骨肿瘤的外科分期骨肿瘤的外科分期Surgical Staging of Bone Surgical Staging of Bone TumorsTumors1 1 Enneking-Musculoskeletal Enneking-Musculoskeletal Tumor Staging System Tumor Staging System 2 2 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 AJCC(American Joint Committee on Cancer) Cancer) 提出提出复杂，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3 3 肌肉骨骼系统肿瘤的外科分期肌肉骨骼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)试试用用Clinical Orthopedics and Related Clinical Orthopedics and Related Research,1980Research,1980AJC(American Joint Committee)AJC(American Joint Committee)修订修订IUCC(International Union Against IUCC(International Union Against Cancer) Cancer) 国际推广国际推广4 4 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、切除范围的治疗的要求：手术时机、手术方法、切除范围的治疗的要求：手术时机、手术方法、切除范围的治疗的要求：手术时机、手术方法、切除范围的选择；辅助治疗方法的选择选择；辅助治疗方法的选择选择；辅助治疗方法的选择选择；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标准化的要求：统一标准、有利于治疗资料和疗标准化的要求：统一标准、有利于治疗资料和疗标准化的要求：统一标准、有利于治疗资料和疗效的交流效的交流效的交流效的交流(interinstitutional and (interinstitutional and (interinstitutional and (interinstitutional and interdisciplinary communication)interdisciplinary communication)interdisciplinary communication)interdisciplinary communication)5 5 适用范围适用范围 肌肉、骨骼系统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6 6 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、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤肉瘤肉瘤肉瘤转移性肿瘤转移性肿瘤7 7 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 Grade)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：肿瘤有无转移，包括区域和远处：肿瘤有无转移，包括区域和远处：肿瘤有无转移，包括区域和远处转移转移转移转移8 8 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9 9 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BroderBroderBroderBroder s s s s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LodwickLodwickLodwickLodwick s s s s分级分级分级分级G G G G0 0：良性病变；：良性病变；：良性病变；：良性病变；G G G G1 1：低度恶性；：低度恶性；：低度恶性；：低度恶性；G G G G2 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如组织学表现偏良性而放射和临床表现为高度侵如组织学表现偏良性而放射和临床表现为高度侵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袭性者应定为高度恶性袭性者应定为高度恶性袭性者应定为高度恶性1010 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 Fluoroscopy with C-arm guidance C-arm guidance ，CT-guided biopsy CT-guided biopsy 切取活检切取活检切除活检切除活检1111 影像学：影像学：X-ray Lodwick X-ray Lodwick 放射学分放射学分级级Grade 1A, 1B, and 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 ranging from well defined to poorly ranging from well defined to poorly ranging from well defined to poorly ranging from well defined to poorly defined. defined. defined. defined. Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant lesions with invasive features, lesions with invasive features, lesions with invasive features, lesions with invasive features, particularly those with total penetration particularly those with total penetration particularly those with total penetration particularly those with total penetration of the cortex. of the cortex. of the cortex. 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 invasive, permeative, and lesions with invasive, permeative, and lesions with invasive, permeative, and destructive features destructive features destructive features destructive features 1212 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 destruction (geographic or not Pattern of destruction (geographic or not geographic, appearance of marginal geographic, appearance of marginal geographic, appearance of marginal geographic, appearance of marginal interface zone) interface zone) interface zone) interface zone) Penetration of cortex by lesion 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) Absence 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 shell1313 SundaramSundaram分级系统分级系统Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do not require further investigation or treatment. not require further investigation or treatment. not require further investigation or treatment. not require further investigation or treatment. Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being benign, but this finding should be confirmed by benign, but this finding should be confirmed by benign, but this finding should be confirmed by benign, but this finding should be confirmed by means of clinical or radiographic follow-up means of clinical or radiographic follow-up means of clinical or radiographic follow-up means of clinical or radiographic follow-up examination. examination. examination. 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 aggressive behavior surgical resection because of aggressive behavior surgical resection because of aggressive behavior surgical resection because of aggressive behavior or risk of pathologic fracture. or risk of pathologic fracture. or risk of pathologic fracture. or risk of pathologic fracture. Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions that should be considered malignant. Biopsy should that should be considered malignant. Biopsy should that should be considered malignant. Biopsy should that should be considered malignant. Biopsy should be performed to confirm the histologic grade and be performed to confirm the histologic grade and be performed to confirm the histologic grade and be performed to confirm the histologic grade and the diagnosis. the diagnosis. the diagnosis. the diagnosis. 1414 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 1515 CT in evaluation of local CT in evaluation of local diseasediseaseComplements 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 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 CT is better in assessing the type of CT is better in assessing the type of CT is better in assessing the type of cortical destruction and the presence of cortical destruction and the presence of cortical destruction and the presence of cortical destruction and the presence of matrix mineralization. matrix mineralization. matrix mineralization. matrix mineralization. CT is also helpful in determining the CT is also helpful in determining the CT is also helpful in determining the CT is also helpful in determining the internal contents of some lesions. internal contents of some lesions. internal contents of some lesions. internal contents of some lesions. 1616 CT in evaluating the lungs for CT in evaluating the lungs for metastases metastases More accurate than chest radiographsMore accurate than chest radiographsMay produce false-positive results May produce false-positive results when small lung nodules are detected. when small lung nodules are detected. Follow-up CT scans are useful in Follow-up CT scans are useful in monitoring the nodules. monitoring the nodules. 1717 影像学：影像学：MRIMRI accurate depiction of the soft accurate depiction of the soft tissues allows sensitive detection of tissues allows sensitive detection of soft tissue extension and medullary soft tissue extension and medullary involvement by tumor involvement by tumor 1818 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 healthy demarcated from the surrounding healthy demarcated from the surrounding healthy demarcated from the surrounding healthy tissue. tissue. tissue. tissue. Malignant lesions are typically more Malignant lesions are typically more Malignant lesions are typically more Malignant lesions are typically more extensive and involve surrounding tissue to extensive and involve surrounding tissue to extensive and involve surrounding tissue to extensive and involve surrounding tissue to a greater extent than do benign lesions. a greater extent than do benign lesions. a greater extent than do benign lesions. a greater extent than do benign lesions. MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable in distinguishing benign tumors and in distinguishing benign tumors and in distinguishing benign tumors and in distinguishing benign tumors and malignant tumors. malignant tumors. malignant tumors. malignant tumors. 1919 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 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 neurovascular structures, muscle neurovascular structures, muscle neurovascular structures, muscle compartments, growth plates, and joints. compartments, growth plates, and joints. compartments, growth plates, and joints. compartments, growth plates, and joints. Usually accurately depicts intramedullary Usually accurately depicts intramedullary Usually accurately depicts intramedullary Usually accurately depicts intramedullary spread and soft tissue extension of tumor spread and soft tissue extension of tumor spread and soft tissue extension of tumor spread and soft tissue extension of tumor 2020 MRAMRAProvide additional information Provide additional information regarding neurovascular bundle regarding neurovascular bundle involvement. involvement. Assessing peripheral vascular Assessing peripheral vascular branches and tumor neovascularity. branches and tumor neovascularity. 2121 其他影像学检查其他影像学检查Radionuclide bone scans Radionuclide bone scans UltrasonographyUltrasonographyAngiography Angiography Positron Emission Tomography Positron Emission Tomography 2222 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，组织学表现：细胞分化良好，基质细胞比例正常，组织学表现：细胞分化良好，基质细胞比例正常，组织学表现：细胞分化良好，基质细胞比例正常，核分裂相极少见核分裂相极少见核分裂相极少见核分裂相极少见2323 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，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织肿块，偶有远处转移软组织肿块，偶有远处转移软组织肿块，偶有远处转移软组织肿块，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，可见组织学表现：细胞分化中等，基质细胞较多，可见组织学表现：细胞分化中等，基质细胞较多，可见组织学表现：细胞分化中等，基质细胞较多，可见核分裂相但较少核分裂相但较少核分裂相但较少核分裂相但较少2424 外科分级外科分级G GG G G G2 2 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临床：症状明显，肿瘤生长快，有跳跃性生长和软组织临床：症状明显，肿瘤生长快，有跳跃性生长和软组织临床：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肿块，常早期就发生局部和远处转移肿块，常早期就发生局部和远处转移肿块，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，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多见见见见2525 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2626 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原发病灶和反应带均局限在病灶的原发间室内室内2727 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，未穿破骨膜骨旁间隙内，未进入骨皮质，未穿破骨膜侵犯肌、筋膜侵犯肌、筋膜2828 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，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹股沟等如腹股沟等如腹股沟等如腹股沟等2929 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、腋窝、肘窝、腋窝、guoguo窝、腹股沟、骨盆内窝、腹股沟、骨盆内3030 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3131 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3232 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 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 3333 1 1期期 G G0 0T T0 0M M0 0 ，良性潜隐性，良性潜隐性 临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形放射学：平片示病灶界限清楚、形状和边界规放射学：平片示病灶界限清楚、形状和边界规放射学：平片示病灶界限清楚、形状和边界规放射学：平片示病灶界限清楚、形状和边界规则，有皮质骨样反应骨包围（则，有皮质骨样反应骨包围（则，有皮质骨样反应骨包围（则，有皮质骨样反应骨包围（LodwickA)LodwickA)LodwickA)LodwickA)；CTCTCTCT示病灶呈均质性，无骨皮质穿破示病灶呈均质性，无骨皮质穿破示病灶呈均质性，无骨皮质穿破示病灶呈均质性，无骨皮质穿破组织学：基质成熟，分化好，细胞基质比例组织学：基质成熟，分化好，细胞基质比例组织学：基质成熟，分化好，细胞基质比例组织学：基质成熟，分化好，细胞基质比例低，无恶性细胞学表现，如：细胞核深染、核低，无恶性细胞学表现，如：细胞核深染、核低，无恶性细胞学表现，如：细胞核深染、核低，无恶性细胞学表现，如：细胞核深染、核分裂相、间变、多行性；病灶被成熟的纤维组分裂相、间变、多行性；病灶被成熟的纤维组分裂相、间变、多行性；病灶被成熟的纤维组分裂相、间变、多行性；病灶被成熟的纤维组织或皮质骨包围，极少反应性间质浸润、炎症织或皮质骨包围，极少反应性间质浸润、炎症织或皮质骨包围，极少反应性间质浸润、炎症织或皮质骨包围，极少反应性间质浸润、炎症反应和新生血管形成反应和新生血管形成反应和新生血管形成反应和新生血管形成3434 1 1期（期（G G0 0T T0 0M M0 0）3535 1 1期（期（G G0 0T T0 0M M0 0）3636 2 2期期 G G0 0T T0 0M M0 0 ，良性活动性，良性活动性临床：肿瘤持续、稳定生长，引起症状，有接触临床：肿瘤持续、稳定生长，引起症状，有接触临床：肿瘤持续、稳定生长，引起症状，有接触临床：肿瘤持续、稳定生长，引起症状，有接触抑制但反应性低于正常抑制但反应性低于正常抑制但反应性低于正常抑制但反应性低于正常X X X X线平片：界清，边界有时不规则；有反应骨包围线平片：界清，边界有时不规则；有反应骨包围线平片：界清，边界有时不规则；有反应骨包围线平片：界清，边界有时不规则；有反应骨包围但偏向于松质骨，内部皮质有嵴，覆盖的皮质有但偏向于松质骨，内部皮质有嵴，覆盖的皮质有但偏向于松质骨，内部皮质有嵴，覆盖的皮质有但偏向于松质骨，内部皮质有嵴，覆盖的皮质有变形（变形（变形（变形（LodwickB)LodwickB)LodwickB)LodwickB)同位素检查：摄取增加，范围与平片上病灶范围同位素检查：摄取增加，范围与平片上病灶范围同位素检查：摄取增加，范围与平片上病灶范围同位素检查：摄取增加，范围与平片上病灶范围一致一致一致一致CTCTCTCT和和和和MRIMRIMRIMRI：病灶均质，反应带完整但不规则：病灶均质，反应带完整但不规则：病灶均质，反应带完整但不规则：病灶均质，反应带完整但不规则组织学：细胞基质比例平衡，基质分化好，分组织学：细胞基质比例平衡，基质分化好，分组织学：细胞基质比例平衡，基质分化好，分组织学：细胞基质比例平衡，基质分化好，分布均匀，细胞学表现为良性，可能有薄层纤维、布均匀，细胞学表现为良性，可能有薄层纤维、布均匀，细胞学表现为良性，可能有薄层纤维、布均匀，细胞学表现为良性，可能有薄层纤维、血管组织浸润反应带，骨吸收是因为破骨细胞作血管组织浸润反应带，骨吸收是因为破骨细胞作血管组织浸润反应带，骨吸收是因为破骨细胞作血管组织浸润反应带，骨吸收是因为破骨细胞作用而非肿瘤细胞用而非肿瘤细胞用而非肿瘤细胞用而非肿瘤细胞3737 2 2期（期（G G0 0T T0 0M M0 0）3838 2 2期（期（G G0 0T T0 0M M0 0）3939 2 2期期(G(G0 0T T0 0M M0 0) )4040 2 2期期(G(G0 0T T0 0M MO O) )4141 3 3期期 G G0 0T T1 12 2M M0 01 1 ，良性侵袭性，良性侵袭性临床：有症状，中度创伤就可致病理性骨折，临床：有症状，中度创伤就可致病理性骨折，临床：有症状，中度创伤就可致病理性骨折，临床：有症状，中度创伤就可致病理性骨折，生长快，偶有红斑和硬结生长快，偶有红斑和硬结生长快，偶有红斑和硬结生长快，偶有红斑和硬结X X X X线平片：侵袭性强，与周边正常骨界面呈破线平片：侵袭性强，与周边正常骨界面呈破线平片：侵袭性强，与周边正常骨界面呈破线平片：侵袭性强，与周边正常骨界面呈破碎状，骨皮质破坏明显，有骨膜反应和碎状，骨皮质破坏明显，有骨膜反应和碎状，骨皮质破坏明显，有骨膜反应和碎状，骨皮质破坏明显，有骨膜反应和CodmanCodmanCodmanCodman s s s s三角三角三角三角同位素扫描：摄取增加，范围超过平片所示的同位素扫描：摄取增加，范围超过平片所示的同位素扫描：摄取增加，范围超过平片所示的同位素扫描：摄取增加，范围超过平片所示的病灶范围病灶范围病灶范围病灶范围CTCTCTCT和和和和MRIMRIMRIMRI：病灶不均质，早期就可能超出间室：病灶不均质，早期就可能超出间室：病灶不均质，早期就可能超出间室：病灶不均质，早期就可能超出间室扩散扩散扩散扩散组织学：基质分化好，不同程度的成熟度，可组织学：基质分化好，不同程度的成熟度，可组织学：基质分化好，不同程度的成熟度，可组织学：基质分化好，不同程度的成熟度，可能有细胞核深染，但无细胞学恶性表现，可能能有细胞核深染，但无细胞学恶性表现，可能能有细胞核深染，但无细胞学恶性表现，可能能有细胞核深染，但无细胞学恶性表现，可能有核分裂相，病变可穿破假包膜，可见卫星灶有核分裂相，病变可穿破假包膜，可见卫星灶有核分裂相，病变可穿破假包膜，可见卫星灶有核分裂相，病变可穿破假包膜，可见卫星灶4242 良性骨肿瘤的良性骨肿瘤的GTMGTM分期与治疗措施的选择分期与治疗措施的选择 4343 恶性骨肿瘤恶性骨肿瘤期（期（ A A B B ）：低度恶性）：低度恶性期（期（ A A B B ）：高度恶性）：高度恶性期（期（ A A B B ）：有局部和远处转移）：有局部和远处转移 A A：间室内；：间室内； B B：间室外：间室外4444 A A 期期 G G1 1T T1 1M MO O ，间室内低度，间室内低度恶性恶性临床：生长缓慢，无疼痛等症状，缓慢穿过间临床：生长缓慢，无疼痛等症状，缓慢穿过间临床：生长缓慢，无疼痛等症状，缓慢穿过间临床：生长缓慢，无疼痛等症状，缓慢穿过间隔而非破坏间隔隔而非破坏间隔隔而非破坏间隔隔而非破坏间隔X X X X线平片：周围反应骨呈松质骨样，骨内膜呈线平片：周围反应骨呈松质骨样，骨内膜呈线平片：周围反应骨呈松质骨样，骨内膜呈线平片：周围反应骨呈松质骨样，骨内膜呈扇贝样，可有扇贝样，可有扇贝样，可有扇贝样，可有CodmanCodmanCodmanCodman s s s s三角三角三角三角同位素扫描：摄取增加，范围扩大，但限于病同位素扫描：摄取增加，范围扩大，但限于病同位素扫描：摄取增加，范围扩大，但限于病同位素扫描：摄取增加，范围扩大，但限于病灶的原发间室内灶的原发间室内灶的原发间室内灶的原发间室内CTCTCTCT和和和和MRIMRIMRIMRI：证实病变位于间室内：证实病变位于间室内：证实病变位于间室内：证实病变位于间室内组织学：基质分化成熟好，细胞基质比例接组织学：基质分化成熟好，细胞基质比例接组织学：基质分化成熟好，细胞基质比例接组织学：基质分化成熟好，细胞基质比例接近近近近1 1 1 1：1 1 1 1。有肯定的细胞学恶性表现，包括间变、。有肯定的细胞学恶性表现，包括间变、。有肯定的细胞学恶性表现，包括间变、。有肯定的细胞学恶性表现，包括间变、多形性（多形性（多形性（多形性（BroderBroderBroderBroder s1s1s1s1级，偶尔级，偶尔级，偶尔级，偶尔2 2 2 2级）。有假包级）。有假包级）。有假包级）。有假包膜，有卫星灶膜，有卫星灶膜，有卫星灶膜，有卫星灶4545 B B 期期 G G1 1T T2 2M MO O ，间室外低度恶性，间室外低度恶性临床表现、组织学表现与临床表现、组织学表现与A A A A 期期期期相似相似肿瘤主体或其反应带穿出原发间室肿瘤主体或其反应带穿出原发间室4646 B B(G(G1 1T T2 2M M0 0) )4747 B B(G(G1 1T T2 2M M0 0) )4848 B B(G(G1 1T T2 2M M0 0) )4949 A A 期期 G G2 2T T1 1M MO O ，间室内高度恶性，间室内高度恶性临床：有疼痛等症状，生长快，侵袭性强，临床：有疼痛等症状，生长快，侵袭性强，临床：有疼痛等症状，生长快，侵袭性强，临床：有疼痛等症状，生长快，侵袭性强，迅速穿破屏障而播散迅速穿破屏障而播散迅速穿破屏障而播散迅速穿破屏障而播散X X X X线平片：病灶边界不清，可根据形成的基质线平片：病灶边界不清，可根据形成的基质线平片：病灶边界不清，可根据形成的基质线平片：病灶边界不清，可根据形成的基质判断其组织来源判断其组织来源判断其组织来源判断其组织来源同位素扫描：摄取增加，范围明显大于平片显同位素扫描：摄取增加，范围明显大于平片显同位素扫描：摄取增加，范围明显大于平片显同位素扫描：摄取增加，范围明显大于平片显示的病灶范围，但局限在原发间室内示的病灶范围，但局限在原发间室内示的病灶范围，但局限在原发间室内示的病灶范围，但局限在原发间室内组织学：核深染，核分裂相多见，细胞基质组织学：核深染，核分裂相多见，细胞基质组织学：核深染，核分裂相多见，细胞基质组织学：核深染，核分裂相多见，细胞基质比例高，新生血管浸润，常见坏死和出血。肿比例高，新生血管浸润，常见坏死和出血。肿比例高，新生血管浸润，常见坏死和出血。肿比例高，新生血管浸润，常见坏死和出血。肿瘤细胞可直接破坏正常组织，仅有小部分假包瘤细胞可直接破坏正常组织，仅有小部分假包瘤细胞可直接破坏正常组织，仅有小部分假包瘤细胞可直接破坏正常组织，仅有小部分假包膜或没有包膜。相当于膜或没有包膜。相当于膜或没有包膜。相当于膜或没有包膜。相当于BroderBroderBroderBroder s 2s 2s 2s 2、3 3 3 3、4 4 4 4级级级级5050 B B 期期 G G2 2T T2 2M MO O ，间室外高度恶性，间室外高度恶性大部分高度恶性肿瘤表现为大部分高度恶性肿瘤表现为大部分高度恶性肿瘤表现为大部分高度恶性肿瘤表现为B B 期，偶有病理骨折期，偶有病理骨折期，偶有病理骨折期，偶有病理骨折X X X X线平片：骨皮质破坏，早期就有软组织扩散，骨线平片：骨皮质破坏，早期就有软组织扩散，骨线平片：骨皮质破坏，早期就有软组织扩散，骨线平片：骨皮质破坏，早期就有软组织扩散，骨膜反应常被快速生长的肿瘤破坏膜反应常被快速生长的肿瘤破坏膜反应常被快速生长的肿瘤破坏膜反应常被快速生长的肿瘤破坏同位素扫描：反应带超出原发间室同位素扫描：反应带超出原发间室同位素扫描：反应带超出原发间室同位素扫描：反应带超出原发间室CTCTCTCT和和和和MRIMRIMRIMRI：证实间室外侵犯：证实间室外侵犯：证实间室外侵犯：证实间室外侵犯组织学：同组织学：同组织学：同组织学：同A A 期期期期5151 B B(G(G2 2T T2 2M M0 0) )5252 B B(G(G2 2T T2 2M M0 0) )5353 B B(G(G2 2T T2 2M M0 0) )5454 B B(G(G2 2T T2 2M M0 0) )5555 期期恶性肿瘤任何级别，无论间室内外，只要恶性肿瘤任何级别，无论间室内外，只要有转移，均为有转移，均为期期胸部胸部X X线平片和线平片和CTCT检查应作为常规以发现肺检查应作为常规以发现肺转移灶转移灶同位素扫描可显示远处或跳跃性骨转移灶同位素扫描可显示远处或跳跃性骨转移灶MRIMRI纵向扫描可显示跳跃转移纵向扫描可显示跳跃转移体格检查可发现区域淋巴结转移体格检查可发现区域淋巴结转移5656 恶性骨肿瘤恶性骨肿瘤GTMGTM分期与治疗措施的选择分期与治疗措施的选择5757