常见肾上腺肿瘤的ct诊断与鉴别诊断课件

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Here comes your footer,Page,#,Your Logo,常见肾上腺肿瘤的,CT,诊断与鉴别诊断,CT Diagnosis and Differential Diagnosis of Common,Adrenal Tumors,常见肾上腺肿瘤的CT诊断与鉴别诊断CT Diagnosis,Here comes your footer,Page,2,球状带：盐皮质激素（醛固酮）,肾上腺皮质从外向里分为,束状带：糖皮质激素（皮质醇）,网状带：性激素（脱氢雄酮、雌二醇）,肾上腺素：心跳加快，收缩加强,肾上腺髓质主要分泌,去甲肾上腺素：小动脉平滑肌收缩,Here comes your footer Pag,Here comes your footer,Page,3,正常肾上腺,CT,表现,1,、位置：位于两侧肾脏上方，约,T11,、,T12,椎体水平。,2,、形态：多为倒,V,形或倒,Y,形。,3,、大小：正常侧枝厚度,10mm,（不超过同层膈肌脚）,面积,150mm,2,。,4,、密度：均匀软组织密度，,30-50HU,，不能分,辨皮髓,质。,5,、增强：均匀强化，仍不能分辨皮髓质。,Here comes your footer Pag,Here comes your footer,Page,4,Contents,1,、神经母细胞瘤,2,、嗜铬细胞瘤,3,、转移瘤,4,、皮质腺瘤,5,、皮质腺癌,6,、髓样脂肪瘤,Here comes your footer Pag,Here comes your footer,Page,5,5-year-old boy, complained with abdominal mass,Here comes your footer Pag,Here comes your footer,Page,6,Here comes your footer Pag,Here comes your footer,Page,7,Here comes your footer Pag,Here comes your footer,Page,8,神经母细胞瘤,（,Adrenal,Neuroblastoma,）,儿童腹膜后最常见的实体性恶性肿瘤之一，多在,5,岁内发病，肾上腺为其主要,发病部位。临床症状不典型，常以“腹部包块”就诊。,85%-90%,患儿尿中,VMA,CT,：平扫为不规则,较大,肿块，呈侵润性生长，多见斑片样,钙化,，钙化程度不,同，肿块可见坏死，囊变，出血，常,跨越中线,向对侧延伸，,包绕后腹膜,血管,，也可突入胸腔，增强后实质部分不均匀强化。肾脏常被压迫向后,外侧移位。,如实验室检查有尿,3-,甲氧,-4,羟杏仁酸,(VMA),升高 ，,CT,征象具有上述任何,一种典型表现就可以考虑肾上腺神经母细胞瘤。,常需与肾母细胞瘤鉴别,Here comes your footer Pag,Here comes your footer,Page,9,肾母细胞瘤,神经母细胞瘤,生长方式,膨胀性生长，完整假包膜，较少分叶,生长迅速，多无完整包膜，分叶常见,平扫,密度明显低于肾实质，囊变多见，极少钙化,钙化多见，囊变少,增强,血供不丰富，不明显强化,较明显强化,与肾脏关系,与残肾交界面锐利,交界面模糊，境界不清,转移,瘤周组织多成推移表现，腹膜后淋巴结转移少见,常包埋后腹膜血管，腹膜后淋巴结转移常见,Here comes your footer Pag,Here comes your footer,Page,10,肾,母,细,胞,瘤,Here comes your footer Pag,Here comes your footer,Page,11,肾上腺嗜铬细胞瘤,（,Pheochromocytomas,）,1,、,Pheochromocytomas are sometimes called the,10% tumor,.,Because they are,associated with a 10% risk of malignancy, 10% of the tumors are bilateral, 10%,are hormonally inactive and 10% are extra-adrenal.,2,、,Pheochromocytomas are paragangliomas arising from the adrenal medulla. They,are hormonally active in 90% of cases. Morphologic findings on CT include large,variation in size, homogeneity, and margination of the tumors and significant,enhancement in most cases.,3,、,Usually, tumors are larger than 3 cm when seen. They are highly vascular, and,larger tumors are prone to hemorrhage and necrosis, even when they are benign.,Mean age of Pheochromocytomas is 30 to 50 years old, theres no great difference in the sex of patients.,Here comes your footer Pag,Here comes your footer,Page,12,平扫，肿瘤呈类圆形，不均匀低密度，有明显包膜,病,例,1,Here comes your footer Pag,Here comes your footer,Page,13,增强扫描动脉期，肿瘤呈明显结节状，显著强化,Here comes your footer Pag,Here comes your footer,Page,14,增强扫描延迟期，肿瘤呈向心性强化，强化区,密度高于背部肌肉组织,Here comes your footer Pag,Here comes your footer,Page,15,左侧肾上腺可见一软组织块影，密度均匀，边界清晰，其内可见斑点状低密度血管影,(,箭,),，,CT,值约,25 HU,，胰腺尾部前移。,病,例,2,Here comes your footer Pag,Here comes your footer,Page,16,动脉期肿瘤明显强化，可见肿瘤供血血管,(,箭,),。,Here comes your footer Pag,Here comes your footer,Page,17,静脉期强化稍下降，可见斑点状低密度坏死未强化区,(,白箭,),和肿瘤内血管影,(,黑箭,),。,Here comes your footer Pag,Here comes your footer,Page,18,肾上腺皮质腺瘤,（,Adrenocortical Adenoma,）,原发性肾上腺腺瘤发生率达,2%-9%,。典型的腺瘤常表现为单侧单发，,最大径,60%,可诊断为腺瘤。,Here comes your footer Pag,Here comes your footer,Page,21,肾上腺皮质腺癌,（,Adrenocortical Carcinoma,）,ACC,可发生于任何年龄，以,4050,岁多见，女性比男性略多。其病程短，早期诊断困难，晚期可出现“腰痛、包块、高热、消瘦”四联征。临床上常有激素异常分泌症状，以,Cushing,综合征多见。,特征性,CT,表现：直径多,5cm,，肿瘤,坏死囊变,显著，由于胶原间隔的存在和肿瘤坏死、出血等，,ACC,容易形成,网络状,改变。动态增强动脉期可见不规则肿瘤血管和瘤栓，并可见网络状强化，,门静脉期强化程度增加,、强化面积扩大，但强化明显不均匀。,ACC,邻近,脂肪间隙,、邻近脏器容易受肿瘤组织,浸润,。,Here comes your footer Pag,Here comes your footer,Page,22,平扫，实质性肿瘤伴中央不规则坏死区，可见结节状钙化,Here comes your footer Pag,Here comes your footer,Page,23,动脉期扫描，除中央坏死外，肿瘤实质部分呈网络状,轻度强化，似可见强化的肿瘤血管。,Here comes your footer Pag,Here comes your footer,Page,24,门静脉期扫描，肿瘤实质成分强化明显，因而网络增宽，,肿瘤血管不及动脉期明显。,Here comes your footer Pag,Here comes your footer,Page,25,肾上腺转移瘤,（,Metastases,）,1,、最常见的原发肿瘤有肺癌、乳腺癌、甲状腺癌、结肠癌及黑色素瘤等。,2,、,CT,表现多样，当肿瘤较小时，常呈较均匀的低密度，边缘光滑、清楚，,强化较均匀；而当瘤体增大时，密度不均匀，边界不清，强化不均匀，,肾上腺结构不清。,3,、患者有其他部位的原发癌，且发现双侧肾上腺有肿块，则可诊断肾上腺,转移瘤。但如果仅发现单侧肾上腺有肿块，则需排除肾上腺原发肿瘤，,特别是无功能性肿瘤。,Here comes your footer Pag,Here comes your footer,Page,26,CT,平扫，肿瘤呈网格样改变,病,例,1,Here comes your footer Pag,Here comes your footer,Page,27,动脉期扫描，网络内血管先强化，肿瘤血管不规则，,网络内实质成分呈轻度强化,Here comes your footer Pag,Here comes your footer,Page,28,门静脉期扫描，网络实质成分明显强化，肿瘤血管依稀可见,Here comes your footer Pag,Here comes your footer,Page,29,腺瘤与转移瘤鉴别：,大部分腺瘤,CT,平扫,20HU,。,腺瘤增强后,CT,值和增强程度都明显低于转移瘤，但两者重叠成分较大，鉴别诊断价值不如平扫,CT,值，可能与部分腺瘤血供较丰富致强化明显有关。,肾上腺良性腺瘤,CT,值明显低于恶性肿瘤，,尤其当瘤灶内出现负值时。,Here comes your footer Pag,Here comes your footer,Page,30,平扫密度不均，中央有坏死，增强后呈环状强化，,实质密度平扫及强化程度均,20HU,病,例,2,Here comes your footer Pag,Here comes your footer,Page,31,当肾上腺转移瘤瘤体小，形态规则，边界清楚时，与肾上腺非功能性腺瘤难以鉴别。,文献报道称：非功能性腺瘤中,41.7%,瘤灶同侧可见相对正 常的肾上腺，此表现是鉴别肾上腺腺瘤与转移瘤的可靠征象。而转移瘤瘤侧相对正常的肾上腺组织少见。,Here comes your footer Pag,Here comes your footer,Page,32,肾上腺嗜铬细胞瘤和转移瘤有很多类似的特点，都是既可单侧,也可双侧发生的肿瘤，可长得很大，且易坏死、囊变，甚至出血。,怎样鉴别嗜铬细胞瘤与转移瘤,？,Here comes your footer Pag,Here comes your footer,Page,33,肾上腺嗜铬细胞瘤在增强的动脉期肿瘤实质明显强化，而且,CT,值高于,140 HU,，接近大动脉的强化；静脉期肿瘤实质强化程度比动脉期低，但仍然呈明显强化，,CT,值常高于,100 HU,。这是由于嗜铬细胞瘤肿瘤的细胞团之间存在大量血窦，增强后造影剂很快进入肿瘤内，并且持续存留，使肿瘤早期即明显强化而且持续明显强化。（,80HU,）,转移瘤内没有血窦存在，而且肿瘤血管分布不均匀。动脉期肿瘤实质的,CT,值低于静脉期肿瘤实质的,CT,值，也就是说在增强扫描的动脉期和静脉期，造影剂都是一种逐渐进入肿瘤的状态，而且转移瘤增强动脉期和静脉的,CT,值一般不超过,100 HU,。,Here comes your footer Pag,Here comes your footer,Page,34,肾上腺髓样脂肪瘤,（,Myelolipoma,）,是一种肾上腺无功能性良性肿瘤，常无临床症状，在体检或行其它部位检查时偶然发现。好发年龄,20,70,岁，男女发生率相近，右侧好发，双侧少见。,I,型：单纯肾上腺髓样脂肪瘤，最多见。,型：合并出血的髓样脂肪瘤通常体积较大。,型：肾上腺外髓样脂肪瘤，多见于后腹膜。,型：髓样脂肪瘤长于肾上腺其他病灶内，瘤体脂肪成分少、钙化多。,肿瘤内脂肪成分为主的占多数，以骨髓样组织为主占少数。骨髓样组织呈条索状、分隔样、片状及斑点状较高密度，增强扫描，骨髓样组织有较均匀的轻至中度强化。约,10,一,20, 的病灶内可见斑点状或条状钙化。,Here comes your footer Pag,Here comes your footer,Page,35,均一脂肪密度，,CT,值为,-115HU,，边界清楚，,有包膜，胰腺受压前移，肾上腺显示良好，,动脉期和门脉期未见强化,Here comes your footer Pag,Here comes your footer,Page,36,右侧肾上腺体部后方类圆形病灶，脂肪密度,中见斑片状软组织密度影。增强扫描动脉期,和门脉期，软组织密度成分轻度强化。,Here comes your footer Pag,Here comes your footer,Page,37,箭头指示：,小片脂肪密度,脂肪成分较少的髓质脂肪瘤,OR,皮质腺瘤,？,Here comes your footer Pag,Here comes your footer,Page,38,部分功能性腺瘤密度较低，但一般在,-0.4-20HU,范围内，一般不低于,-20HU,；而髓样脂肪瘤中富含成熟脂肪组织，密度一般要低的多，且功能性腺瘤一般较小。,Here comes your footer Pag,Here comes your footer,Page,39,Here comes your footer Pag,