【双语病例】骨原发性淋巴瘤一例影像表现

23 8月

History

A 21-year-old man with left knee pain for one year.

21岁男性,左膝关节疼痛1年余。

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

1.The knee Radiographs is normal?

这是一幅正常的膝关节正侧位X线片?

True

False

【双语病例】骨原发性淋巴瘤一例影像表现

Additional questions

2.Which bone is abnormal?

哪块骨骼有异常?

Femur 股骨

Fibula 腓骨

Patella 髌骨

Tibia 胫骨

3.Which of the following best describes the findings?

下列对病变的描述,哪一项更合适?

A. Permeative pattern with subtle periosteal reaction laterally

胫骨穿凿样改变伴外侧轻度骨膜反应

B. Well-defined lytic lesion with sclerotic margins

边界清楚的囊性区,伴周围硬化边

C. Pathologic fracture

病理性骨折

D. Both A and C

【双语病例】骨原发性淋巴瘤一例影像表现

CT images

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

4.What is the most likely diagnosis?

最准确的诊断是哪项?

Bone lymphoma 骨淋巴瘤

Osteosarcoma 骨肉瘤

Osteomyelitis 骨髓炎

Eosinophilic granuloma 嗜酸性肉芽肿

【双语病例】骨原发性淋巴瘤一例影像表现

MR images

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

5.What is the most common site of primary bone lymphoma?

骨原发性淋巴瘤最易发生于哪个部位?

Femur 股骨

Fibula 腓骨

Pelvis 骨盆

Tibia 胫骨

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

选择题答案:

  1. False
  2. Tibia
  3. Permeative pattern with subtle periosteal reaction laterallyThere is a permeative moth-eaten appearance of the proximal tibia with subtle periosteal reaction.
  4. Bone lymphomaBone lymphoma is the most likely diagnosis given the permeative infiltrating bone marrow without any extraosseous or cartilaginous matrix.
  5. Femur

【双语病例】骨原发性淋巴瘤一例影像表现

Findings and Diagnosis

Findings

  • Initial radiograph demonstrates moth-eaten/permeative appearance of the proximal tibia with underlying areas of sclerosis and ill-defined margins. No pathologic fracture is seen.最初的X线片可见胫骨近端骨质硬化,边界不清,内可见虫蚀样/穿凿样骨质破坏。无明显病理性骨折。
  • CT images demonstrate moth-eaten/permeative appearance of the proximal tibia with ill-defined margins and aggressive periosteal reaction.CT示胫骨近端虫蚀样/穿凿样骨质破坏,边界不清,局部可见骨膜反应。
  • MRI demonstrates heterogeneously increased T2 and decreased T1 signal involving the proximal left tibia. This is most suggestive of primary bone lymphoma versus primary osseous neoplasm.MRI示左胫骨近端病灶T2WI呈不均匀稍高信号,T1WI呈低信号。在原发性骨骼肿瘤中,首先考虑骨原发性淋巴瘤。
Differential Diagnosis

  • Primary bone lymphoma骨原发性淋巴瘤
  • Osteosarcoma骨肉瘤
  • Osteomyelitis骨髓瘤
  • Metastatic disease转移瘤
DiagnosisPrimary bone lymphoma骨原发性淋巴瘤

【双语病例】骨原发性淋巴瘤一例影像表现

Discussion

Primary bone lymphoma accounts for less than 5% of primary bone tumors. It is also called reticulum cell sarcoma, malignant lymphoma of the bone, and osteolymphoma. Most of these are non-Hodgkin’s lymphoma with around 5% to 6% of cases being Hodgkin’s lymphoma. It is important to identify primary bone lymphoma from other primary bone tumors because of excellent treatment response and much better long-term prognosis compared with most other primary bone malignancies.骨原发性淋巴瘤约占全部骨骼原发肿瘤的不到5%,又称网状细胞肉瘤、骨恶性淋巴瘤、骨淋巴瘤。其中大部分是非霍奇金淋巴瘤,而仅有5%-6%是霍奇金淋巴瘤。该肿瘤与其他原发性骨骼恶性肿瘤相比,治疗效果和长期预后都较好,所以定性诊断非常重要。

Epidemiology

  • Can occur at any age, peak in fourth and fifth decades.可发生于任何年龄段,尤其是40-50岁。
  • Males > females.男性多于女性
  • Femur is the most common (25%) site of involvement. Other sites being pelvis, humerus, head and neck, and tibia.最常发生于股骨(25%),其次为骨盆、肱骨、头颈、胫骨。
Clinical Feature

  • Primary lymphoma of bone manifests with insidious and intermittent bone pain present for months.骨原发性淋巴瘤常见症状为隐匿性、间歇性疼痛,病程可达数月。
  • Other signs and symptoms include the following: 1.Local swelling;2.Palpable mass;3.Systemic symptoms such as weight loss and fever其他症状包括:1.局部肿胀;2.肿胀;3.全身症状,如体重减轻、发热等。
  • Vertebral involvement can cause radicular symptoms and can even lead to compression of the spinal cord.如果发生于椎体,可引起神经根症状,甚至可以压迫脊髓。
【双语病例】骨原发性淋巴瘤一例影像表现Imaging Feature

The criteria for diagnosis of primary bone lymphoma initially suggested by Coley in 1950 with minor modifications are as follows: “lymphoma presenting in an osseous site with no evidence of disease elsewhere for at least 6 months after diagnosis.” The presence of regional lymph node involvement does not exclude a diagnosis of primary bone lymphoma, but histologic confirmation of the diagnosis is necessary.骨原发性淋巴瘤的诊断标准最早在1950年由Coley提出,后略微修改为:确诊淋巴瘤时仅有骨骼病变,且6个月内未发现其他部位淋巴瘤。区域性淋巴结肿大并不能排除骨原发性淋巴瘤的诊断,但需要病理证实。
Radiographs/CT

  • Three patterns:X线/CT表现共包括3型:

    1. Near-normal-appearing bone on radiographs with abnormal bone scan and MRI.

    X线上骨骼无明显异常表现,MRI可见异常改变。

    2. Focal lytic lesion with geographic margins or diffusely permeative/moth-eaten appearance with cortical destruction and soft-tissue involvement. This can be associated with a sequestrum sometimes, which helps distinguish this from osteosarcoma.

    边缘不规则的局限性囊变区,或弥漫性穿凿样/虫蚀样改变,伴有骨皮质破坏、软组织受侵。有时病灶内可见死骨片,有助于与骨肉瘤鉴别。

    3. Mixed sclerotic-lytic lesion, more common with metastatic bone lymphoma.

    硬化-囊变混杂区,多见于转移性淋巴瘤。

  • Periosteal reaction is seen in about 60% of cases and is usually aggressive with lamellated or layered appearance, wherein layers of periosteal bone are seen parallel to the long axis of the bone (also called onion-peel appearance), or broken, when discontinuous or interrupted periosteal new bone is seen.约60%的病例可见骨膜反应,多为板状或层状。其中层状骨膜反应多平行于骨骼长轴(又称葱皮样)。骨膜新生骨发生断裂或不连续。
MR
  • T1-weighted images: Low signal intensity compared with the normal marrow and lower signal than the muscle.T1WI:与正常骨髓相比呈低信号,低于肌肉信号。
  • T2-weighted images: Increased signal with peritumoral edema and extensive marrow disease.T2WI:呈高信号,可见瘤周水肿及广泛的骨髓受侵
  • Contrast-enhanced images: Demonstrate areas of enhancement within the lesion.增强扫描:病灶内可见强化。

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

【双语病例】骨原发性淋巴瘤一例影像表现

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