肝富血供占位影像鉴别诊断课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,肝脏,富血供占位,影像鉴别,诊断,肝脏富血供占位影像鉴别诊断,1,病例一 女性，,67,岁，上腹痛,3,月余。,病例一 女性，67岁，上腹痛3月余。,2,病例二,女性，,37,岁，上腹部胀痛不适半年。,病例二 女性，37岁，上腹部胀痛不适半年。,3,病例三,女性，,52,岁，上腹部不适,3,月。,病例三 女性，52岁，上腹部不适3月。,4,肝富血供占位影像鉴别诊断课件,5,肝脏富血供病变,非肿瘤性病变,1.,动脉,-,门脉瘘,2.,一过性肝实质强化增加,3.,结节性再生性增生,4.,上腔静脉阻塞,5.,肝紫癜,6.,肝脓肿,上皮样性肿瘤：肝细胞性,1.,原发性肝细胞癌（,HCC,）,2,.,肝腺瘤,3,.FNH,混合性或来源不明的恶性肿瘤,1.,癌肉瘤,2.,混合型肝细胞和胆管癌,3.,肝母细胞瘤,间质肿瘤,1.,血管平滑肌脂肪瘤（,PEComa,）,2.,血管瘤,3.,肝炎性假瘤,4.,上皮,样血管内皮瘤（,EHE,）,转移瘤（神经内分泌瘤,/,癌）,肝脏富血供病变非肿瘤性病变混合性或来源不明的恶性肿瘤转移瘤（,6,动脉期强化，门静脉期及实质期仍强化,动脉期强化，门静脉期及实质期仍强化,7,平扫,动脉期,门脉期,平衡期,海绵状血,管,瘤,平扫动脉期门脉期平衡期海绵状血,8,T1WI,T2WI-FS,T1WI+C,动脉期,T1WI+C,平衡期,T1WI,增强肝胆特异期,T1WI,增强肝胆特异期,灯泡征，普美显增强肝胆特异期低信号,T1WI,9,诊 断 要 点,T1WI,低信号，,T2WI,信号高，灯泡征；,动脉期边缘结节样强化；,门静脉期及延迟期持续强化，边缘向中央填充；,普美显增强肝胆特异期低信号；,临床症状通常不明显，无肿瘤标志物增高。,诊 断 要 点 T1WI低信号，T2WI信号高，灯泡征；,10,Axial CECT shows dozens of vascular masses in the liver (and spleen) that have marked but irregular enhancement. Some portions of some lesions simulate the nodular peripheral pattern of enhancement seen with hemangiomas, but the lesions do not meet other criteria for benign lesions.,血 管 肉 瘤,Axial CECT shows dozens of vas,11,诊 断 要 点,多发富血供肿瘤,；,肝脾同时累及；,易转移到淋巴结，骨，肺；,内部信号不均，伴坏死；,早期转移，进展快，预后差。,诊 断 要 点 多发富血供肿瘤；,12,男，,36,岁，体检发现肝占位，临床及实验室检查无殊,男，36岁，体检发现肝占位，临床及实验室检查无殊,13,局灶性结节增生,局灶性结节增生,14,诊 断 要 点,T1WI,等或稍低信号，,T2WI,信号稍高，中央放射状疤痕,T2,信号更高，无包膜，同反相位无信号衰减；,动脉期明显强化，中央疤痕不强化或轻度强化；,门静脉期及实质期呈高或等信号，中央疤痕延迟强化；,普美显增强肝胆特异期等高信号，内可有或无低信号区；,临床症状通常不明显，无肿瘤标志物增高。,诊 断 要 点 T1WI等或稍低信号，T2WI信号稍高，中央,15,感谢复旦大学附属中山医院饶圣祥教授提供病例,肝,细,胞,腺,瘤,炎,症,型,感谢复旦大学附属中山医院饶圣祥教授提供病例肝,16,肝富血供占位影像鉴别诊断课件,17,诊 断 要 点,四型：炎症型，,HNF-1,𝛼,-,突变型，,𝛽,-catenin,突变型，未分类型；,富含脂质，,T1WI,同反相位有信号衰减；,易囊变，坏死，出血，包膜；,动脉期显著强化，门脉期及延迟期呈等或高信号；,肝胆特异期对分型有辅助价值；,大部分肝胆特异期呈低信号；,少部分呈等高信号，多见于炎症型；,长期口服避孕药病史，高雌激素环境，糖原累积,症，合成类类固醇，糖尿病。,诊 断 要 点 四型：炎症型， HNF-1𝛼-突变型，,18,女性，,37,岁，上腹部胀痛不适半年。,女性，37岁，上腹部胀痛不适半年。,19,2002,年,WHO,将血管周上皮样细胞瘤定义为由血管周上皮样细胞来源的间叶组织肿瘤，包括一组肿瘤，如肝肾血管平滑肌脂肪瘤、肺的透明细胞“糖”瘤及镰状韧带和圆韧带的透明细胞肌黑色素瘤等,免疫组化检测特点为黑 色 素 标 记,HMB45,和 肌 源 性 抗,SMA,阳性。,良性多见,年轻女性多见,与乙型肝炎病毒感染及肝硬化无明显关系,肝血管平滑肌,脂肪瘤,（,PEComa,）,2002年 WHO将血管周上皮样细胞瘤定义为由血管周上皮样细,20,诊 断 要 点,脂肪成分，可以定性；,富含平滑肌，,T2WI,等低信号；,动脉期开始强化，门脉期及延迟期呈等或高信号；,血管成分多，内可见增粗血管影；,肝胆特异期呈低信号；,无乙肝及肝硬化病史，肿瘤标志物无增高。,诊 断 要 点 脂肪成分，可以定性；,21,Axial CECT of the same patient shows that most of the hepatic mass is hypervascular with large feeding vessels (white curved arrow).,肝富血供占位影像鉴别诊断课件,22,In this 67-year-old woman, arterial-phase CECT shows a large mass with foci of hypervascularity (white solid arrow). Enlarged nodes (cyan solid arrow) in the porta hepatis enhance in a similar manner.,a delayed-phase CECT shows heterogeneous, persistent foci of enhancement (white curved arrow) that are hyperdense to liver and blood vessels, unlike what would be expected of a cavernous hemangioma. Cholangiocarcinoma was confirmed on biopsy and resection.,胆,管,细胞,癌,胆,23,诊 断 要 点,圆形或不规则形，周围胆管扩张，包膜内陷,；,动脉期边缘明显强化、轻度强化或不强化；,门静脉期及延迟期周边强化消退，中央纤维基,质持续强化；,普美显增强肝胆特异期低信号；,AFP,不高，,CA199、CEA,及,CA125,增高。,诊 断 要 点 圆形或不规则形，周围胆管扩张，包膜内陷；,24,25,T2WI,T2WI,DWI,T,1,WI,神经内分泌肿瘤肝转移,T2WIT2WIDWIT1WI神经内分泌肿瘤肝转移,26,Pre,A,P,P,PreAPP,27,诊 断 要 点,圆形或环形,；,动脉期明显强化；,门静脉期及延迟期持续强化，或消退；,普美显增强肝胆特异期低信号；,原发肿瘤，胰腺来源常见。,诊 断 要 点 圆形或环形；,28,鉴 别 诊 断,鉴 别 诊 断,29,In this patient with Budd-Chiari syndrome, arterial-phase CECT shows many small hypervascular masses (white solid arrow) (large regenerative nodules). Note the occluded IVC (white curved arrow), ascites, and a dysmorphic liver.,结节性再生性增生,结节性再生性增生,30,动脉期强化，静脉期及延迟期等密度,动脉期强化，静脉期及延迟期等密度,31,T1WI,同相位,T1WI,反相位,T1WI-FS,T2WI-FS,DWI,ADC,T1WI同相位,32,T1+C,动脉期,T1WI+C,门脉期,T1WI +C,门脉期,T1+C,肝胆特异期,T1+C动脉期,33,Abdom Imaging (2013) 38:290296,LGDN,HGDN,HCC,大细胞为主，无异型,间质无孤行动脉，无膨胀性生长,肝胆特异期呈等信号,小细胞，核大，异型,孤行动脉增多,肝胆特异期呈低信号,细胞间质浸润,（假）包膜，结中结,动脉血供增加，门脉血供减少。,肝胆特异期呈低信号,Abdom Imaging (2013) 38:29029,34,两年前左肝,HCC,切除术，,2014-12,至感染科门诊复查，,AFP,：,65.72,至放射科行,MR,普美显增强检查,两年前左肝HCC切除术，2014-12至感染科门诊复查，A,35,影像诊断：肝,IV,段包膜下,HCC,病理：（左肝）肝细胞,癌,普美显肝胆特异期呈低信号,影像诊断：肝IV段包膜下HCC病理：（左肝）肝细胞癌普美显,36,诊 断 要 点,DWI,高信号,；,部分含脂质，,T1WI,同反相位有信号衰减；,动脉期血供增加；,门脉血供减少；,肝胆特异期呈低信号；,乙肝病史，,AFP,增高,。,诊 断 要 点 DWI高信号；,37,女性，,40,岁，体检发现,NEW,女性，40岁，体检发现NEW,38,肝富血供占位影像鉴别诊断课件,39,肝富血供占位影像鉴别诊断课件,40,诊 断 要 点,四型：炎症型，,HNF-1,𝛼,-,突变型，,𝛽,-catenin,突变型，未分类型；,富含脂质，,T1WI,同反相位有信号衰减；,易囊变，坏死，出血；,动脉期显著强化，门脉期及延迟期呈等或高信号；,肝胆特异期对分型有辅助价值；,大部分肝胆特异期呈低信号；,少部分呈等高信号，多见于炎症型；,长期口服避孕药病史。,诊 断 要 点 四型：炎症型， HNF-1𝛼-突变型，,41,鉴 别 诊 断,鉴 别 诊 断,42,肝动脉,-,门脉瘘,肝动脉-门脉瘘,43,In this man with hepatic metastases from pancreatic cancer, arterial-phase CECT shows peripheral, wedge-shaped zones of hepatic hyperperfusion (white solid arrow) that became isodense to liver on the portal venous phase; typical transient hepatic attenuation differences (THADs).,This portal venous-phase CT shows the multiple hypodense, spherical metastases (white curved arrow) that caused the THADs seen on arterial-phase CECT. THAD lesions often result from occlusion of portal vein branches by tumor.,THAD,一过性肝实质灌注异常,In this man with hepatic metas,44,In this middle-aged man with a family history of hereditary hemorrhagic telangiectasia (HHT), arterial-phase CT shows heterogeneous enhancement of the hepatic parenchyma, enlarged, tortuous hepatic arteries (black solid arrow), and early opacification of enlarged hepatic veins (black curved arrow) and the inferior vena cava (IVC).,Portal venous-phase CECT shows homogeneous enhancement of the liver with dilated hepatic veins and IVC.,遗传性出血性毛细血管扩张症,In this middle-aged man with a,45,In this 60-year-old woman with superior vena cava (SVC) occlusion, arterial-phase CECT shows bright enhancement of portions of the left hepatic lobe (white solid arrow) along with collateral veins (white curved arrow) in the chest wall and capsular surface of the liver. The liver was homogeneous on venous-phase CECT.,上腔静脉阻塞伴侧枝循环形成,上腔静脉阻塞伴侧枝循环形成,46,动脉期强化，门静脉期及延迟期低密度,动脉期强化，门静脉期及延迟期低密度,47,女性，,72,岁。,B,超发现肝占位。,女性，72岁。B超发现肝占位。,48,肝富血供占位影像鉴别诊断课件,49,肝富血供占位影像鉴别诊断课件,50,诊 断 要 点,DWI,高信号,包膜,；,部分含脂质，,T1WI,同反相位有信号衰减；,动脉期血供增加，门脉血供减少，快进快出；,肝胆特异期呈部分高信号（高分化）或低信,号（中低分化）；,乙肝病史，,AFP,增高,。,诊 断 要 点 DWI高信号,包膜；,51,男，,54,岁，,CT,示肝脏占位，,AFP733.29ng/ml,男，54岁，CT示肝脏占位，AFP733.29ng/ml,52,低分化肝细胞肝癌,低分化肝细胞肝癌,53,男性，,48,岁。上腹部疼痛不适,男性，48岁。上腹部疼痛不适,54,肝富血供占位影像鉴别诊断课件,55,肝富血供占位影像鉴别诊断课件,56,神经内分泌癌肝转移,神经内分泌癌肝转移,57,女性，,60,岁，发现胰腺占位,2,月,女性，60岁，发现胰腺占位2月,58,In this patient with hypervascular hepatic metastases (white solid arrow), the primary endocrine tumor of the pancreas (malignant glucagonoma) is also evident as a hypervascular mass (white curved arrow).,In this patient with hypervasc,59,小 结,多期增强扫描，多动脉期，延迟时间,；,普美显增强肝胆特异期；,同一疾病多种不同的强化方式；,临床病史；,肿瘤标志物。,小 结 多期增强扫描，多动脉期，延迟时间；,60,Thank You for Your Attention!,Thank You for Your Attention!,61,