Çocukta litik kemik lezyonları: enfeksiyon ve tümör taklitçileri

Özet

Çocukta litik kemik odağı gelişimsel lezyon, enfeksiyon veya iyi ya da kötü huylu tümör olabilir; yaş ve kemik içindeki yerleşim ayırıcı tanıyı değiştirir. Şüpheli fokal kemik lezyonunda ilk inceleme direkt grafidir. BT korteks bütünlüğünü, periostal kemiği ve mineralize matriksi ayrıntılandırır; kemik iliği ve yumuşak doku yayılımında MR tamamlayıcıdır. Geçiş zonu, anatomik merkez ve korteks dışı bileşen birlikte tanımlanmalı, görüntü paterni histolojik tanı yerine kullanılmamalıdır. Agresif enfeksiyonu tümör ya da maligniteyi enfeksiyon sanmak tanı ve evrelemeyi geciktirebilir.

Faz ve pencere

Kemik algoritması tanısal

Kontrastsız ince kesit kemik rekonstrüksiyonunda litik odağın medüller, kortikal ya da yüzey merkezini; geçiş zonunu, kortikal incelme veya kesintiyi, periostal yeni kemiği ve osteoid ya da kondroid matriks mineralizasyonunu gösterir.

Önerilen pencereler: Kemik (G 1800 / M 400), Yumuşak doku (G 400 / M 40).

BT bulguları

• Dar ve keskin geçiş zonu, özellikle çevresinde sklerotik kenar varsa daha yavaş büyüyen coğrafi litik paterni tarif eder; benignlik kanıtı değildir.
• Geniş, belirsiz geçiş zonuna eşlik eden güve yeniği ya da permeatif yıkım, agresif kemik davranışını gösterir; enfeksiyon ve malignite örtüşebilir.
• Metafiz, diafiz, epifiz, medüller kanal, korteks ve kemik yüzeyinden hangisinin odağın merkezi olduğu ayırıcı tanıyı daraltır.
• Kortikal incelme ve dışa bombeleşme ekspansiyonu; kortikal kesinti ise lezyonun kemik kabuğunu aşmış olabileceğini gösterir.
• Periostal yanıtın türü ayırıcı tanıyı daraltmaya yardımcı olabilir.
• Matriks mineralizasyonunun biçimi ayırıcı tanıyı daraltmaya yardımcı olabilir.
• Korteksi aşan solid yumuşak doku, özellikle agresif kemik yıkımıyla komşuysa lokal tümör yayılımı açısından kayda değerdir.
• Uzun kemiklerde litik odağın medüller, kortikal veya yüzey merkezini belirlemek; geçiş zonunu, kortikal bütünlüğü ve periostal yanıtı değerlendirmek ayırıcı tanıyı daraltır.

Ölçütler ve sınıflamalar

Lodwick-Madewell paterni ve önerilen Caracciolo revizyonu

Lodwick-Madewell sınıflaması: I coğrafi yıkım; IA sklerotik kenarlı, IB keskin sınırlı fakat sklerotik kenarsız, IC belirsiz kenarlı ve geniş geçiş zonlu; II güve yeniği; III permeatif paterndir. Caracciolo'nun revizyonunda IC ile II birleştirilir; tip III A seri görüntülerde sınır değişikliği veya ilerleyen endosteal kazıma, B güve yeniği ve permeatif desenler, C radyografik olarak gizli olarak sınıflandırılır. Bu radyografik paternler agresifliği tarif eder; histolojik tanı yerine geçmez.

Normalde

Kemik lezyonu değerlendirilirken yerleşim, sınır ve yoğunluk özellikleri tanımlanmalıdır. Kemik lezyonunun yerleşimi ve sınırları, ayırıcı tanıyı daraltmaya yardımcı olur.

Ayırıcı tanı

Osteomiyelit litik kemik lezyonlarının ayırıcı tanısında yer alır.

Ewing sarkomu

diafizer permeatif yıkım, lameller periostal yanıt ve solid ekstraosseöz kitle birlikte görülebilir; bu bulgular enfeksiyondan kesin ayrım sağlamaz.

Osteosarkom

çoğunlukla metafizer yerleşim, agresif kortikal değişiklik ve bulutsu osteoid mineralizasyonu görülebilir.

Langerhans hücreli histiyositoz

çocuklarda çoklu litik kemik lezyonlarına yol açabilir; eşlik eden bulgular ve diğer kemik odaklarının varlığı ayırıcı tanıda yardımcı olur.

Basit kemik kisti

uzun kemiğin merkezî medüllasında, çoğunlukla iyi sınırlı ekspansil litik lezyon oluşturur; agresif periostal kılıf veya solid dış kitle tipik değildir.

Anevrizmal kemik kisti

ekspansil, septalı litik lezyon görünümü verebilir; sıvı-sıvı seviyelerini BT güvenilir biçimde karakterize edemez, MR daha uygundur.

Tuzaklar

• Geniş geçiş zonu enfeksiyonda da görülebilir; ateş veya inflamasyon bulgusu eşlik etse bile agresif tümörü tek başına dışlamaz.
• Açık fizis, apofiz ve gelişen ossifikasyon merkezleri düzensiz görünebilir; gerçek litik odağın çevresinde medüller trabekül kaybı ve karşı tarafla fark aranır.
• Matriks mineralizasyonunun görülmemesi tümörü dışlamaz; küçük veya az mineralize lezyonlarda BT’de matriks belirgin olmayabilir.
• Periostal yanıtın katmanlı ya da ışınsal olması tümör türünü tek başına adlandırmaz; kırık, enfeksiyon ve tümör benzer yanıt oluşturabilir.

Kendini dene

1. Adölesanda distal femur metafizinde agresif litik kitle ve osteoid matriks mineralizasyonu var. En olası tanı hangisidir?

   • Osteosarkom
   • Ewing sarkomu
   • Anevrizmal kemik kisti
   • Osteomiyelit
   Cevabı göster

   Osteosarkom. S1'e göre osteosarkom metafizer yerleşimli ve osteoid matriks üreten klasik bir tümördür. Ewing sarkomu ise sıklıkla diafizleri tutar. Anevrizmal kemik kisti ve osteomiyelit osteoid matriks üretmez.

2. Diafizer litik lezyonda permeatif yıkım ve katmanlı periostal yanıt var. Hangi tümör öncelikle düşünülür?

   • Ewing sarkomu
   • Nonossifiye fibrom
   • Basit kemik kisti
   • Osteoid osteoma
   Cevabı göster

   Ewing sarkomu. S1'e göre Ewing sarkomu sıklıkla diafizleri tutar ve permeatif/güve yenmiş yıkım ile periostal reaksiyon yapar. Bu bulgular enfeksiyonla örtüşebilir ancak malignite açısından Ewing sarkomu akla gelir.

İlgili konular

• Brodie apsesi ve kronik osteomiyelit

Kaynaklar

Bu sayfadaki 45 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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