骨髓瘤的临床与影像学诊断(Clinical and imaging diagnosis of myeloma)

骨髓瘤的临床与影像学诊断（Clinical and imaging diagnosis of
myeloma）
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 manifestation
A double concave deformation, vertebral body. Destruction of bone (without soft tissue mass): the bone is destroyed by insect like bone
The ribs, pelvis was punched out), change (skull) or large osteolytic destruction (like limbs long Guan Gu). Bone mass
Destruction with soft tissue mass. Bone sclerosis type: characterized by simple, diffuse, elevated density, or during bone destruction
Sign of bone sclerosis. The single hair: the characteristics of the lesions occur in long bone metaphysis, showing cystic or
Multiple 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 thinning
Uneven thickness and corrugated mark were the early X-ray findings of myeloma. Its rare X-ray findings are irregular
Fuzzy bonedestruction radial spicules occur around the soft tissue mass in the bone surrounding the bone hard failure zone
Of.
3.2 CT inspection and performance:
The CT scan shows its advantages with unique high-density resolution and clear cross sectional images. It can clear
It clearly shows the internal structure, soft tissue, pathological changes, extent and the invasion of the internal and external medullary cavity
Such 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 unclear
Because bone destruction occurs, later cortical bone on the plain film can obscure the manifestation of intramedullary lesions. The chief of myeloma
CT is characterized by osteolytic destruction of bone, irregular edges, blurring, destruction of cortical bone, and sometimes periosteal proliferation
Local soft tissue mass. In addition, adjusting the proper window width and window position during the CT scan is helpful for the detection of minor diseases
Variable.
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 has
Short T1, medium T2 signal characteristics, the production of this signal is the structure of fat and water, where fat is to produce a signal
The 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 high
Signal. Libshitz HI reported the MRI findings of 32 cases of multiple myeloma arising from the lumbar spine and combined with clinical practice
Laboratory 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 lipid
The range of fat substituted, the greater variability, so even in the same age group. Both T1WI and T2WI are available
Low 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 multiple
The MRI findings of myeloma (T1WI, low signal, T2WI high signal) were classified into diffuse, mottled and
There are three focal types. Stabler and so on, through the cytological contrast, the MRI manifestations of myeloma are divided into five types, that is, positive
Regular, 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 ratio
There were no changes and no abnormal changes in MRI signal were normal. Diffuse, focal or diffuse foci were observed
The 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 marrow
The red bone marrow mixes with each other to form T1WI black and white dots or small grainy mixed signal shadows. Among them, diffuse type and
Foci 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 and
There 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 al
The study concluded that MRI, especially the enhanced scan, could help to observe the response of multiple myeloma to treatment
The remission signal disappeared, or although the lesion was present, the lesion was not enhanced or only marginal enhancement. Wakahara
Diffuse 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 sensitive
imaging technique. Its imaging principle is: 99mTc or
113mIn 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 tumors
When the lesion is located, the local blood flow is increased, and more frequent bone tissues are collected
The 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 technique
In the diagnosis of myeloma, comprehensive diagnosis should be made in combination with clinical, laboratory and bone marrow aspiration tests
Broken.
4 clinical diagnosis and differential diagnosis
The clinical manifestations of multiple myeloma are very complicated. Most of them are occult and have different symptoms, but they can last for 1~5 years
Asymptomatic stage (preclinical stage), with multiple complications as a precursor. Therefore, the diagnosis of MM must be integrated
Clinical manifestation, laboratory examination, imaging examination and pathological examination, etc.. The following points can be used as the primary diagnosis
According to: rational fracture of systemic bone pain accompanied by disease. Osteolytic bone destruction. Osteoporosis accompanied by blood
Anemia and anemia. Urine Bence Jones protein positive. Serum globulin increased, A/G ratio inversion, protein
Electrophoresis of r- globulin elevated and showed M protein composition. The increase of immunoglobulin. The bone marrow biopsy and smear of bone
Myeloma cells are at least 15%, abnormal in morphology. The renal failure. The following points suggest that the disease has
Significance: one patient suffered from multiple bone pain, pathological fracture, anemia and renal failure due to unknown
causes,
Think of the disease. Imaging examination revealed diffuse osteoporosis, that is, laboratory examinations should be carried out to detect poverty
Increased serum and serum globulin, A/G ratio inversion, protein electrophoresis, elevated r- globulin, or M protein composition, urine
Bence Jones protein positive, it should be highly suspected of the disease. X-ray features typical bone destruction and sclerosis
Basically 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 globulin
Identification of blood. The diseases that X-ray needs to differentiate are bone metastasis, hyperthyroidism, senile osteoporosis and bone
Quality and decalcification of giant cell tumor, osteitis deformity etc.. Vertebral hemangiomas are similar to the CT findings of myeloma and must be noted
Identify。

Vertebral compression fractures and normal bone marrow focal fatty deposits in the elderly are required on MRI
Myeloma differentiation.。