肾脏囊性占位ppt课件

肾脏囊性占位2013-11肾脏囊性占位肾脏囊性占位2013-11肾脏囊性占位1IntroductionIgnore,FolloworExciseRadiologicalInterpretationCalcificationHyperdenseorHighsignalSeptationsEnhancementMultiloculatedNodularityWallthickeningRoleofBiopsyDrBosniaksopinionBosniakClassificationofRenalCysticDisease肾脏囊性占位IntroductionIgnore,Followor2RenalcystsarecommonlyencounteredlesionsinRenalcystsarecommonlyencounteredlesionsindailyradiologicalpractice.dailyradiologicalpractice.Usuallythesearesimplebenigncysts,buttheycanUsuallythesearesimplebenigncysts,buttheycanbecomecomplicatedincaseofhemorrhage,becomecomplicatedincaseofhemorrhage,infectionandischemia.infectionandischemia.WhenthisoccursitcanbedifficulttodifferentiateWhenthisoccursitcanbedifficulttodifferentiatethesecomplicatedcystsfromcysticrenalcellthesecomplicatedcystsfromcysticrenalcellcarcinomas(10%ofallrenalcellcarcinomas)carcinomas(10%ofallrenalcellcarcinomas)SincetheonlytreatmentforrenalcellcarcinomaisSincetheonlytreatmentforrenalcellcarcinomaissurgeryorablation,weneedtorecognizethesesurgeryorablation,weneedtorecognizethesecysticrenalcellcarcinomas.cysticrenalcellcarcinomas.ImagingisareliablemeansfordifferentiatingImagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesions.benignfrommalignantcysticlesions.肾脏囊性占位Renalcystsarecommonlyencou3Evenongrossexaminationacysticrenalcellcarcinoma(left)maybeindistinguishablefromacomplicatedcyst(right)肾脏囊性占位Evenongrossexaminationacy4Ignore,FolloworExciseRenalcystscanbeclassifiedaccordingtotheBosniakclassificationdependingontheirfeatures.TypeIcystsaresimplecysts.TypeIIaretheminimallycomplicatedcysts.TypeIandIIcanbeignored.TypeIIFareprobablybenign,butneedtobefollowed.TypeIIIandIVbotharesurgicallesions.TypeIVisinevitablymalignantandinthetypeIIIgroupabout80-90%turnouttobemalignantaswell.Inourcommunicationwiththecliniciansitisimportant,thatweexplainthesignificanceofourfindingsandthemeaningoftheclassificationintermsof:Ignore(typeIandII),Follow(typeIIF)orExcise(typeIIIandIV).SointhislecturewewillonlytalkaboutIgnore,FolloworExcise.ForthosewhowanttoseetheoriginalBosniakclassification,lookatthetablewhichispresentedattheendofthelecture.肾脏囊性占位Ignore,FolloworExcise肾脏囊性占位5肾脏囊性占位肾脏囊性占位6RadiologicalInterpretationAlthoughthefinaldifferentiationofcysticrenalmassesisbaseduponhistologicdiagnosis,thereareimagingfindingsthattellyouthatacystisnotasimplecystandwhetheritisprobablybenignormalignant.ThefollowingimagingfeaturesindicatethatacystisNOTsimple:-Calcification-Hyperdense/highsignal-Septations-Multiplelocules-Enhancement-Nodularity/wallthickening肾脏囊性占位RadiologicalInterpretation肾脏囊7Differentiationisbaseduponhistologicdiagnosis,butImagingisareliablemeansfordifferentiatingbenignfrommalignantcysticlesions肾脏囊性占位Differentiationisbasedupon8Thetableontheleftsummarisestheseimagingfeaturestogetherwiththemanagementconsequences:Ignore,FolloworExcise.Whenwelookattheseimagingfeatures,wehavetorealise,thatthemostworrisomeportionofacysticmassshouldbeusedindecidingappropriatemanagement.Sowhenthefindingsarediscordanteitherwithinoneexaminationorusingdifferentradiologicalexaminations,thelesionshouldbemanagedbaseduponthemostaggressiveimagingfindings.Whenwelookatthetableontheleft,wecansaythatweareprettygoodwiththefirst3parameters(calcification,hyperdensandseptations),becausewearecorrectinabout95%ofthecases.Theotherfourareevenmoreeasy,becausewhenyouhaveanyofthese(enhancement,multiloculated,nodularityorwallthickening),thelesionisalmostalwaysasurgicallesion.Regardingfollowup,therearenorulesatthemoment.Onecoulddoafollowupat6monthsandifthelesionisstablethendoublethefollowuptime.Wewillnowdiscussalltheseimagingfeaturesindetail.肾脏囊性占位Thetableontheleftsummaris9肾脏囊性占位肾脏囊性占位10CalcificationThemostimportantthingisagooddescriptionofthetypeofcalcifications.Wecanignoresmallamountsofcalcificationthataresmooth,septalorifitismilkofcalcium,whichmovestothelowestpointwithpositionalchanges.Wehavetomakesure,thatnoenhancement(=Alllesionsthatshowenhancementandlesionswithwallthickeningornodularityofthewalloutsidethecalcificationsshouldbeexcised.Wecanfollowlesionswiththickornodularcalcificationwithoutanyenhancement.肾脏囊性占位CalcificationThemostimporta11肾脏囊性占位肾脏囊性占位12Benigncalcifications:smallpunctateandmilkofcalcium.IgnoreOntheleftweseeacysticlesion.Thereisasmallpunctatecalcificationthatwecanignore.Onthebottomofthecystthereisalayerofcalciumtypicalformilkofcalcium.Thisisalsoabenigncalcificationthatwecanignore.肾脏囊性占位Benigncalcifications:smallp13LEFT:NECTwithasmoothlinearLEFT:NECTwithasmoothlinearcalcificationandnodularcalcificationandnodularcalcification.RIGHT:EnhancedCTcalcification.RIGHT:EnhancedCTshowsenhancement.Exciseshowsenhancement.ExciseOntheleftapatientwithnefrolithiasis.Thereisalsoacysticlesionwithlinearandnodularcalcification.Iftherewereonlytheselinearcalcificationswecouldignorethelesion.Incaseofnodularcalcificationwecanfollowit,ifthereisnoenhancement.Inthiscasehoweverweseeenhancement,sothislesionhastobeexcised.肾脏囊性占位LEFT:NECTwithasmoothlinea14OnCThyperdensemeans:20HUonaNECTOnMRIhyperintensemeansallthathashighersignalintensitythanwateronaT1weightedimage.Hyperdensityorhyperintensityusuallyindicateshemorrhageorhighproteincontentofthecyst.Ignorealllesionwithsharpmargins;lesionsOnUStheyhavetobeclearlycysticFollowalllesionsthataretotallyintrarenal,becauseyoucannotappreciatethewallandfollowalllesions3cm,becausethereisatthemomentnotmuchexperiencewiththeselesions.Alltheselesionsmustshownoenhancement.Excisealllesionsthatarepoorlydefinedorheterogenousorshowenhancement.Alsowhenultrasoundshowsthatthelesionissolid,thelesionshouldbeexcised.Hyperdense or High signal肾脏囊性占位OnCThyperdensemeans:2015LEFT:NECTshowsalesionwithLEFT:NECTshowsalesionwithadensityof27adensityof27HU.IgnoreRIGHT:MRIshowsHU.IgnoreRIGHT:MRIshowsaintrarenallesionthatisaintrarenallesionthatishyperintenseonT1:higherhyperintenseonT1:highersignalthanwater.Followsignalthanwater.FollowOntheleftweseeahyperdenscysticlesiononCTandahyperintenselesiononaT1-weightedMR.Bothlesionshaveasharpmarginandarehomogeneous,althoughthereissomenoiseintheCTimage.Ontheenhancedscans(notshown)thelesionsdidntshowanyenhancement.Wethereforecanignorethelesionontheleftandwehavetofollowthelesionontheright,becauseitistotallyintrarenal.肾脏囊性占位LEFT:NECTshowsalesionwith16SeptationsSeptationsIgnorethinseptations(Followallseptationsthatareonlyslightlygreaterthanhairline.Theystillhavetoshownoenhancement.Exciseallseptationsthatarethick,irregularornodularandallseptationsthatshowenhancement.肾脏囊性占位SeptationsIgnorethinseptati17LEFT:thin,smoothLEFT:thin,smoothseptation.IgnoreRIGHT:thickseptation.IgnoreRIGHT:thickenhancingseptation.Exciseenhancingseptation.ExciseOntheleftwesee2casesThereisacysticlesionwithathinsmoothnonenhancingseptationthatwecanignore.Theothercaseisathickenhancingseptationthathastobeexcised.肾脏囊性占位LEFT:thin,smoothseptation.18CysticlesionwiththickseptationCysticlesionwiththickseptationandanodule.Exciseandanodule.ExciseTheultrasoundimageontheleftshowsathickseptation.Thereisalsoanoduleinthewallofthecyst.Sowehavetworeasonstoexcisethiscysticlesion.肾脏囊性占位Cysticlesionwiththicksepta19EnhancementEnhancementEnhancementisourbestpredictablesignofmalignancy.Sowehavetoexcisealllesions,thatclearlyshowenhancement.Theonlyexceptionisinfection.肾脏囊性占位EnhancementEnhancementisour20Significantenhancement:Significantenhancement:UnenhancedCT:44HUUnenhancedCT:44HU(left)Enhancedscan:61HU(right)(left)Enhancedscan:61HU(right).Excise.ExciseEnhancementisdefinedasfollows:IncreaseinHounsfieldUnitsofthemassaftercontrastinjection:10-15HU=indeterminate15HU=vascularityOnMR:15%=enhancement=surgical肾脏囊性占位Significantenhancement:Unenh21EnhancedCTshowsEnhancedCTshowsenhancementofathickwallenhancementofathickwallandacentralarea.exciseandacentralarea.exciseThecaseontheleftdoesntshowsmuchontheNECT.Howeverwhenwegivecontrastwecanappreciateathickwallandweseeenhancementbothofthewallandofacentralareainthemedialpartofthecysticlesion.Weshouldneverseethisinanbenigncyst,sothisisasurgicallesion.肾脏囊性占位EnhancedCTshowsenhancement22MultiloculatedMultiloculatedMasseswiththreeormoreseptaarenotcalledmultiseptatedbutmultiloculated.Allmultiloculatedlesionsshouldbeexcised,unlessthereisclearevidenceofinfection.肾脏囊性占位MultiloculatedMasseswiththr23MultiloculatedcysticmassonMultiloculatedcysticmassonUSandonCT.ExciseUSandonCT.Excise Intheadult,thetwomostcommonmultiloculatedmassesareMLCN(multilocularcysticnephroma)whichisusuallybenign,butsometimesmalignantandMLRCC(multilocularrenalcellcarcinoma)whichisalwaysmalignant.Onimagingthereisnowaythatwecanseparatethesetwoandtherefore,allmultiloculatedmassesaresurgical(unlessinfection).肾脏囊性占位Multiloculatedcysticmasson24Multilocularrenalcellcarcinoma(left)Multilocularrenalcellcarcinoma(left)andamultilocularcysticnephromaandamultilocularcysticnephroma(right)(right)Eventhepathologistcannotseparatetheusuallybenignmultilocularcysticnephromafromthemalignantmultilocularrenalcellcarcinomaongrossspecimen.Thedifferentiationisbasedonthehistologyoftheepithelialcellsliningtheselocules.Soallmultilocularrenalmasseshavetobeexcised.肾脏囊性占位Multilocularrenalcellcarcin25NodularityNodularityIgnore:noneFollow:onlyverysmallnonenhancingnodules,andfollowcarefullyExcise:allothernodularlesions肾脏囊性占位NodularityIgnore:noneFollow26VerysmallnonenhancingVerysmallnonenhancingnodules.Follownodules.Follow ThecaseontheleftshowsverysmallnodulesonaCECTandaT2WI.Fromalltheotherimageswecouldtellthattheywerenotenhancing.Sowecanprobablyfollowthislesion.Iftheystarttogroworshowanyenhancement,thenwehavetoexcisethelesion.肾脏囊性占位Verysmallnonenhancingnodul27CysticlesionwithabigenhancingCysticlesionwithabigenhancingnodule.Excisenodule.ExciseOntheleftaneasycase.Thereisabignodulewithenhancement,sothislesionhastobeexcised.Eveniftherewasnoenhancement,thelesionstillhadtobeexcised.肾脏囊性占位Cysticlesionwithabigenhan28T2WIshowsamultiloculatedcysticT2WIshowsamultiloculatedcysticmasswithmultiplenodules.Excisemasswithmultiplenodules.Excise ThecaseontheleftisaT2WIwithFatsat.Weseemultiplenodulessothismasshastobeexcised.Itdoesntmatterwhetherornotthesenodulesenhance.肾脏囊性占位T2WIshowsamultiloculatedcy29WallthickeningWallthickeningAlllesionswithathickenedwall,withorwithoutenhancement,shouldbeexcised,unlessthereisclearevidenceofinfection.Intheselattercasesthelesionsshouldbefollowed.肾脏囊性占位WallthickeningAlllesionswi30TwocysiclesionswitharegularthickTwocysiclesionswitharegularthickwall.Excisewall.ExciseOntheleftweseetworenallesionsthatarecystic.Thelesiononthefarleftclearlyshowsathickenedwall.Thisiseasytoappreciatebecausepartofthelesionisextrarenal.Thecysticlesionnexttoitistotallyintrarenal,whichmakesithardertoappreciate,butthereiswalltickening.Sobothlesionshavetobeexcised,whetherthereisenhancementofthewallornot.Theonlyexceptionwouldbeiftherewereevidentsignsofinfection.肾脏囊性占位Twocysiclesionswitharegul31CysticlesionwithathickirregularCysticlesionwithathickirregularenhancingwall.Exciseenhancingwall.Excise Thecysticlesionontheleftisclearlyasurgicallesion.Ithasathickirregularwall,itisexophyticandshowsenhancement.肾脏囊性占位Cysticlesionwithathickirr32RoleofBiopsyRoleofBiopsyIntheliteraturetherearedifferentopinionsconcerningtheroleofbiopsyinrenalcysticlesions.HereweprovideDrBosniaksopinion.AdifferentopinionisgivenbyDrLanginthearticeonCT-guidedbiopsyofindeterminaterenalcysticmasses(Bosniak3and2F):accuracyandimpactonclinicalmanagement(seereferences)肾脏囊性占位RoleofBiopsyIntheliteratu33DrBosniaksopinionBiopsyplaysalimitedrole.Onlyincaseofclinicalsuspicionthatthemassisinflammatory(pyuria,etc.)orthereisradiologicalevidencesuggestinginflammation(suchasperinephricfatstranding),punctureisacceptable.Whentheoutcomeisinfection,thelesioncanbetreatedandfollowed.Althoughconsideredrare,needletrackspreadoftumorisanunderestimatedrisk.Acorebiopsyofthewallofacysticlesion(benignormalignant)cancauseittoruptureandspillitscontentsintothesurroundingtissues.Anegativebiopsyresultdoesnotruleoutmalignancy,particularlyincysticlesionsthathavelessbulkoftissuetosample.肾脏囊性占位DrBosniaksopinion肾脏囊性占位34BosniakClassificationofRenalBosniakClassificationofRenalCysticDiseaseCysticDiseaseTheBosniakclassificationwasdescribedin1986.Aftertheoriginaldescription,itbecameobviousthatsomerevisionwasneededbecausethereweresomecategoryIIcyststhatwereslightlymorecomplicatedthanmostcategoryIIlesions,butnotcomplicatedenoughtoplacethemincategoryIII.Forthatreason,acategoryIIF(Fforfollow-up)wasintroducedin1993.CategoryI(simplecysts),CategoryII(mildlycomplicatedbenigncysts),andCategoryIV(cysticneoplasms)areeasytodiagnose.Theirclinicalmanagementisstraightforward,withsurgeryindicatedforcategoryIVmasseswhilecategoryIandIImassescanbedismissedasbenign.CategoryIIF(Fforfollow-up;moderatelycomplicatedcysticmassesthatrequirefollow-upimagingtodemonstratestabilityandthereforebenignity)andCategoryIIImasses(indeterminatemassesthatrequiresurgeryinmostcases)canbedifficulttodifferentiateandaresubjecttointerobservervariability.Thisdistinctionisessentialbecausetheirtreatmentisdifferent.肾脏囊性占位BosniakClassificationofRena35