【作者】 王丹丹；

【导师】 郭传瑸； 孟娟红；

【作者基本信息】 北京大学医学部 ， 口腔颌面外科学（专业学位）， 2021， 博士

【摘要】 目的:1.通过回顾分析颞下颌关节弥漫型腱鞘巨细胞瘤(Diffuse tenosynovial giant celltumor,D-TSGCT)的临床、影像、组织病理学特点以及治疗方法等,为D-TSGCT的诊断和治疗预后提供参考。2.通过研究D-TSGCT中骨破坏相关蛋白的表达情况,以及肿瘤中CD14阳性(CD14+)和CD14阴性(CD14-)细胞的不同特点,初步探讨D-TSGCT骨破坏的相关机制。3.研究含软骨样成分的D-TSGCT的组织病理学及影像学表现,并探究软骨样成分的来源以及D-TSGCT中CD14-细胞是否具有干细胞特性。材料与方法:1.选取2008年3月至2021年2月,于北京大学口腔医院接受手术治疗的D-TSGCT或色素绒毛结节性滑膜炎患者,共33例。通过回顾性研究,分析并讨论颞下颌关节D-TSGCT的年龄分布、性别比例、发病部位、临床表现、影像特点及治疗方式等;通过免疫组化实验,分析D-TSGCT中CD68、Ki67以及CD31的表达情况。2.通过RT-PCR、Western Blot、免疫荧光等方法,分析D-TSGCT肿瘤组织中RANKL、RANK、M-CSF、MMP9等基因及蛋白的表达情况;通过磁珠分选,对D-TSGCT中的CD14+和CD14-细胞进行分离培养,分析不同种类的细胞中相关蛋白的表达情况;通过破骨细胞诱导实验、细胞迁移和侵袭实验,验证CD14-细胞与CD14+细胞对破骨细胞形成的不同作用。3.通过HE染色及免疫组化实验,分析D-TSGCT中软骨样成分的特点;通过流式细胞学分析CD14-细胞中干细胞表面标志物的表达情况;通过成骨、成软骨、成脂诱导实验,分析D-TSGCT中CD14-细胞是否具有干细胞特性。结果:1.本研究共纳入颞下颌关节区D-TSGCT患者33例。男女比例约为1:1.2。左侧12例,右侧21例。发病年龄为24-62岁,中位年龄为47岁。临床症状为耳前区肿物或肿胀,可伴有疼痛或无痛,下颌运动障碍等。15.2%有听力下降表现。CT主要表现为颞下颌关节周围边界不清的软组织肿物,93.9%伴有关节骨质的破坏,48.5%伴有颅底骨质破坏。增强CT显示88%的病变伴有强化。在MRI的T1WI像、T2WI像均可见比例不等的低信号影像,或以低信号影像为主的混杂信号影像。D-TSGCT的大体标本呈棕褐色,实性,质脆。镜下可见肿瘤由大片单核细胞、破骨细胞样多核巨细胞、泡沫细胞及炎细胞等组成。所有患者均接受开放性手术治疗。10例患者接受术后辅助放疗。随访2个月-13年,5例患者复发。复发的患者平均Ki67指数为9%,未复发患者为6%,复发患者的Ki67指数高于未复发者(P<0.05)。2.颞下颌关节D-TSGCT中与破骨细胞形成及基质降解相关的M-CSF、RANKL、RANK和MMP9基因及蛋白均呈明显高表达。其中CD14-细胞高表达M-CSF,能够促进多核巨细胞的形成,以及CD14+细胞的侵袭和迁移;CD14+细胞能够融合形成多核巨细胞,且高表达MMP9,具有一定的基质降解能力。3.在33例肿瘤中有15例显微镜下可见软骨样成份,软骨样成分占的比例和表现不完全相同,可呈透明软骨样、软骨内骨化、蕾丝状钙化等表现,呈局灶性散在分布或成片状分布。3例D-TSGCT伴发SC的病例与其余病例相比,软骨样成分明显增多,可见较多软骨结节及游离体。部分D-TSGCTCD14-细胞表达干细胞表面标志物CD90、CD105、CD73,且在特定培养条件下,可向成软骨细胞、成骨细胞、成脂细胞分化,具有间充质干细胞特点。结论:1.发生在颞下颌关节的D-TSGCT,临床表现具有非特异性。临床上易被误诊为腮腺肿物、颞下颌关节紊乱病及其他颞下颌关节区的良、恶性肿瘤等。D-TSGCT具有局部侵袭性,易侵犯周围骨质,与周围肌肉等软组织边界不清。目前主要治疗方式为开放性手术,对于范围广泛或者侵犯颅底的病例,可采取术后辅助低剂量放疗以降低复发率。2.颞下颌关节D-TSGCT易破坏周围骨质,颅底骨质破坏可达48.5%。其骨破坏机制可能与RANKL、RANK、M-CSF、MMP9等表达增高有关。肿瘤中的CD14-细胞能促进破骨细胞形成,且有增殖能力,可能是真正的肿瘤细胞;CD14+细胞有降解基质的能力,并且可能是破骨细胞的前体细胞。两种细胞相互作用,共同促进骨质破坏。3.含有软骨样成分的D-TSGCT在颞下颌关节较为常见,组织学上需与软骨母细胞瘤、滑膜软骨瘤病等鉴别。肿瘤组织中的CD14-细胞具有间充质干细胞特点,可能与软骨样成分的产生有关。更多还原

【Abstract】 Objectives:Firstly,to provide evidences for the differential diagnosis and treatment of temporomandibular joint(TMJ)diffuse tenosynovial giant cell tumor(D-TSGCT)by retrospectively analyzing the clinical and imaging features,treatment methods,histopathological features and immunophenotypes.Then,to explore the mechanism of the bone destruction in D-TSGCT by analyzing the expression of related proteins and the characteristics of CD 14-negative(CD14-)and CD 14-positive(CD 14+)cells.Lastly,to further analyze the histopathological and imaging findings of D-TSGCT with chondroid components,explore the origin of the chondroid components and the differential potiential of CD14-cells in D-TSGCT.Methods:1.Thirty-three cases of TMJ D-TSGCT or pigmented villonodular synovitis were enrolled in this study.The demographics,clinical manifestations,imaging features,treatment selections,complications and the recurrence rate were summarized and analyzed.Immunohistochemical staining was used to detect the expression of Ki67,CD68,and CD31.2.The expression of RANKL,RANK,M-CSF and MMP9 in tissues of D-TSGCT were detected by RT-PCR,western blot and immunofluorescence.Magnetic absorting cell sorting were used to isolate the CD14+cells and CD14-cells.The expression of related proteins in two types of cells were detected respectively.The roles of two types of cells on the formation of osteoclasts were verified through the induction of osteoclasts,cell migration and invasion assays.3.The histopathological and immunohistochemical charateristics of chondroid components in D-TSGCT were further analyzed.The expression of surface markers of stem cells,CD90,CD 105 and CD73,in CD 14-cells were analyzed by flow cytometry.The differential potential of osteogenesis,chondrogenesis and adipogenesis were detected.Results:1.The mean age of 33 cases of TMJ D-TSGCT was 47 years old(range,24-62 years old).The ratio of female to male was 1.2:1.All cases were unilateral onset.Swelling and mandibular dysfunction are dominant symptoms.15.2%of cases showed hearing loss.CT showed 93.9%with bone destruction and 48.5%with the skull-base destruction.Contrast-enhanced CT showed 88%with enhancement.Magnetic resonance imaging(MRI)revealed heterogeneous low signals in most cases on both T1WI and T2WI.The specimens were brownish and friable.Microscopic appearance revealed expansive sheets of mononuclear cells,scattered osteoclast-like multinucleated giant cells,inflammatory cells and foam cells.All cases underwent surgery.Ten patients received postoperative radiotherapy.The follow-up duration ranged from 2 months to 13 years.Five cases showed recurrence on imaging examination.The Ki67 index of the recurrent cases was higher than that of the non-recurrent ones.2.RANKL,M-CSF,RANK and MMP9,which were contributed to the formation and function of osteoclasts,were overexpressed in D-TSGCT.CD 14-cells had proliferation ability.CD 14-cells overexpressed M-CSF,and could promote the formation of osteoclasts.In addition,CD14-cells promoted the invasion and migration of CD14+cells.CD14+cells could fuse into osteoclasts and overexpress MMP9.3.Fifteen cases of D-TSGCT contained different proportion of chondroid components microscopically.The microscopic appearance of chondroid components revealed hyaline cartilage,chondro-osseous or lace-like intercellular calcification.A large amount of cartilage nodules and free bodies could be seen in three cases of simultaneous D-TSGCT and synovial chondromatosis.A subpopulation of CD14-cells express CD90,CD105 and CD73.These cells had chondrogenic,osteogenic and adipogenic potential.Conclusions:1.The common clinical manifestations of TMJ D-TSGCT are swelling and dysfunction of temporomandibular joint.The nonspecific clinical manifestations make TMJ D-TSGCT easily misdiagnosed as parotid tumors,temporomandibular disorders and tumors.D-TSGCT has aggressive and recurrent nature.Open surgery is the common treatment option.Adjunct postoperative treatment should be taken for the lesion with intracranial invasion and extensive margins.2.D-TSGCT has aggressive nature.The rate of skull-base destruction was 48.5%.The mechanism of bone destruction in D-TSGCT may be related to the overexpression of M-CSF,RANKL,RANK and MMP9.CD14-cells,with proliferation ability,overexpressed M-CSF which could promote the formation of osteoclasts.CD 14+cells which were progenitor cells of osteoclasts could fuse into multinucleated giant cells.CD 14+cells overexpressed MMP9,and had the invasion ability.Two sorts of cells interacted with each other to promote bone destruction in D-TSGCT.3.D-TSGCT with chondroid component is a rare subset of D-TSGCT whose predilection is TMJ.D-TSGCT with chondroid component is needed to be differentiated with chondroblastoma and synovial chondromatosis histologically.The chondroid components may be derived from the differential potential of CD 14-cells.更多还原