骨肿瘤分期课件.ppt

《骨肿瘤分期课件.ppt》由会员分享，可在线阅读，更多相关《骨肿瘤分期课件.ppt（57页珍藏版）》请在得力文库 - 分享文档赚钱的网站上搜索。

1、关于骨肿瘤分期第1页，此课件共57页哦Enneking-Musculoskeletal Enneking-Musculoskeletal Tumor Staging System Tumor Staging System 第2页，此课件共57页哦骨与软组织肿瘤骨与软组织肿瘤TNMGTNMG分期系统分期系统AJCC(American Joint Committee on Cancer)AJCC(American Joint Committee on Cancer)提提出出复杂，对手术治疗无指导价值复杂，对手术治疗无指导价值很少使用很少使用第3页，此课件共57页哦肌肉骨骼系统肿瘤的外科分期肌肉骨骼

2、系统肿瘤的外科分期（MTSMTS分期系统）分期系统）佛罗里达大学，佛罗里达大学，EnnekingEnneking，19771977MTS(Musculoskeletal Tumor Society)MTS(Musculoskeletal Tumor Society)试用试用Clinical Orthopedics and Related Clinical Orthopedics and Related Research,1980Research,1980AJC(American Joint Committee)AJC(American Joint Committee)修订修订IUCC(Inte

3、rnational Union Against Cancer)IUCC(International Union Against Cancer)国际推广国际推广第4页，此课件共57页哦外科分期目的外科分期目的治疗的要求：手术时机、手术方法、切除范围的选择；治疗的要求：手术时机、手术方法、切除范围的选择；治疗的要求：手术时机、手术方法、切除范围的选择；治疗的要求：手术时机、手术方法、切除范围的选择；辅助治疗方法的选择辅助治疗方法的选择辅助治疗方法的选择辅助治疗方法的选择预后判断预后判断预后判断预后判断标准化的要求：统一标准、有利于治疗资料和疗效标准化的要求：统一标准、有利于治疗资料和疗效标准化的要

4、求：统一标准、有利于治疗资料和疗效标准化的要求：统一标准、有利于治疗资料和疗效的交流的交流的交流的交流(interinstitutional and interdisciplinary(interinstitutional and interdisciplinary(interinstitutional and interdisciplinary(interinstitutional and interdisciplinary communication)communication)communication)communication)第5页，此课件共57页哦适用范围适用范围 肌肉、骨骼系统

5、起源于间充质组织的肿瘤肌肉、骨骼系统起源于间充质组织的肿瘤第6页，此课件共57页哦排除范围排除范围来源于骨髓、网状内皮组织的肿瘤来源于骨髓、网状内皮组织的肿瘤 白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤转移性肿瘤转移性肿瘤第7页，此课件共57页哦EnnekingG-T-MEnnekingG-T-M外科分期系统外科分期系统G G G G（Histologic Grade)Histologic Grade)Histologic Gra

6、de)Histologic Grade)：分级：分级：分级：分级肿瘤的外科分级肿瘤的外科分级肿瘤的外科分级肿瘤的外科分级T(Anatomic Site)T(Anatomic Site)T(Anatomic Site)T(Anatomic Site)：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系M(Metastasis)M(Metastasis)M(Metastasis)M(Metastasis)：肿瘤有无转移，包括区域和远处转移：肿瘤有无转移，包括区域和远处转移：肿瘤有无转移，包括区域和远处转移：肿瘤有无转移，包括区域和远处转移第8页，此课件共

7、57页哦EnnekingEnneking分期分期 良性骨肿瘤良性骨肿瘤良性骨肿瘤良性骨肿瘤 1 1 1 1期：潜隐性期：潜隐性期：潜隐性期：潜隐性 2 2 2 2期：活动性期：活动性期：活动性期：活动性 3 3 3 3期：侵袭性期：侵袭性期：侵袭性期：侵袭性 恶性骨肿瘤恶性骨肿瘤恶性骨肿瘤恶性骨肿瘤 期（期（期（期（A A A A B B B B ）：低度恶性）：低度恶性）：低度恶性）：低度恶性 期（期（期（期（A A A A B B B B ）：高度恶性）：高度恶性）：高度恶性）：高度恶性 期（期（期（期（A A A A B B B B ）：有局部和远处转移）：有局部和远处转移）：有局部和远

8、处转移）：有局部和远处转移 A A A A：间室内；：间室内；：间室内；：间室内；B B B B：间室外：间室外：间室外：间室外第9页，此课件共57页哦外科分级外科分级G G临床或外科分级临床或外科分级临床或外科分级临床或外科分级在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度组织学、放射和临床三结合组织学、放射和临床三结合组织学、放射和临床三结合组织学、放射和临床三结合 组织学分级组织学分级组织学分级组织学分级BrodersBrodersBrodersBroders分级分级分级分级 放射学分级放射学分级放射学分级放射学分级Lod

9、wickLodwickLodwickLodwicks s s s分级分级分级分级G G G G0 0 0 0：良性病变；：良性病变；：良性病变；：良性病变；G G G G1 1 1 1：低度恶性；：低度恶性；：低度恶性；：低度恶性；G G G G2 2 2 2：高度恶性：高度恶性：高度恶性：高度恶性恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，如组织学表现偏良性而放射和临床表现为高度侵袭如组织学表现偏良性而放射和临床表现为高度侵袭如组织学表现偏良性而放射和临床表现为

10、高度侵袭如组织学表现偏良性而放射和临床表现为高度侵袭性者应定为高度恶性性者应定为高度恶性性者应定为高度恶性性者应定为高度恶性第10页，此课件共57页哦组织学组织学细针穿刺活检细针穿刺活检 影像引导下穿刺活检如影像引导下穿刺活检如Fluoroscopy with C-Fluoroscopy with C-arm guidance arm guidance，CT-guided biopsy CT-guided biopsy 切取活检切取活检切除活检切除活检第11页，此课件共57页哦影像学：影像学：X-ray Lodwick X-ray Lodwick 放射学分级放射学分级Grade 1A,1B,a

11、nd 1C lesions represent Grade 1A,1B,and 1C lesions represent Grade 1A,1B,and 1C lesions represent Grade 1A,1B,and 1C lesions represent benign lesions with edge characteristics benign lesions with edge characteristics benign lesions with edge characteristics benign lesions with edge characteristics r

12、anging from well defined to poorly defined.ranging from well defined to poorly defined.ranging from well defined to poorly defined.ranging from well defined to poorly defined.Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade

13、 2 lesions are low-grade malignant lesions with invasive features,particularly lesions with invasive features,particularly lesions with invasive features,particularly lesions with invasive features,particularly those with total penetration of the cortex.those with total penetration of the cortex.tho

14、se with total penetration of the cortex.those with total penetration of the cortex.Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant lesions with invasive,permeative,and lesions with inv

15、asive,permeative,and lesions with invasive,permeative,and lesions with invasive,permeative,and destructive features destructive features destructive features destructive features 第12页，此课件共57页哦重要的放射学征象重要的放射学征象Pattern of destruction(geographic or not Pattern of destruction(geographic or not Pattern of

16、 destruction(geographic or not Pattern of destruction(geographic or not geographic,appearance of marginal interface geographic,appearance of marginal interface geographic,appearance of marginal interface geographic,appearance of marginal interface zone)zone)zone)zone)Penetration of cortex by lesion

17、Penetration of cortex by lesion Penetration of cortex by lesion Penetration of cortex by lesion Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence and extent(if present)Absenc

18、e or presence and extent(if present)Absence or presence and extent(if present)Absence or presence and extent(if present)of the expanded cortical shellof the expanded cortical shellof the expanded cortical shellof the expanded cortical shell第13页，此课件共57页哦SundaramSundaram分级系统分级系统 Group 1 lesions are ra

19、diographically benign and do not Group 1 lesions are radiographically benign and do not Group 1 lesions are radiographically benign and do not Group 1 lesions are radiographically benign and do not require further investigation or treatment.require further investigation or treatment.require further

20、investigation or treatment.require further investigation or treatment.Group 2 lesions have a high likelihood for being benign,Group 2 lesions have a high likelihood for being benign,Group 2 lesions have a high likelihood for being benign,Group 2 lesions have a high likelihood for being benign,but th

21、is finding should be confirmed by means of clinical but this finding should be confirmed by means of clinical but this finding should be confirmed by means of clinical but this finding should be confirmed by means of clinical or radiographic follow-up examination.or radiographic follow-up examinatio

22、n.or radiographic follow-up examination.or radiographic follow-up examination.Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require surgical resection because of

23、aggressive behavior or surgical resection because of aggressive behavior or surgical resection because of aggressive behavior or surgical resection because of aggressive behavior or risk of pathologic fracture.risk of pathologic fracture.risk of pathologic fracture.risk of pathologic fracture.Group

24、4 lesions are aggressive-appearing lesions that should Group 4 lesions are aggressive-appearing lesions that should Group 4 lesions are aggressive-appearing lesions that should Group 4 lesions are aggressive-appearing lesions that should be considered malignant.Biopsy should be performed to be consi

25、dered malignant.Biopsy should be performed to be considered malignant.Biopsy should be performed to be considered malignant.Biopsy should be performed to confirm the histologic grade and the diagnosis.confirm the histologic grade and the diagnosis.confirm the histologic grade and the diagnosis.confi

26、rm the histologic grade and the diagnosis.第14页，此课件共57页哦影像学：影像学：CTCTEvaluation of local disease in detail Evaluation of local disease in detail Assessing the lungs for pulmonary Assessing the lungs for pulmonary metastases metastases 第15页，此课件共57页哦CT in evaluation of local diseaseCT in evaluation of l

27、ocal diseaseComplements radiography Complements radiography Complements radiography Complements radiography Assess disease in areas not easily Assess disease in areas not easily Assess disease in areas not easily Assess disease in areas not easily visualized with radiography,eg,the spine visualized

28、with radiography,eg,the spine visualized with radiography,eg,the spine visualized with radiography,eg,the spine and pelvis and pelvis and pelvis and pelvis CT is better in assessing the type of cortical CT is better in assessing the type of cortical CT is better in assessing the type of cortical CT

29、is better in assessing the type of cortical destruction and the presence of matrix destruction and the presence of matrix destruction and the presence of matrix destruction and the presence of matrix mineralization.mineralization.mineralization.mineralization.CT is also helpful in determining the in

30、ternal CT is also helpful in determining the internal CT is also helpful in determining the internal CT is also helpful in determining the internal contents of some lesions.contents of some lesions.contents of some lesions.contents of some lesions.第16页，此课件共57页哦CT in evaluating the lungs for CT in ev

31、aluating the lungs for metastases metastases More accurate than chest radiographsMore accurate than chest radiographsMay produce false-positive results when May produce false-positive results when small lung nodules are detected.small lung nodules are detected.Follow-up CT scans are useful in Follow

32、-up CT scans are useful in monitoring the nodules.monitoring the nodules.第17页，此课件共57页哦影像学：影像学：MRIMRI accurate depiction of the soft tissues accurate depiction of the soft tissues allows sensitive detection of soft allows sensitive detection of soft tissue extension and medullary tissue extension and

33、 medullary involvement by tumor involvement by tumor 第18页，此课件共57页哦MRIMRI良恶性影像学特征良恶性影像学特征Benign lesions are well defined and sharply Benign lesions are well defined and sharply Benign lesions are well defined and sharply Benign lesions are well defined and sharply demarcated from the surrounding heal

34、thy demarcated from the surrounding healthy demarcated from the surrounding healthy demarcated from the surrounding healthy tissue.tissue.tissue.tissue.Malignant lesions are typically more extensive Malignant lesions are typically more extensive Malignant lesions are typically more extensive Maligna

35、nt lesions are typically more extensive and involve surrounding tissue to a greater and involve surrounding tissue to a greater and involve surrounding tissue to a greater and involve surrounding tissue to a greater extent than do benign lesions.extent than do benign lesions.extent than do benign le

36、sions.extent than do benign lesions.MRI signal intensity alone is not reliable in MRI signal intensity alone is not reliable in MRI signal intensity alone is not reliable in MRI signal intensity alone is not reliable in distinguishing benign tumors and malignant distinguishing benign tumors and mali

37、gnant distinguishing benign tumors and malignant distinguishing benign tumors and malignant tumors.tumors.tumors.tumors.第19页，此课件共57页哦MRIMRI对分期的价值对分期的价值Assessing local spread of tumor(Enneking Assessing local spread of tumor(Enneking Assessing local spread of tumor(Enneking Assessing local spread of

38、tumor(Enneking sites T1 and T2).sites T1 and T2).sites T1 and T2).sites T1 and T2).Accurately detecting tumor involvement of Accurately detecting tumor involvement of Accurately detecting tumor involvement of Accurately detecting tumor involvement of neurovascular structures,muscle compartments,neur

39、ovascular structures,muscle compartments,neurovascular structures,muscle compartments,neurovascular structures,muscle compartments,growth plates,and joints.growth plates,and joints.growth plates,and joints.growth plates,and joints.Usually accurately depicts intramedullary spread Usually accurately d

40、epicts intramedullary spread Usually accurately depicts intramedullary spread Usually accurately depicts intramedullary spread and soft tissue extension of tumor and soft tissue extension of tumor and soft tissue extension of tumor and soft tissue extension of tumor 第20页，此课件共57页哦MRAMRAProvide additi

41、onal information regarding Provide additional information regarding neurovascular bundle involvement.neurovascular bundle involvement.Assessing peripheral vascular branches Assessing peripheral vascular branches and tumor neovascularity.and tumor neovascularity.第21页，此课件共57页哦其他影像学检查其他影像学检查Radionuclid

42、e bone scans Radionuclide bone scans UltrasonographyUltrasonographyAngiography Angiography Positron Emission Tomography Positron Emission Tomography 第22页，此课件共57页哦外科分级外科分级G GG G0 0 良性病变良性病变临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移X X X X线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿

43、破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破囊壁者囊壁者囊壁者囊壁者组织学表现：细胞分化良好，基质细胞比例正常，核分组织学表现：细胞分化良好，基质细胞比例正常，核分组织学表现：细胞分化良好，基质细胞比例正常，核分组织学表现：细胞分化良好，基质细胞比例正常，核分裂相极少见裂相极少见裂相极少见裂相极少见第23页，此课件共57页哦外科分级外科分级G GG G1 1 低度恶性病变低度恶性病变临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织临床：肿瘤可向囊外生长，

44、但生长速度较慢，可有软组织临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织肿块，偶有远处转移肿块，偶有远处转移肿块，偶有远处转移肿块，偶有远处转移X X X X线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长组织学表现：细胞分化中等，基质细胞较多，可见核分组织学表现：细胞分化中等，基质细胞较多，可见核分组织学表现：细胞分化中等，基质细胞较多，可见核分组织学表现：细胞分化中等，基质细胞较多，可见核分裂相但较少裂相但较少裂相但较少裂相但较少第24页，此课件共57页哦外科分级外科分级G GG G G G2 2 2 2

45、高度恶性病变高度恶性病变高度恶性病变高度恶性病变临床：症状明显，肿瘤生长快，有跳跃性生长和软组织肿块，临床：症状明显，肿瘤生长快，有跳跃性生长和软组织肿块，临床：症状明显，肿瘤生长快，有跳跃性生长和软组织肿块，临床：症状明显，肿瘤生长快，有跳跃性生长和软组织肿块，常早期就发生局部和远处转移常早期就发生局部和远处转移常早期就发生局部和远处转移常早期就发生局部和远处转移X X X X线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块组织学表现：细胞分化极差，基质细胞

46、多，核分裂相多见组织学表现：细胞分化极差，基质细胞多，核分裂相多见组织学表现：细胞分化极差，基质细胞多，核分裂相多见组织学表现：细胞分化极差，基质细胞多，核分裂相多见第25页，此课件共57页哦肿瘤与解剖学间隙的关系肿瘤与解剖学间隙的关系T TT T0 0：良性囊内和间室内病变：良性囊内和间室内病变T T1 1：间室内病变：间室内病变T T2 2：间室外病变：间室外病变第26页，此课件共57页哦间室内间室内 T T1 1无真性包膜，但有假包膜无真性包膜，但有假包膜反应带内有指状突起或卫星灶反应带内有指状突起或卫星灶原发病灶和反应带均局限在病灶的原发间室内原发病灶和反应带均局限在病灶的原发间室内第

47、27页，此课件共57页哦间室内间室内 T T1 1皮质骨内，未穿破骨膜和骨髓腔皮质骨内，未穿破骨膜和骨髓腔关节内，未穿破关节囊关节内，未穿破关节囊骨旁间隙内，未进入骨皮质，未穿破骨膜侵犯骨旁间隙内，未进入骨皮质，未穿破骨膜侵犯肌、筋膜肌、筋膜第28页，此课件共57页哦间室外间室外 T T2 2间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：肿块本身穿出肿块本身穿出肿块本身穿出肿块本身穿出 反应带超出原发间室反应带超出原发间室反应带超出原发间室反应带超出原发间室意外创伤和不恰当的手术切除污染多个间室意外创伤和不恰当的手术切除污染多个间室意外

48、创伤和不恰当的手术切除污染多个间室意外创伤和不恰当的手术切除污染多个间室病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹股沟等股沟等股沟等股沟等第29页，此课件共57页哦间室外间室外 T2T2骨内病变向软组织侵犯骨内病变向软组织侵犯骨旁病变侵犯骨皮质骨旁病变侵犯骨皮质侵犯髓腔侵犯髓腔肘窝

49、、腋窝、肘窝、腋窝、guoguo窝、腹股沟、骨盆内窝、腹股沟、骨盆内第30页，此课件共57页哦病变范围的确定病变范围的确定临床资料临床资料常规常规X X线检查线检查CTCTMRIMRI血管造影血管造影同位素扫描同位素扫描第31页，此课件共57页哦转移转移 M M跳跃转移、区域淋巴结或远处转移跳跃转移、区域淋巴结或远处转移M M0 0：无局部和远处转移：无局部和远处转移M M1 1：有局部和远处转移：有局部和远处转移第32页，此课件共57页哦良性骨肿瘤良性骨肿瘤1 1 1 1期：潜隐性（期：潜隐性（期：潜隐性（期：潜隐性（latent)-Glatent)-Glatent)-Glatent)-G0

50、 0 0 0 T T T T0 0 0 0 M M M M0 0 0 02 2 2 2期：活动性期：活动性期：活动性期：活动性(active)-G(active)-G(active)-G(active)-G0 0 0 0 T T T T0 0 0 0 M M M M0 0 0 03 3 3 3期：侵袭性期：侵袭性期：侵袭性期：侵袭性(aggressive)-G(aggressive)-G(aggressive)-G(aggressive)-G0 0 0 0 T T T T1 1 1 1 或或或或T T T T2 2 2 2 M M M M0 0 0 0 或或或或 M M M M1 1 1 1