骨次生的大模仿：棕色肿瘤，出现退化性木盘，如疼痛

Zuhal Bayramoglu^1*，RavzaYılmaz¹and Aysel Bayram²

¹伊斯坦布尔医学院放射学系，伊斯坦布尔大学，CAPA，FATIH，34093，伊斯坦布尔，土耳其

²伊斯坦布尔医学院病理学系，伊斯坦布尔大学，CAPA，FATIH，34093，伊斯坦布尔，土耳其

*通讯地址：伊斯坦布尔医学院放射学系Zuhal Bayramoglu博士，伊斯坦布尔大学，CAPA，FATIH，34093，土耳其伊斯坦布尔，电话： +90-212-414-20-0028;电子邮件：incezuhal@yahoo.com

Dates:提交：06 June 2017;得到正式认可的：2017年7月14日；发布：2017年7月17日

如何引用本文：Bayramoglu Z，YılmazR，BayramA。骨含量的伟大模仿：棕色肿瘤，表现出退化性的木盘，如疼痛。Arch Pathol Clin Res。2017;1：018-023。doi：10.29328/journal.hjpcr.1001004

版权许可证：© 2017 Bayramoglu Z et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

关键字：棕色肿瘤；多种的;iLiac骨；半径;s骨；磁共振成像；CT检查;s骨炎；辐射病；甲状旁腺功能亢进

一名45岁的女性提到了物理疗法和康复诊所，抱怨渐进的下背部和臀部疼痛两年，沿着大腿后部，左腿的后外侧辐射，左脚的后外侧方面，尤其是走路，尤其是走路。考虑到腰ac骨根瘤菌病，随着静止的速度而减少。进行双侧Faber（屈曲，外展，外部旋转），压缩和干扰测试并确认双侧s骨关节疼痛。据报道，由于除肿胀以外，由于肘部运动疼痛，病人忽略了她的左手。近端肌肉无力的多灶性疼痛关节运动表明进一步的放射学研究。裂解，膨胀的质量接近双侧s骨关节，该关节是由s骨和右骨的左半部分产生的，另一个位于超梯形区域中的另一个是传统的放射线照相（CR）。手和腕部X光片也显示出质量位于半径相邻的半径远端，延伸到软骨下骨，膨胀重塑，具有相似的放射学表面，与骨盆骨的肿瘤相似，图1.第二个metacarpal和第二个metacarpal和第二个metacarpal and radne骨的肿瘤区域图1描绘了半径皮层。据报道，CR的硬化边缘不存在，并且没有任何恶性肿瘤的病史。提供了骨盆磁共振成像[MRI]，以阐明辐射病的原因。T1加权（T1W）MRI的质量是异质的，并且在T2加权（T2W）MRI图3,4上显示出异质性和轻微的高强度信号。 Heterogeneous and intense contrast enhancement on fat-saturated T1W MRI figure 5. All of the masses were expansile and extending to closest joint surface. The one located on the left hemisacrum obliterated the left L5-S1 and S1-S2 neural foramina and compressed the adjacent left L5 and S1 sacral nevre roots figure 5. The mass on the right iliac bone was arising to sacroiliac joint surface associated with the sacroiliac joint dysfunction and the other mass was arising to acetabular surface associated with hip pain. Hyperparathyroidism was investigated through biochemical analysis and a high level of calcium [11.8mg/dl] and parathormone [PTH:674pg/ml], with an increased ALP level were depicted. Laboratory outcomes found a diagnosis of primary hyperparathyroidism and a parathyroid adenoma was depicted at the lower aspect of the left paratracheal region by ultrasound and confirmed after surgical excision figure 6.

CT-guided percutaneous bone tru-cut biopsy was performed after obtaining written informed consent from the patient. Histopathology revealed fibroblastic tissue containing numerous osteoclast-like giant cells figure 7. The PTH level was 35 pg/ml and the calcium level was 8.5mg/dl a few days after surgery. After adenoma removal, whole masses totally regressed and massive sclerotic bone formation was observed on MRI within a year figure 8 and confirmed the diagnosis of BTs.

Based on radicular pain in this adult most common cause of radiculopathy is known to caused by degenerative disc diseases. Also, contralateral painful sacroiliac joint movement could consider osteitis condensans ilii in an adult female patient presented with sacroiliitis like pain. Thus, initial diagnostic tool could be conventional radiograph in order to demonstrate osteophytic processes and triangular shaped sclerosis adjacent to the the articular surface of the iliac bone. Despite these common degenerative processes, we discuss multiple Brown tumors due to primary hyperparathyroidism as a cause of radiculopathy and sacroiliitis like pain.

据报道，棕色肿瘤（BTS）的频率在原发性中为3％，继发性甲状旁腺功能亢进症为2％[1]。棕色肿瘤是原发性甲状旁腺功能亢进症的不太常见的肉豆蔻骨骼表现[2]。据报道，最常见的与BT的部分相关的部分是面部骨骼[下颌骨，上颌骨]，胸骨，肋骨，法兰克斯和股骨[3]。尽管任何骨骼都可能受到BT的影响，但据报道，骨脊柱的参与极为罕见[4]。在原发性甲状腺功能亢进症的情况下，多个棕色肿瘤极为罕见[5]，可以被误诊为与Paget疾病有关的转移或巨细胞肿瘤（GCT）。巨细胞肿瘤的最接近鉴别诊断被排除在副氨基甲抑制和钙水平升高。the骨会引起多个骨骼，并出现巨大的细胞肿瘤，出现疼痛和s骨炎，但在BT表现方面尚未证明这种临床和放射学实体。

计算机断层扫描上多种骨化肿块的鉴别诊断包括骨囊肿，巨型细胞肉芽肿，GCT，多发性骨髓瘤，动脉瘤性骨囊肿，BTS和弦瘤，尤其是当它们位于sachum中时[6]。大多数良性骨骼病变都表现出硬化缘和多发性骨髓瘤，转移和GCT没有这种发现，也没有提出的情况。

Bone lypmphomas commonly involve the pelvic bones and femur and commonly demonstrate a permeative bone destruction pattern instead of a well marginated expansile lytic mass [7]. Chordomas of the spine are rare lesions but they are the most common primary spinal malignancy in adults after lymphoproliferative diseases [8]. Cordomas are often well-circumscribed lytic expansile masses which may include irregular intratumoral calcifications due to sequestra of normal bone, may present marginal sclerosis and involve more than one vertebral segment. Thus, they have a strong potential of a possible differential diagnosis. Exantric and cortical location in absence of a history of malignancy could consider BTs rather than metastasis, myeloma and lymphoma. MRI is a useful imaging modality in order to detect the cystic and solid components, the hemosiderin deposits based on susceptibility artifacts, enhancing reactive fibrovascular tissue and the cause of neurologic disorder as well. The diagnosis of aneurysmal bone cysts and BTs were histopathologically controversial while MRI has significant diagnostic role by showing both cystic and solid portions and fluid levels. Since interventions or simple traumas could cause hemorrhagic areas in the mass, susceptibility artifacts are known to be sensitive but not specific for BTs. Attenuation values of BTs on CT are variable and depend on the internal hemorrhagic, fibrous and cystic components.

Multiple myeloma has to be confirmed with plasma protein electrophoresis and metastasis, chordoma, lymphoma and giant cell tumors could be ruled out with histopathological evaluation. As an initial investigation in a case with multiple lytic bone lesions, plasma calcium, parathormone and phosphorus an vitamin D levels has to be determined. Multiple BTs are seen in cases with parathyroid carcinoma and end stage renal disease due to excess parathormone levels. BTs with numerous lesions are unexpected in primary hyperparathyroidism and a few cases were reported as simulating malignancy [9]. Multiple GCTs may be seen association with Paget disease. The expansile masses without a sclerotic margin in addition to extension to closest articular surfaces were highly suggestive for GCTs. Since GCTs are the second most common type of primary tumor involving the sacrum [10], and the distribution of the lytic masses as the sacrum and distal radius considered GCTs. Spinal involvement of BTs are very rare and thorasic vertebral involvement is most common site while sacral involvement is extremely rare. Multiple BTs in primary hyperparathyroidism in addition to sacral involvement has not been reported [11]. Thus, BTs are great mimickers of GCTs with the clinical, radiological and histopathological aspect depending on the same physiopathological pathway.

从腺瘤切除后一个月后获得的症状完全分辨出来，并在MRI上观察到快速而大规模的骨形成。据报道，甲状旁腺功能亢进症的表现通常是非特异性的，例如普遍的骨骼和肌肉疼痛，抑郁，睡眠问题，胃食管反流疾病和浓度降低，但大多数患有甲状旁腺功能亢进症的患者无症状[12]。伴有臀部和肘关节油漆的辐射下腰痛的症状可能会考虑严重的骨质疏松症和神经系统疾病，在患有性甲状旁腺功能亢进症的情况下可能是由病理性骨折或神经根压缩引起的，尤其是与BTS相关。尽管由于GCT通常期望将肿块扩展到关节表面，但BTS将具有相似的临床，放射学和组织病理学表现，但由于将肿块扩展到关节表面而引起的痛苦的关节运动。组织病理学诊断是在具有间隙出血，微裂，血压素和具有成纤维细胞的血管化纤维组织的巨细胞上进行的。但是，对于棕色肿瘤和巨细胞肉芽肿和巨细胞肿瘤，这些发现中的任何一个都不是病理性的。在巨细胞肿瘤中，预计没有间质出血的均匀分布的巨细胞和成纤维细胞的基质细胞。

脊柱受累的BTS通常需要神经外科干预和部分牺牲术，而iLiac翼切除术是据报道的治疗方法，在患有s骨和乳突的情况下。在提出的腺瘤切除术中，尽管神经系统症状是足够的。腺瘤的手术切除通常可以完全清除病变，并回想起椎骨[3]。评估后，症状和发现，例如骨矿物质密度，与神经系统发现相关的轴向受累以及可能的病理骨折；与GCTS或神经外科或骨科干预相反，手术方法可能仅限于腺瘤切除术。由于对脊柱病变的延迟干预可能会因不可逆的神经系统疾病而复杂化，因此应检查患者并认真对待患者。

总之，可以通过放射学检查看到BTS的完全回归。放射线和症状改进都可以按时提供足够有效的管理。在没有病理骨折的情况下，BT是非常罕见的非接触骨病变。BT和GCT应评估为多种溶造，膨胀骨骼质量的患者的差异诊断。在这种情况下，临床，放射学，病理和生化相关性具有重要的价值，可以实现正确的诊断。