骨骼肌肉系统疾病液液平面征.ppt

骨骼肌肉系统疾病液液平面征（Musculoskeletal Lesions With Fluid-Fluid Level）Department of Radiology the 2nd affiliated hospital of Sun yat-sen university1.一.概述（overview）2.911.2%的骨病的骨病变中可出中可出现液液-液平面。液平面。Prevalence of FFL in bone tumors is 2.911.2%.T2WI上上观察佳察佳。Most conspicuous on T2WI.常与出血及常与出血及肿瘤坏死有关。瘤坏死有关。Related to prior hemorrhage or tumor necrosis.CT上，各上，各层CT值的不同形成了的不同形成了FFL。The difference in the density of these layers can be observed on CT imaging.MRI上，各上，各层信号上的差异形成了信号上的差异形成了FFL。The difference in the signal characteristics of these layers allow for visualization of the FFL on MRI.2.单发FFL(single FFL):8;多发FFLs(Multiple FFLs):75。良性benign恶性malignant 非肿瘤non-neoplastic合计2/3 13（81）3（19）016entire120012结论：2/3,大部分为良性病变3.2/3entire1/32/34.5.二二.病病变的种的种类(typies of the lesion)（一）骨病（一）骨病变：动脉瘤脉瘤样骨囊骨囊肿Aneurysmal Bone Cyst,ABC单纯性骨囊性骨囊肿Simple Bone Cyst骨骨纤维异常增殖症异常增殖症Fibrous Dysplasia骨内脂肪瘤骨内脂肪瘤Intraosseous Lipoma软骨母骨母细胞瘤胞瘤Chondroblastoma毛毛细血管血管扩张型骨肉瘤型骨肉瘤Telangiectatic Osteosarcoma6.（二）（二）软组织病病变血血肿 Hematoma肌肌间血管瘤血管瘤 Intramuscular Hemangioma动静脉畸形静脉畸形 Arteriovenous Malformation关关节周周围钙质沉着沉着 Periarticular Calcinosis软组织平滑肌瘤平滑肌瘤 Soft Tissue Leiomyoma 肉瘤肉瘤 Sarcoma二、病二、病变的种的种类(typies of the lesion)7.动脉瘤脉瘤样骨囊骨囊肿(aneurysmal bone cyst,ABC)薄壁分隔、血性液体充盈多房房腔为特点的膨胀性骨病变。ABC is an expansile lesion containing mixed multiple thin walled,blood filled cystic cavities.创伤是引发该病的原因之一。Trauma has been indicated as a cause.常伴发于其他骨病变。Often arises secondary to apreexisting lesion.好发年龄在5-20岁，长管状骨的干骺端多见，也可见于脊柱附件。Most commonly occur within the metaphysis of long tubular bones,but they are also found within the posterior elements of the spine.8.Imaging manifestation偏心性膨胀性骨质破坏，常伴骨性分隔，甚者可呈气球样，病变内缘常完整。Eccentric,osteolytic lesion,often with septations,the cortical surface expanded or ballooned,and the inner margin is well defined,MRI上，ABC常呈薄而完整的低信号边缘，病灶内信号不均匀，房腔间信号可存在显著差异。A thin,well-defined rim of low-signal intensity about the ABC is common.There is inhomogeneity of the signal intensity,with individual lobules having markedly different signal characteristics.85%可见液-液平面，常为多个液平，是ABC发展到中期或晚期阶段的典型表现。FFLs can be seen in 85%patients,and are typical of the mid or late phase of development of the ABC.9.16%的ABC可发生于骨表面，分为骨膜下型、骨皮质型及混合型。Sixteen percent of ABC arise from surface of bones，including subperiosteal;cortical;mixed.骨膜下型ABC常具有侵袭性，可致周围软组织水肿，易误诊为毛细血管扩张型骨肉瘤。ABCs in subperiosteal location can demonstrate aggressive radiographic appearance and edema of adjacent soft tissues mimicking telangiectatic osteosarcomaImaging manifestation10.Aneurysmal bone cyst.Axial T2WI shows large multilocular cystic lesion with multiple fluid-fluid levels(arrow),occupying more than one half of the lesion.The inferior layer is slightly hyperintense compared to muscle,and the superior layer is hyperintense.11.ABC secondary to giant cell tumors of the Sacrum12.ABC secondary to the ameloblastoma of jaws13.21 years old man with cortical aneurismal bone cyst of the tibia14.单纯性骨囊性骨囊肿(Simple Bone Cyst)含液体性的病变，可继发于淋巴或静脉回流障碍。Fluid-containing lesion that may arise secondary to lymphatic or venous obstruction.常发生于长管骨的干骺端并向骨干生长。Usually arises in the metaphysis of long bones adjacent to the physis.80%的病变发生于20岁以下。80%of the lesions occur under 20 years.发生于20岁以上者，可见于髂骨和跟骨。Over the age of 20,they may located at the iliac bone and the calcaneus.极少出现临床症状，除非发生病理性骨折。rarely symptomatic unless with a pathologic fracture.15.中央性骨透亮区，伴骨皮质变薄和中度骨膨胀改变。Centrally located radiolucent lesion with cortical thinning and mild osseous expansion20%出现“骨片陷落征”。“Fallen fragment”sign may be seen in 20%of cases液-液平面的出现可能与病理性骨折有关。FFL arised probably due to the pathologic fracture.Imaging manifestation16.Nine-year-old male with SBC of proximal humerus.17.Simple bone cyst Axial TSE T2WI shows a cystic aspect of the lesion with a single fluid-fluid level(arrow).The dependent fluid layer is slightly hyperintense compared to muscle,and,relative to the inferior layer,the superior layer is hyperintense,suggesting serous fluid.18.骨骨纤维异常增殖症异常增殖症（Fibrous Dysplasia）为原始间叶组织发育异常。FD is a developmental anomaly of bone forming mesenchyme.多数病例发生于2-30岁。Mostly be seen between the ages of 2 and 30.70-80%为单发，无临床症状.70-80%of cases are monostotic and asymptomatic.20-30%为多发型，多见于10岁前，常发生跛行、疼痛、骨折或畸形，50%以上可见皮肤牛奶咖啡斑，且有一侧身体受累更广泛的倾向。20-30%are polyostotic,and present before the age of 10,often with a limp,pain,fracture,or deformity.Cafe-au-lait spots are seen in over 50%of patients.There is a propensity to involve one side of the body more extensively.19.骨骨纤维异常增殖症异常增殖症（Fibrous Dysplasia）2-3%的多发型FD伴有内分泌疾病。2-3%of patients with polyostotic disease associated endocrinopathy.Albright综合征：伴女性青春期性早熟和皮肤色素沉着。McCune Albright syndrome involves precocious puberty in females and cutaneous pigmentation in addition to the bone lesions.Mazabraud综合征：合并软组织粘液瘤。Mazabraud syndrome involves a soft tissue myxoma in association with the osseous lesions.20.Imaging manifestation具有网状新生骨的透亮区，界限清楚并可见硬化边。Radiolucent lesions with woven bone.usually well defined and may have a sclerotic rind常发生骨骼畸形，并伴发骨折、骨弯曲和生长障碍。Skeletal deformity is often noted,with fractures,bowing,and growth disturbance.可恶变为骨肉瘤和纤维肉瘤。Malignant transformation can be seen with osteosarcoma and fibrosarcoma being the most common.囊性FD可出现液-液平面。FFL has been reported in cystic fibrous dysplasia.21.Fibrous dysplasia.Sagittal T2WI shows inhomogeneous and overall low signal intensity of the bone marrow.A fluid-fluid level(arrow)in a large,single cavity can be seen.The inferior fluid layer is slightly hyperintensecompared to muscle,and,the superior layer is hyperintense.22.twenty-six-year-old man with polyostotic cystic fibrous dysplasia.23.骨内脂肪瘤骨内脂肪瘤（Intraosseous Lipoma）罕见，多见于30-60岁。Be rare，usually found in 30-60 years of age.好发于腓骨、股骨、胫骨的干骺端和跟骨。The most common sites are the metaphysis of the fibula,femur,tibia,and calcaneus.24.Imaging manifestation具有硬化边的境界清楚的骨破坏区，可呈轻度膨胀改变，无骨皮质破坏或骨膜反应。Osteolytic lesion surrounded by a well-defined sclerotic border with slightly expansileand without cortical destruction or periosteal reaction.CT及MRI上呈脂肪密度/信号。Fat density/signal characteristics.液-液平面很罕见。FFL is rarely seen.25.28岁男性，跟骨骨内脂肪瘤 26.软骨母骨母细胞瘤胞瘤（Chondroblastomas）少见的良性实质性的软骨来源肿瘤。Uncommon,solitary,and benign cartilaginous neoplasms.常见于5-25岁间，男女发病率之比为2:1。Mostly occur between the ages of 5 and 25，with a male to female predominance of 2:1.好发于长管骨的骨骺或隆突处，可扩展至干骺端。Arise in the epiphysis or apophysis of a long tubular bone,and can extend into the metaphysis.27.Imaging manifestation常呈地图样偏心性骨质破坏区，但少有膨胀性改变。Geographic lytic lesion,usually eccentric,and rarely expansile.30-50%的病例可见软骨基质钙化，可见骨膜反应。The calcified chondroid matrix is noted in 30-50%.A periosteal reaction may also be seen.MRI上，病变T1WI呈低信号，T2WI信号复杂。On MRI,often low signal on T1WI,with variable T2WI signal characteristics.28.足骨软骨母细胞瘤（chondroblastomas of the foot）13%可见于足骨。13%of chondroblastomas are found in the foot.平均发病年龄为26岁。Mean age is 26 years.跟骨者均发生于跟骨的跟距关节面且邻近跟骨后部骨皮质处。Most commonly found in posterior subchondral areas of talus and calcaneus and in calcaneal apophysis.可见硬化缘，偶尔还可见病灶内钙化和分隔。Sclerotic margin was present,occasionally calcifications and septations were seen.29.twenty-five-year-old man withchondroblastoma of calcaneus30.31.毛毛细血管血管扩张型骨肉瘤型骨肉瘤（Telangiectatic Osteosarcoma）占骨肉瘤的2.5-12%。Represents 2.5-12%of all osteosarcomas.膨胀性破坏性骨肿瘤，大多由含坏死组织和出血的囊腔构成。An expansile,destructive tumor,which is largely composed of cystic cavities containing necrosis and hemorrhage.常见于干骺端，可扩展至骨骺，并常合并病理性骨折。Mostly origin from the metaphysis ,and frequent extension into the monly present with pathologic fractures.32.Imaging manifestation 地图样骨破坏区，伴有较宽的移行带，并膨胀变形及周围软组织肿块。Geographic bone destruction with a wide zone of transition，expansile remodeling and soft tissue mass.病灶内见多个相互分隔的膨胀囊腔，囊壁上可见壁结节。Multiple dilated cavities are separated by septations,and nodularity can be seen within these septation.T2WI呈显著高信号，T1WI呈中等信号。74%的病例可见到液-液平面。On MRI,signal intensity is redominately high on T2WI,and intermediate on T1WI,FFLs are noted in 74%of cases.33.Twenty-one-year-old man withtelangiectatic osteosarcoma of distal femur34.telangiectatic osteosarcoma.AP radiograph shows aggressive bone destruction with a pathological fracture.MRI confirm a large,extraosseous mass.Axial T2WI show most of the mass(estimated to be 2/3)to be occupied by FFLs.35.Others 液-液平面也以个例报道见于骨巨细胞瘤、骨腱鞘囊肿、骨髓炎、骨转移瘤和多发骨髓瘤。FFLs have also been reported in giant cell tumor,intraosseous ganglia,osteomyelitis,metastasis,and multiple myeloma as case reports.36.血血肿 Hematoma肌肌间血管瘤血管瘤 Intramuscular Hemangioma动静脉畸形静脉畸形 Arteriovenous Malformation关关节周周围钙质沉着沉着 Periarticular Calcinosis软组织平滑肌瘤平滑肌瘤 Soft Tissue Leiomyoma 肉瘤肉瘤 Sarcoma软组织病病变（Soft Tissue Lesions）37.血血肿（Hematoma）影像学表现依赖于其内部成分及演变进程。Imaging characteristics depend on the internal component and development of the lesion.超急性期，T1WI和T2WI上均呈高信号.In the hyperacute setting,the lesion have high T1 and T2 signal intensity.亚急性期及以后，病变内可见到“同心环征”，由外周高信号及中心低信号区所构成。In the subacute phase and beyond,may see the“concentric ring sign”,which has high-signal intensity with eventual central regions of decreased signal intensity.38.Fifty-eight-year-old woman withhematoma39.肌肌间血管瘤血管瘤（Intramuscular Hemangioma）最常见的软组织肿瘤之一。One of the most common soft tissue tumors.属于良性血管性病变，可含有非血管成分，如脂肪、纤维和粘液样组织、平滑肌、血栓甚至骨组织。Benign vascular lesions,which may contain nonvascular elements such as fat,fibrous and myxoid tissue,smooth muscle,thrombus,and even bone.30%的病例可见静脉石，最多见于海绵状血管瘤。30%contain phleboliths,most frequently in the cavernous type.40.Imaging manifestation分叶状、分隔状，增强后显著强化。Lesions are lobulated,septated,with marked enhancement on MRI.T2WI上见病灶内的低信号纤维分隔及蜿蜒走行的血管影。On T2WI,low-signal fibrous septa and high-signal serpentine vascular channels are seen.中央低信号影为横切的间隔、玻璃样变或栓塞血管、平滑肌、血管流空或钙化。Central low-intensity dots may represent septa imaged in cross-section,hyalinized or thrombosed vascular channels,smooth muscle components,fast flow within blood vessels,or calcification.41.Thirty-two-year-old woman withintramuscular hemangioma of thigh42.Intramuscular cavernous hemangioma.Axial T2WI showing Multilocular lesion,hyperintense to muscle.Multiple fluid-fluid levels(arrows)occupying more than one half of the lesion can be seen.43.动静脉畸形静脉畸形（Arteriovenous Malformation）可为先天性，出现于生后几年内；也可以继发于创伤。Lesions may be developmental in origin,appearing in the first few years of life,or they may occur after an injury.MRI表现包括肌肉萎缩、皮下脂肪浸润，以及静脉石或血管流空而形成的灶性低信号。MR features include muscle atrophy,subcutaneous fatty prominence,and foci of low-signal intensity,which may be indicative of phleboliths or flow void effects.20液-液平面较为罕见。FFL is rarely seen.44.Thirty-six-year-old woman witharteriovenous malformation of thigh45.关关节周周围钙质沉着沉着(Periarticular Calcinosis)多见于血液透析病人。May be seen in patients on hemodialysis.髋关节及臀部肌肉组织是好发部位。The hips and gluteal musculature are common sites of involvement液-液平面出现是液体悬置所致。FFL seen within the calcium deposits are due to aqueous suspensions.可伴有软骨下、骨膜下或韧带下骨吸收，骨质疏松和棕色瘤。Additional radiographic findings include subchondral,subperiosteal,or subligamentous bone resorption,osteoporosis,and Brown tumor.46.64 year-old woman on hemodialysis for renal failure with para-articular calcinosis47.软组织平滑肌瘤平滑肌瘤（Soft Tissue Leiomyoma）发生于胃肠道和泌尿生殖系统之外的软组织平滑肌瘤很罕见。Leiomyomas found outside the gastrointestinal and genitourinary systems are rare.可单发也可多发，可发生坏死和钙化。May be solitary or multiple and may have necrotic and calcific components.液-液平面较为罕见。FFL is rarely seen.48.Twenty-seven-year-old man with soft tissue leiomyoma49.滑膜肉瘤滑膜肉瘤（Synovial Sarcoma）好发于20-40岁患者四肢大关节附近。The most common location is close to the large joint of 20-40 years of age.常形成囊变区及多房状。Features include cyst formation and multilocularity.常见临床症状有疼痛/肿胀。Symptoms are often pain and/or swelling.50.Imaging manifestation大关节、肌腱、滑囊旁非均匀分房状肿块，可侵犯关节及骨质。Inhomogeneous septate mass close to a joint,a tendon or a bursa.Bone and joint invasion can be present.1/3病灶内部尤其是边缘部位可见多发小钙化或骨化影。The most characteristic finding is the multiple focal calcifications or ossifications typically in the periphery of the lesion in 1/3 patients.MRI上信号不均匀，T2WI上同时呈低、中、高信号及T1WI上斑点状高信号可提示诊断。Triple signal pattern on T2WI together with the small high signal foci on T1WI is suggestive for synovial sarcoma.51.synovial sarcoma.Axial T2WI with fatsuppression.Large relatively well-defined inhomogeneous lesionwith areas of hyper-，hypo-，and intermediate signal intensity(triple signal)and multiple fluid-fluid levels occupying more than one half of the lesion.52.Synovial sarcoma53.恶性性纤维组织细胞瘤胞瘤（Malignant Fibrous Histiocytoma）为间叶组织起源的恶性肿瘤。A malignant tumor of mesenchymal origin.临床上呈病史较长的伴有疼痛和隐袭发作倾向的可扪及的包块。The clinical presentation is usually a palpable mass of long duration,with pain and tenderness of insidious onset.影像学上，恶性纤维组织细胞瘤与其他软组织肉瘤鉴别困难。On imaging studies,they may be difficult to differentiate from other types of soft tissue sarcomas.54.54 years old man with malignant fibrous histiocytoma of the adductor55.Malignant fibrous histiocytoma56.Fibrosarcoma of the humerus57.三三.小小结（Conclusion）液液-液平面是一种非特异性的征像，液平面是一种非特异性的征像，结合合临床病史及病床病史及病变其它典型的、特征性的表其它典型的、特征性的表现有助于有助于缩小小鉴别诊断范断范围。FFL is a nonspecific finding,its presence can significantly aid in formulating a limited differential diagnosis.in combination with clinical history and other imaging findings.58.骨病骨病变中的液中的液-液平面液平面较软组织多多见。FFL is seen more frequently with bone than soft tissue lesions.最常出最常出现FFL的骨病的骨病变是是ABC和毛和毛细血管血管扩张型骨肉瘤。型骨肉瘤。The most common bone lesions containing a fluidYfluid level are ABC and telangiectatic osteosarcoma.最常出最常出现FFL的的软组织病病变是血管瘤、囊是血管瘤、囊变的滑膜肉瘤和的滑膜肉瘤和纤维肉瘤、血肉瘤、血肿。The most common soft tissue lesions containing a FFL are hematoma,hemangioma,cystic synovial sarcoma,and fibrosarcoma.59.谢谢！Thanks60.