR Study (cont’d) Our Patient’s MR Study (cont’d) So what do we do now that we know that it’s metastatic disease? Reasons for Performing CT-guided Bone Biopsy Approach for CT-Guided Bone Biopsy Pathology Results: Treatment Options/Prognosis Summary of Course of Action for Metastases Special thanks to: References