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来源：熊猫放射 
58岁男性，背部疼痛。（A 58-year-old man with back pain.） 影像学表现 X线片(a 和 b)显示颅骨和右侧股骨可见无数小圆形溶骨性病变（innumerable small rounded lytic lesions）。这些病灶大小极为相似(<1cm)，可见“穿凿样”表现（have a “punched out” appearance）且无硬化缘（lack a sclerotic rim），耻骨上、下支的病理性骨折（Pathologic superior and inferior pubic ramus fractures）也很明显。 矢状位CT图像(c)显示广泛的骨质减少和多发的椎体压缩性骨折（diffuse osteopenia and multiple vertebral body compression fractures）。鉴别诊断(前3位) 多发性骨髓瘤 Multiple myeloma 溶骨性转移瘤 Lytic metastases - 朗格汉斯细胞组织细胞增生症(LCH) Langerhans cell histiocytosis
讨论 颅骨的多发“穿凿样”圆形的溶骨性病变（Multiple “punched out” round lytic lesions in the skull）高度提示骨髓瘤（highly suggestive of myeloma），尤其当其大小相似时（when similar in size）。广泛的骨质减少和椎体压缩骨折支持骨髓瘤的诊断。 溶骨性转移瘤不大可能是离散且大小一致的，也不大可能引起分散的内骨膜贝壳样受侵（less likely to be discrete and uniform in size or to create discrete endosteal scalloping）。 朗格汉斯细胞组织细胞增生症(LCH)在儿童可造成多发溶骨性破坏和椎体压缩骨折，而在成人则常表现为单骨或几个骨的病变（cause multiple lytic lesions and vertebral body compressions in children, but, in adults, it usually presents with only one to a few bone lesions）。诊断 要点 为最常见的原发恶性骨肿瘤。Most common primary malignant tumor of bone. 可发生于任何骨，但中轴骨是最常见的发病部位（其次是成人的造血骨髓）。Can occur in any bone, but axial skeleton is the most common site (follows sites of adult hematopoietic marrow). 12%~25%的患者在就诊即有广泛的骨质减少，但无可见的局部病灶。At presentation, 12–25% have diffuse osteopenia, without detectable focal lesion. 99%的患者在血清或尿蛋白电泳中可见单克隆M蛋白高峰，而75%的患者在血清中可出现Bence-Jones蛋白(单克隆轻链）。Monoclonal M component spike is present in serum or urine protein electrophoresis in 99%, Bence-Jones proteins (monoclonal light chain) in serum in 75%. 检查及随访要应用骨骼检查而非骨扫描，这是因为仅有一小部分病灶可在骨扫描上显示活性，某些部位可用PET扫描或“全身”MRI。Workup and follow-up is performed with skeletal survey rather than bone scan, because only a small percentage of lesions will show activity on bone scans; some sites use PET scans or “whole body” MRI. - 小部分(<3%)病变呈纯硬化性表现，而这其中的一些病变与POEMS综合征有关。Small percentage (<3%) of lesions are purely sclerotic and some of these are associated with POEMS syndrome.
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