骨髓瘤的临床与影像学诊断

骨髓瘤的临床与影像学诊断（Clinical and imaging diagnosis ofmyeloma）多发性骨髓瘤 (multiple myetoma, 为一复杂而特殊的恶性肿瘤 mm 或骨髓瘤).据统计, 其发病率 (0.2～0.4 / 10万人口) 较其它全部恶性肿瘤的总和还多, 其死亡率也较其它恶性肿瘤高3～10倍, 而临床诊出率则仅为其发病率的0.5% 左右.误诊率高达54% ～100%.因此, 研究骨髓瘤的病因、病理、临床表现及影像学特征减少误, 对提高此病的正确诊断率, 诊率均具有重要意义 (漏).1 骨髓瘤的病因、病理及分类骨髓瘤是浆细胞异常增生的恶性肿瘤, 属浆细胞病的一种.它通常分为孤立性骨髓瘤、多发性骨髓瘤、髓外骨髓瘤和浆细胞白血病四种类型.目前多数学者按病也可按瘤细胞的病理分化程度灶数目将其分为单发性骨髓瘤和多发性骨髓瘤两种.分为高分化型 (小细胞型) 和低分化型 (大细胞型根据蛋白电泳特点 (按m蛋).白性质不同) 分为igg (50～60%) 、iga 7% ～42%) 、igd、 ige等型.骨髓瘤的病因目前尚不明确, 一般认为c - myc基因重组、淋巴因子中的白介素(b) 等因素与其发病有关病理上, 病变始于红骨髓, 呈局限性或弥漫性大.量浆细胞浸润, 瘤细胞聚集成堆, ～90 引起某处或多处的可占骨髓内细胞的5%%骨质疏松或骨质破坏, 其中以脊柱、肋骨、颅骨最多见, 并且尸检证实约70% 的骨髓瘤有髓外浸润, 以肝、脾、肾和淋巴结最多见, 瘤细胞聚集于脏器与组织间形成实质性肿块.瘤组织在骨髓腔内形成灰红色结节骨髓瘤引起骨质疏松或骨质破坏的机理是.随.着瘤细胞群体的不断增殖, 瘤细胞激活破骨细胞, 使其数量增多, 活性增加, 促进骨质溶解吸收瘤组织广泛增生可引起骨质疏松.由于骨质溶解吸收加快, 肾小球.滤过率减低, 使得血钙增高, 骨质脱钙, 从而加重了骨质疏松的程度.2 临床表现及实验室检查骨髓瘤好发于50～60岁的男性, 以颅骨、脊柱、肋骨、骨盆等部位最易受累.骨痛常为早期和主要症状, 并随病情发展而加重.以腰骶部和胸背部疼痛最为常见可出现病理性骨折和软组织肿块.此外, 临床上可出现感染、贫血、出血倾向、.泌尿系症状, 肝、脾、淋巴结肿大等.实验室检查可出现多种异常.贫血、全血细胞减少、血沉增快、血液中可见大则称为浆细胞性白血病.骨髓涂片量骨髓瘤细胞.若骨髓瘤细胞超过2000个 / mm3.可见浆细胞异常增生, 占有核细胞的15% 以上, 并伴有质的改变.血液生化检查.血清蛋白电泳r球蛋显示血清球蛋白增高而白蛋白降低或正常、出现a / g比例倒置.白升高和出现m蛋白; 血清钙增高; 90% 以上患者有蛋白尿患者尿液中出～60% 40%现本 - 周 (bence 氏蛋白 jones).3 影像学检查及表现3.1 x线检查.在ct及mri出现之前, x线检查是骨髓瘤的主要影像学检查手段.因此, 有关骨髓瘤的早期x线表现、特殊表现及典型表现、x线分型及鉴别诊断, 许多作者均作了广泛而深入的探讨, 积累了丰富的经验.主要x线表现及分型骨髓瘤的主要x线表现有骨质疏松、骨质破坏、骨 3.1.1:质硬化和软组织肿块.根据上述表现不同, x线上一般分为5型① 骨质正 (或6型).Normal type: there was no obvious X ray manifestation of bone. Osteoporosis: Universal osteoporosis is the main X-ray manifestationA double concave deformation, vertebral body. Destruction of bone (without soft tissue mass): the bone is destroyed by insect like boneThe ribs, pelvis was punched out), change (skull) or large osteolytic destruction (like limbs long Guan Gu). Bone massDestruction with soft tissue mass. Bone sclerosis type: characterized by simple, diffuse, elevated density, or during bone destructionSign of bone sclerosis. The single hair: the characteristics of the lesions occur in long bone metaphysis, showing cystic orMultiple bone destruction can be accompanied by bony mass or pathological fracture, and periosteal reaction is rare.3.1.2 early X-ray findings and rare manifestations: the upper margin of the ribs, bone cortex or internal and external limitations of the skull plate thinningUneven thickness and corrugated mark were the early X-ray findings of myeloma. Its rare X-ray findings are irregularFuzzy bonedestruction radial spicules occur around the soft tissue mass in the bone surrounding the bone hard failure zoneOf.3.2 CT inspection and performance:The CT scan shows its advantages with unique high-density resolution and clear cross sectional images. It can clearIt clearly shows the internal structure, soft tissue, pathological changes, extent and the invasion of the internal and external medullary cavitySuch degree. It is reported that CT shows the extent of intramedullary infiltration of bone tumors compared with the pathological results, the accuracy rate is 91.3% to 99.1%. In myeloma cases, CT is especially valuable in patients who have bone pain and who have negative X-ray findings or whose lesions are unclearBecause bone destruction occurs, later cortical bone on the plain film can obscure the manifestation of intramedullary lesions. The chief of myelomaCT is characterized by osteolytic destruction of bone, irregular edges, blurring, destruction of cortical bone, and sometimes periosteal proliferationLocal soft tissue mass. In addition, adjusting the proper window width and window position during the CT scan is helpful for the detection of minor diseasesVariable.3.3 MRI inspection and performance:Because of the advantages of MRI imaging, MRI has become the best imaging method for the evaluation of bone marrow diseases. It is able to observe the whole body bone marrow changes without trauma and overcome some limitations of bone marrow aspiration and / or biopsy. Effective combination of these two methods will provide more accurate information for clinical diagnosis and follow-up. The MRI of normal bone marrow hasShort T1, medium T2 signal characteristics, the production of this signal is the structure of fat and water, where fat is to produce a signalThe main structure of. Human marrow at different ages, red pulp and yellow pulp content is not the same, so the signal strength can be different. When the bone marrow is invaded, the fat cells in the bone marrow are replaced by tumor tissue, and the T1WI signal is low and the T2WI is highSignal. Libshitz HI reported the MRI findings of 32 cases of multiple myeloma arising from the lumbar spine and combined with clinical practiceLaboratory examinations and bone marrow biopsies show that the MRI findings of myeloma depend not only on the extent of the lesion, but also on the lipidThe range of fat substituted, the greater variability, so even in the same age group. Both T1WI and T2WI are availableLow and moderate signal intensity is present, and high signal foci can be seen during fat invasion.Some scholars classified the MRI manifestations of myeloma: Moulopoulos and so on, observed 20 cases of vertebral body multipleThe MRI findings of myeloma (T1WI, low signal, T2WI high signal) were classified into diffuse, mottled andThere are three focal types. Stabler and so on, through the cytological contrast, the MRI manifestations of myeloma are divided into five types, that is, positiveRegular, diffuse, focal, diffuse, focal, salt, and pepper (salt, and, Pepper, sign)The results showed that a small amount of plasma cells infiltrated in the bone marrow, the number of adipocytes was normal or slightly increased, and the fat / water ratioThere were no changes and no abnormal changes in MRI signal were normal. Diffuse, focal or diffuse foci were observedThe bone marrow fat cells were extensively replaced or tumor cells aggregated into nodules, and T1WI showed diffuse and nodular low signal;Bone marrow infiltration of salt and pepper is associated with diffuse small granular tumor cells and peripheral fat cells and parts of the bone marrowThe red bone marrow mixes with each other to form T1WI black and white dots or small grainy mixed signal shadows. Among them, diffuse type andFoci are two common types.The MRI classification of these myeloma helps to fully observe the status of bone marrow abnormalities, various types of MRI findings andThere is some relation between clinical stage and prognosis. If the normal type and salt and pepper type show, the degree of bone marrow infiltration is mild,It is seen in stage I myeloma, and other types are found in stage II and III. Therefore, Rahmouni and Moulopoulos et alThe study concluded that MRI, especially the enhanced scan, could help to observe the response of multiple myeloma to treatmentThe remission signal disappeared, or although the lesion was present, the lesion was not enhanced or only marginal enhancement. WakaharaDiffuse to focal or mottled type suggests only partial remission of the treatment.3.4 radionuclide examination and manifestation:Radionuclide imaging, bone scintigraphy, is a highly sensitiveimaging technique. Its imaging principle is: 99mTc or113mIn labeled phosphorus or phosphonate compounds are chemically adsorbed with crystalline surfaces and organic matter (bone glue)Combine and deposit in a bone to cause bone tissue to gather radioactivity and to image. In bone metastases or primary malignant tumorsWhen the lesion is located, the local blood flow is increased, and more frequent bone tissues are collectedThe abnormal drug concentration zone appeared on the imaging drug. Because of its high sensitivity, it can be found early lesions,The X-ray showed that the lesion was advanced 3~6 months earlier. Bone scan can show the skeletal invasion of myeloma,Characterized by radioactivity, accumulation, or defect.Although bone scintigraphy has a Gao Min sensibility, it is still a nonspecific imaging techniqueIn the diagnosis of myeloma, comprehensive diagnosis should be made in combination with clinical, laboratory and bone marrow aspiration testsBroken.4 clinical diagnosis and differential diagnosisThe clinical manifestations of multiple myeloma are very complicated. Most of them are occult and have different symptoms, but they can last for 1~5 yearsAsymptomatic stage (preclinical stage), with multiple complications as a precursor. Therefore, the diagnosis of MM must be integratedClinical manifestation, laboratory examination, imaging examination and pathological examination, etc.. The following points can be used as the primary diagnosisAccording to: rational fracture of systemic bone pain accompanied by disease. Osteolytic bone destruction. Osteoporosis accompanied by bloodAnemia and anemia. Urine Bence Jones protein positive. Serum globulin increased, A/G ratio inversion, proteinElectrophoresis of r- globulin elevated and showed M protein composition. The increase of immunoglobulin. The bone marrow biopsy and smear of boneMyeloma cells are at least 15%, abnormal in morphology. The renal failure. The following points suggest that the disease hasSignificance: one patient suffered from multiple bone pain, pathological fracture, anemia and renal failure due to unknowncauses,Think of the disease. Imaging examination revealed diffuse osteoporosis, that is, laboratory examinations should be carried out to detect povertyIncreased serum and serum globulin, A/G ratio inversion, protein electrophoresis, elevated r- globulin, or M protein composition, urineBence Jones protein positive, it should be highly suspected of the disease. X-ray features typical bone destruction and sclerosisBasically can diagnose. If not typical, it is supplemented by laboratory findings and can be diagnosed basically.In the differential diagnosis, clinical attention should be paid to reactive plasma cell hyperplasia, and benign monoclonal globulinIdentification of blood. The diseases that X-ray needs to differentiate are bone metastasis, hyperthyroidism, senile osteoporosis and boneQuality and decalcification of giant cell tumor, osteitis deformity etc.. Vertebral hemangiomas are similar to the CT findings of myeloma and must be notedIdentify。

治疗意义：了解骨质疏松程度有助于制定针对性的治疗方案，提高疗效
骨密度测定表现：多发性骨髓瘤患者的骨密度普遍增高，呈现骨质硬化的特征。
原因：骨质硬化是由于骨髓瘤细胞在骨髓内大量增殖，导致骨质密度增加。
诊断价值：骨质硬化是多发性骨髓瘤的重要影像学特征之一，对于诊断和评估病情具 有重要意义。
与其他疾病的鉴别：骨质硬化也可见于其他骨疾病，如骨关节炎、骨折等，但骨髓 瘤的骨质硬化通常更为弥漫和严重。
血管侵犯是骨髓瘤细胞侵犯血管壁的一种表现。 MRI检查可以清晰地显示骨髓瘤细胞侵犯血管的情况。 血管侵犯通常表现为血管壁增厚、管腔狭窄或闭塞等异常信号。 血管侵犯是评估多发性骨髓瘤病情和预后的重要指标之一。
多发性骨髓瘤的 PET-CT表现
肿瘤代谢活性的 概念
PET-CT在肿瘤代 谢活性检测中的 原理
骨膜反应表现为骨膜增厚、 骨质破坏和骨膜新生骨形成
骨膜反应是骨髓瘤细胞侵犯 骨膜时引起的骨膜反应
骨膜反应在多发性骨髓瘤的影 像学表现中具有一定的特征性
骨膜反应有助于多发性骨髓 瘤的诊断和鉴别诊断
感谢您的观看
汇报人：XX
多发性骨髓瘤的 PET-CT表现
肿瘤代谢活性与 疾病进展和预后 的关系
肿瘤主要分布在骨髓腔内 可侵犯骨皮质和骨膜 可累及骨髓、淋巴结和软组织 肿瘤分布情况与疾病分期相关
疗效评估标准：根据PET-CT的SUV值和病灶变化情况评估疗效
SUV值的意义：SUV值越高，肿瘤活性越强，疗效越差
病灶变化情况：通过观察病灶大小、形态、密度等变化情况评估疗效
疗效评估的临床意义：为后续治疗方案的制定提供依据，有助于提高患者的生存率和生活质 量
多发性骨髓瘤的骨 密度测定表现
骨密度测定表现：多发性骨髓瘤患者骨密度普遍降低，骨质疏松明显 发生机制：肿瘤细胞侵蚀骨质，破坏骨小梁结构，降低骨密度

多发性骨髓瘤影像学
多发性骨髓瘤是一种以浆细胞在骨髓内异常增殖而引起的恶性肿瘤，临床表现多样，影像学检查是诊断该病的重要手段之一。

本文将介绍
多发性骨髓瘤的影像学表现和诊断要点。

在X线检查中，多发性骨髓瘤的骨质破坏表现为多发性小圆形透亮区，骨质呈“蜂窝状”改变。

这种表现称为“骨砂样改变”，是多发性骨髓瘤的特征性X线征象之一。

此外，骨瘤、软组织肿块和骨质破坏也可
见于X线片上。

CT检查对于评估骨髓瘤的生长情况和周围结构的受累程度具有重
要意义。

在CT图像上，多发性骨髓瘤呈多灶性分布，可见到病灶周围软组织肿块和邻近组织器官的受累情况。

CT检查有助于及时明确病变
的范围和程度，指导临床治疗。

MRI检查是多发性骨髓瘤影像学评估的重要手段之一。

MRI技术对
软组织的显示更为敏感，可以清晰地显示骨髓瘤的部位、大小、形态
及周围组织的受累情况。

在MRI图像上，多发性骨髓瘤呈“低信号”或“等信号”影像，病变周围软组织也可能受累。

核素显像技术在多发性骨髓瘤的诊断中扮演着重要的角色。

放射性
同位素的摄取和分布情况能够清晰显示骨骼的代谢活动和异常改变，
对于病变的定位和评估至关重要。

核素显像技术可以帮助医生更准确
地进行诊断，为患者制定个性化的治疗方案提供依据。

综上所述，多发性骨髓瘤的影像学检查是诊断和治疗该病的重要手段。

X线、CT、MRI和核素显像技术各有优势，结合应用可以全面评估病变的特点和范围，为患者的治疗提供指导。

在临床实践中，医生应根据患者的具体情况选择适当的影像学检查方案，做到及时明确诊断，有效进行治疗。

cystoperitoneal shunting ［J ］.Neurosurgery,1996,39(6):1108-13.［6］Di Rocco C,Tamburrini G,Caldarelli M,et al.Prolonged ICP monitoring in sylvian arachnoid cysts ［J ］.Surg Neurol,2003,60(3):211-8.［7］Nowostawska E,Polis L,Kaniewska D,et al.Neuroendoscopic techniques in the treatment of arachnoid cysts in children and comparison with other operative methods ［J ］.Childs Nerv Syst,2006,22:599-604.［8］Marin-Sanabria EA,Yamamoto H,Nagashima T,et al.Evaluationof the management of arachnoid cyst of the posterior fossa in pediatric population:experience over 27years ［J ］.Childs Nerv Syst,2007,23(5):535-42.［9］Tamburrini G,D'Angelo L,Paternoster G,et al.Endoscopic management of intra and paraventricular CSF cysts ［J ］.Childs Nerv Syst,2007,23(6):645-51.收稿日期：2008-11-10作者简介：陈任政（1971-），男，在读硕士研究生，副主任医师通讯作者：成官迅，E-mail:chengguanxun@多发性骨髓瘤的临床与影像诊断陈任政，张刚，成官迅，张雪林(南方医科大学南方医院影像中心，广东广州510515)摘要:目的探讨多发性骨髓瘤的X 线、CT 及MRI 表现，提高对多发性骨髓瘤的影像诊断水平。